Notice of Privacy Practices
Houman Farzin, M.D., Inc., dba Mystic Health
Mystic Health, Inc.
Effective date: October 30, 2026
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Who Follows This Notice
This Notice is issued by Houman Farzin, M.D., Inc., a California professional medical corporation doing business as Mystic Health (the “Practice”), 2901 Wilshire Blvd., Suite 105, Santa Monica, California 90403. It applies to all physicians, nurse practitioners, psychologists, therapists, staff, trainees and volunteers who provide or support your care at the Practice.
Mystic Health, Inc. provides administrative, technology and management services to the Practice. Mystic Health, Inc. accesses your health information only as a business associate of the Practice, under a written Business Associate Agreement, and is bound by this Notice.
Where California law protects your information more strictly than federal law, including the Health Insurance Portability and Accountability Act (“HIPAA”), the Practice follows California law.
Our Duties
- The Practice is required by law to maintain the privacy and security of your protected health information.
- The Practice will notify you promptly if a breach occurs that may have compromised the privacy or security of your information.
- The Practice must follow the duties and privacy practices described in this Notice and give you a copy of it.
- The Practice will not use or disclose your information other than as described in this Notice unless you authorize it in writing. You may revoke an authorization in writing at any time, except to the extent action has already been taken in reliance on it.
Your Rights
To exercise any of these rights, submit a request to the Privacy Officer using the contact information at the end of this Notice.
Right to inspect and obtain copies of your records. You may inspect your records within five working days of a written request and receive paper or electronic copies within 15 days. The Practice may charge a reasonable, cost-based fee. If a clinician determines that access to specific mental health records would pose a substantial risk of significant adverse or detrimental consequences to you, the Practice will explain the reason in writing and, at your request, make the records available to a licensed professional you designate.
Right to request amendment. You may ask the Practice to correct or complete information you believe is incorrect or incomplete. The Practice will respond in writing within 60 days, extendable once by 30 days with notice. If the request is denied, you may submit a written statement of disagreement, and under California law you may add a written addendum of up to 250 words for each item you believe is incorrect or incomplete.
Right to request confidential communications. You may ask the Practice to contact you in a specific way or at a specific location, such as a different telephone number or address. The Practice will accommodate all reasonable requests and will not ask the reason.
Right to request restrictions. You may ask the Practice to limit its use or disclosure of your information for treatment, payment or health care operations. The Practice is not required to agree, except that if you pay for an item or service in full out of pocket, the Practice will honor your request not to disclose that information to your health plan for payment or health care operations, unless the law requires the disclosure.
Right to an accounting of disclosures. You may request a list of disclosures the Practice made during the six years before your request, including the recipient and the purpose. The list excludes disclosures for treatment, payment and health care operations, disclosures you authorized, and certain other disclosures. One accounting in any 12-month period is free; additional requests may incur a reasonable, cost-based fee.
Right to a paper copy of this Notice. You may request a paper copy at any time, even if you agreed to receive it electronically.
Right to choose a representative. A person holding your medical power of attorney, or your legal guardian, may exercise your rights. The Practice will verify that person’s authority before acting.
Right to be notified of a breach. You will be notified if a breach of your unsecured protected health information occurs.
Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer or with the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue S.W., Washington, D.C. 20201, telephone 1-877-696-6775, www.hhs.gov/ocr/complaints. You may also contact the Medical Board of California at (800) 633-2322, www.mbc.ca.gov. The Practice will not retaliate against you for filing a complaint.
Your Choices
You may tell the Practice your preference in the following situations, and the Practice will follow your instructions:
- Sharing information with family members, close friends or others involved in your care or payment for your care.
- Sharing information in a disaster relief situation.
If you are unable to state a preference, for example because you are unconscious, the Practice may share information if it believes doing so is in your best interest, or when needed to lessen a serious and imminent threat to health or safety.
The Practice will not do the following without your written authorization:
- Use or disclose your information for marketing purposes.
- Sell your information.
- Disclose psychotherapy notes, except in the limited circumstances permitted by law.
- Disclose your medical information to your employer or use it for employment decisions, except as permitted by California law.
Fundraising. The Practice may contact you for fundraising purposes. You may opt out of further fundraising communications at any time, and the Practice will honor your request.
How the Practice Uses and Discloses Your Information
Treatment. The Practice uses your information and shares it with other professionals who are treating you. Example: your psychiatrist and your therapist coordinate your ketamine-assisted psychotherapy plan.
Payment. The Practice uses and shares your information to bill and obtain payment from health plans and other payers. Example: the Practice provides your health insurer with information needed to process a claim for SPRAVATO® treatment.
Health care operations. The Practice uses and shares your information to run the Practice, improve care, train personnel and conduct quality review. Example: the Practice reviews treatment outcomes to improve its services.
Business associates. The Practice shares information with companies that perform services on its behalf, including Mystic Health, Inc., billing, scheduling, records storage, secure communications and technology providers. Each business associate must sign a written agreement to protect your information.
Appointment reminders and service communications. The Practice may contact you by telephone, text message or email regarding appointments and your care. Standard text messages and email are not encrypted; you may request a different method of communication.
Incidental disclosures. Limited incidental disclosures may occur despite reasonable safeguards, such as another patient overhearing your name in a waiting area.
Other Uses and Disclosures Permitted or Required by Law
Public health and safety. The Practice may disclose information to prevent or control disease, injury or disability; report adverse reactions to medications; assist with product recalls; and report suspected abuse, neglect or domestic violence.
Serious threats to health or safety. When a patient communicates a serious threat of physical violence against a reasonably identifiable victim, California law requires the Practice to make reasonable efforts to communicate the threat to the victim and to a law enforcement agency.
Research. The Practice may use or disclose information for research only with your written authorization, or when an institutional review board or privacy board has approved the research under federal law.
Required by law. The Practice will disclose information when federal or state law requires it, including to the U.S. Department of Health and Human Services to demonstrate compliance with federal privacy law.
Organ and tissue donation. The Practice may disclose information to organ procurement organizations.
Medical examiners, coroners and funeral directors. The Practice may disclose information when an individual dies.
Workers’ compensation, law enforcement and government functions. The Practice may disclose information for workers’ compensation claims; for law enforcement purposes or to a law enforcement official as permitted by law; to health oversight agencies for activities authorized by law, such as audits, investigations and licensure; and for specialized government functions, including military, national security and protective services.
Legal proceedings. The Practice may disclose information in response to a court or administrative order, or in response to a subpoena or other lawful process that meets the requirements of state and federal law.
Additional Protections Under California Law
Mental health information. Mental health information receives additional protection under the California Confidentiality of Medical Information Act and the psychotherapist-patient privilege. The Practice discloses it outside treatment, payment and health care operations only as these laws permit.
HIV test results and other sensitive information. HIV test results and other categories of sensitive information are disclosed only as California law specifically permits.
Minors. Where California law permits a minor to consent to their own care, the minor controls access to and disclosure of the related records, except as otherwise provided by law.
Substance use disorder records. If the Practice receives records protected by federal regulations at 42 C.F.R. Part 2, those records will not be used or disclosed in civil, criminal, administrative or legislative proceedings against you without your written consent or a court order that meets the requirements of that regulation.
Changes to This Notice
The Practice may change the terms of this Notice. Changes will apply to all information the Practice maintains about you. The current Notice is available on request, in the Practice’s office and at www.mystic.health/notice-of-privacy-practices.
Contact Information
Privacy Officer: Kabir Ali
Houman Farzin, M.D., Inc., dba Mystic Health
Mystic Health, Inc.
2901 Wilshire Blvd., Suite 105, Santa Monica, California 90403
Email: info@mystic.health
Telephone: (310) 550-1006
For more information about your rights, visit www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Acknowledgment of Receipt
I acknowledge that I have received the Notice of Privacy Practices of Houman Farzin, M.D., Inc., dba Mystic Health, effective October 30, 2026.
Patient name: ______________________________________
Signature of patient or personal representative: ______________________________________
Date: ____________________
If signed by a personal representative, relationship to patient: ______________________________________
For office use only. If acknowledgment was not obtained, describe the good-faith effort made and the reason: ______________________________________