Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

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 or 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 the client portal.

For Treatment. Your PHI may be used and disclosed with your authorization by those who are involved in your care for the purpose 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 the 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 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 your counselor’s 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 (with your written consent), court order, administrative order, or similar process.

Deceased Patients. Your counselor may disclose PHI regarding deceased patients, 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 patients may be limited to an executor or administrator of a deceased person’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 person, 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, you 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 or 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 shared or sold 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.

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 10707 Corporate Drive, Suite 203, Stafford, TX 77477.

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. Your counselor may charge a reasonable, cost-based fee for copies. You may also request an electronic copy of you PHI as well as request that a copy of your PHI be provided to another person.

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 the method of communication used between you and your counselor. 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 10707 Corporate Drive, Suite 203, Stafford, TX 77477 or with the Texas Behavioral Health Executive Counsel or by calling (512) 305-7700.

Your counselor will not retaliate against you for filing a complaint.