Your Privacy Matters
NOTICE OF PRIVACY PRACTICES (Effective August 2023)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how your Counselor may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules. It also describes your rights regarding how you may gain access to and control your PHI.
Your Counselor is required by law to maintain the privacy of PHI and to provide you with notice of legal duties and privacy practices with respect to PHI. Your Counselor is required to abide by the terms of this Notice of Privacy Practices. Your Counselor reserves the right to change the terms of this Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that your Counselor maintains at that time. Your Counselor will provide you with a copy of the revised Notice of Privacy Practices through your client portal.
I. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
· Make sure that protected health information (“PHI”) that identifies you is kept private.
· Give you this notice of my legal duties and privacy practices with respect to health information.
· Follow the terms of the notice that is currently in effect.
· I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
HOW YOUR COUNSELOR MAY USE OR DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment: Your PHI may be used and disclosed with your authorization to those who are involved in your care for the purposes of providing, coordinating, or managing your health care treatment and related services.
For Payment: Your Counselor may use and disclose the minimum amount of PHI necessary without your authorization to receive payment for treatment services provided to you. This may include a designated third-party payer or collection agency for lack of payment.
For Health Care Operations: Your Counselor may use or disclose without your authorization, as needed, your PHI in order to support business activities including, but not limited to, licensing or quality assessment provided that there is a written contract with the business that requires it to safeguard the privacy of your PHI.
Required by Law: Under the law, your Counselor must disclose your PHI to you upon your request. In addition, your Counselor must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining compliance with the requirements of the Privacy Rule.
Child Abuse or Neglect: Your Counselor may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.
Judicial and Administrative Proceedings: Your Counselor may disclose your PHI pursuant to a subpoena, court order, administrative order or similar process.
Deceased Client: Your Counselor may disclose PHI regarding a deceased client as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased clients may be limited to an executor or administrator of a deceased client’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.
Medical Emergencies: Your Counselor may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. You have the right to be provided a copy of the notice as soon as reasonably practicable after resolution of the emergency.
Family Involvement in Care: With your authorization or in an emergency situation, your Counselor may disclose information to close family members or friends directly involved in your treatment.
Health Oversight: If required, your Counselor may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payers based on your prior consent) and peer review organizations performing utilization and quality control.
Law Enforcement: Your Counselor may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena, court order, administrative order or similar order, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased client, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
Specialized Government Functions: Your Counselor may review requests from U.S. military command authorities, if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI.
Public Health: If requested, your Counselor may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.
Public Safety: Your Counselor may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
Research: PHI may only be disclosed after a special approval process or with your authorization.
Fundraising: Your PHI will not be sent for fundraising communications without your written authorization. You will always have the right to opt out of such fundraising communications you may receive.
Verbal Permission: Your Counselor may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that the use and disclosure was already made. In addition, authorization may be required for the use or disclosure of PHI if a more stringent state or federal law applies, such as substance abuse treatment information protected by 42 C.F.R. Part 2.
CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: a. For my use in treating you. b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c. For my use in defending myself in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e. Required by law and the use or disclosure is limited to the requirements of such law. f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. g. Required by a coroner who is performing duties authorized by law. h. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.
CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws. 10 Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI your Counselor maintains about you. To exercise any of these rights, please submit your request in writing to your Counselor who serves as the Privacy Officer at 411 Park Grove Dr. Ste 720 Katy, Tx 77450.
Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. Your counselor will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and Your Counselor may charge a reasonable, cost-based fee for copies. You may also request an electronic copy of your PHI as well as request that a copy of your PHI be provided to another person for a reasonable fee.
Right to Amend: If you feel that the PHI your Counselor has about you is incorrect or incomplete, you may request an amendment to the information, however, your Counselor is not required to agree to the amendment. If your Counselor denies your request for amendment, you have the right to file a statement of disagreement with your Counselor. Your Counselor may prepare a rebuttal to your statement and will provide you with a copy. You may contact the Privacy Officer who is your Counselor if you have any questions concerning this matter.
Right to an Accounting of Disclosures: You have the right to request an accounting of certain disclosures that your Counselor makes of your PHI. Your Counselor may charge a reasonable fee if you request more than one accounting in any 12-month period.
Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment or health care operations. Your Counselor is not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket.
Right to Request Confidential Communication: You have the right to request that your Counselor communicate with you about health matters in a certain way or at a certain location. Your Counselor will accommodate reasonable requests. Your Counselor may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. You will not be asked to explain your reason for making the request.
Breach Notification: If there is a breach of unsecured PHI concerning you, your Counselor may be required to notify you of this breach, including what happened and what you can do to protect yourself.
I authorize my Counselor to provide verbal notice in the event of a breach of my protected health information (PHI).
Right to a Copy of this Notice: You have the right to a copy of this notice.
If you believe your privacy rights have been violated, you have the right to file a complaint in writing to your Counselor who serves as the Privacy Officer at 411 Park Grove Dr. Suite 720 Katy, TX 77450 or with the Texas Behavioral Health Executive Council or by calling (512) 305-7700.
Your Counselor will not retaliate against you for filing a complaint.
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.