NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION REGARDING YOU
AND/OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health
information about your 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.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The
following categories describe different ways that I use and disclose health
information. For each category of uses or disclosures I will explain what I mean and
try to give some examples. Not every use or disclosure in a category will be listed.
However, all of the ways I am permitted to use and disclose information will fall within
one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules
(regulations) allow health care providers who have direct treatment relationship with
the patient/client to use or disclose the patient/client’s personal health information
without the patient’s written authorization, to carry out the health care provider’s own
treatment, payment or health care operations. I may also disclose your protected
health information for the treatment activities of any health care provider. This too can
be done without your written authorization. For example, if a clinician were to consult
with another licensed health care provider about your condition, we would be
permitted to use and disclose your personal health information, which is otherwise
confidential, in order to assist the clinician in diagnosis and treatment of your mental
health condition.
Disclosures for treatment purposes are not limited to the minimum necessary
standard. Because therapists and other health care providers need access to the full
record and/or full and complete information in order to provide quality care. The word
“treatment” includes, among other things, the coordination and management of health
care providers with a third party, consultations between health care providers and
referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health
information in response to a court or administrative order. I may also disclose health
information about you in response to a subpoena, discovery request, or other lawful
process by someone else involved in the dispute, but only if efforts have been made
to tell you about the request or to obtain an order protecting the information
requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1. 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.
2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI
for marketing purposes.
3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course
of my business.
IV. 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:
1. 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.
2. 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.
3. For health oversight activities, including audits and investigations.
4. 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.
5. For law enforcement purposes, including reporting crimes occurring on my
premises.
6. To coroners or medical examiners, when such individuals are performing duties
authorized by law.
7. 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.
8. 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.
9. 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.
10. Payment: I may use and disclose protected health information to obtain
reimbursement for the health care provided to you, including determination of
eligibility and coverage and other utilization review activities. Individuals
involved in your care or payment for your care: Unless you object, we may
disclose your protected health information to an individual identified by you
when they are involved in your care or the payment for your care. We will only
disclose the protected health information directly relevant to their involvement
in your care or payment.
11. Business Associates: There may be some services provided through Business
Associates. Example includes a copy services when making copies of your
health record. When these services are contracted, I may disclose some or all
of your health information to my Business Associate so that they can perform
the job we have asked them to do. To protect your health information, however,
I require the Business Associate to appropriately safeguard the information.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE
OPPORTUNITY TO OBJECT.
1. 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.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have
the right to ask me not to use or disclose certain PHI for treatment, payment, or
health care operations purposes. I am not required to agree to your request,
and I may say “no” if I believe it would affect your health care.
2. The Right to Choose How I Send PHI to You. You have the right to ask me to
contact you in a specific way (for example, home or office phone) or to send
mail to a different address, and I will agree to all reasonable requests.
3. The Right to See and Get Copies of Your PHI. 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. I 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 I may charge a
reasonable, cost based fee for doing so.
4. The Right to Correct or Update Your PHI. If you believe that there is a mistake
in your PHI, or that a piece of important information is missing from your PHI,
you have the right to request that I correct the existing information or add the
missing information. I may say “no” to your request, but I will tell you why in
writing within 60 days of receiving your request.
5. The Right to ask us not to share information for the purpose of our operations
with your health insurer if you pay for a service or health care item out-of-
pocket in full. We will say “yes” unless a law requires us to share that
information.
6. The Right to ask for a list (accounting) of the times we’ve shared your health
information for six years prior to the date you ask, who we shared it with, and
why. We will include all the disclosures except those about treatment, payment,
and healthcare operations, and certain other disclosures. We’ll provide one
accounting a year for free, but will charge a reasonable, cost-based fee if you
ask for another one within 12 months.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right
get a paper copy of this Notice, and you have the right to get a copy of this
notice by e-mail. And, even if you have agreed to receive this Notice via e-mail,
you also have the right to request a paper copy of it.
VII: BUSINESS PRACTICES: The following business practices, though not all-
inclusive, may constitute a potential risk to your confidentiality, in spite of the security
measures that I have in place to protect your privacy. By signing at the end of this
document you understand and acknowledge the possible risk and your consent for
such practices to be utilized: use of an electronic calendar, use of a paper calendar,
use of a cell phone for communication with you and other professionals, use of a
laptop computer, use of unencrypted email, use of computerized billing, use of shared
office space with the independent practices of other health professionals with
potential access to, among other things, common storage and file space, mailboxes,
messages, fax machines.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on September 1, 2019
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.
If you have questions about this notice or would like additional information, you may
contact Amelia Ancell at the telephone above. If you believe that your privacy rights
have been violated, you have the right to file a complaint with the Secretary of the
Department of Health and Human Services (1-877-696-6775), with the Texas Attorney
General’s Office (800-252-8011). The complaint must be in writing, describe the acts
of omissions that you believe violate your privacy rights, and be filed within 180 days
of when you knew or should have known that the act or omission occurred. I will take
no retaliatory action against you if you make such complaints.
NOTICE OF PRIVACY PRACTICES AVAILABILITY: This notice will be prominently
posted in the office. You may also obtain a hard copy upon request, and the notice
will be maintained on your Simple Practice account for downloading.