This notice describes how Psychological and Medical Information about you may be used and disclosed and how you can get access to this information.
Please review this notice carefully.
I. Uses and Disclosures for Treatment, Payment and Health Care Operations.
Your health record contains personal information about you and your health. This information is referred to as Protected Health Information (PHI)
I may use or disclose your (PHI) for treatment, payment, and health care operations purposes with your consent.
How I may use and disclose Health Information about you.
Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician. I must obtain your authorization before disclosing your PHI.
Payment is when I obtain reimbursement for your healthcare. An example is when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Health Care Operations are activities that relate to the performance and operation of my practice. Examples are quality assessment and improvement activities, licensing, audits and administrative and case management services. I may share your PHI with third parties that perform business activities such as billing provided I have a written contract with that party to safeguard your PHI.
Communication: I may use your PHI to confirm or follow up on appointments or provide receipts for services. Email, Texting, Phone messages are susceptible to access by unauthorized people, thus compromising confidentiality. Please let me know if you do not want me to use any or all of these modes of communication.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when you have authorized it. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information.
Verbal Authorization- You may give me verbal permission to disclose PHI to your family members that are directly involved in the treatment.
You may revoke authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that 1) I have relied on that authorization; or 2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures without Consent or Authorization.
I may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: If I have cause to believe that a child has been, or may be, abused, neglected, or sexually abused, I must make a report within 48 hours to the Texas Department of Protective and Regulatory Services, The Texas Youth Commission, or to any local or state law enforcement agency.
Adult and Domestic Abuse: If I have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, I must immediately report such to the Department of Protective and Regulatory Services.
Serious Threat to Yourself or Someone Else: If I determine that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, I may disclose relevant confidential mental health information to medical or law enforcement personnel.
Health Oversight: If a complaint is filed against me with the State Board of Examiners of Professional Counselors, they have the authority to subpoena confidential mental health information from me relevant to that complaint.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for PHI, such information is privileged under state law, and I will not release information without written authorization from you or your representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
Workers’ Compensation: If you file a workers’ compensation claim, I may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.
IV. Your Rights regarding PHI:
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
Right to Inspect and Copy: You have the right to inspect or obtain a copy of PHI in my records used to make decisions about your care for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. I may charge a reasonable, cost-based fee for copies.
Right to Request Confidential Communications: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send information or leave messages at another location.)
Right to Amend: If you believe the PHI I have in your records is incorrect or incomplete, you have the right to request us to amend the PHI for as long as the PHI is maintained in the record. I may deny your request.
Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI without your consent or authorization (as described in Section III of this Notice.)
Right to a Paper Copy: You have the right to obtain a copy of this notice from me upon request, even if you have agreed to receive the notice electronically.
V. Mental Health Professionals’ Duties:
- I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
- I reserve the right to change the privacy practices described in this notice at any time. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
- If I revise my policies and procedures, I will provide the amended form to current clients on my website, at their next scheduled appointment, or for inactive clients by mail within 15 days of receiving a written request.
VI. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, please talk to me about your concerns.
If you believe that your privacy rights may have been violated and wish to file a complaint with me, you may send your written complaint to me. You may also send a written complaint to:
Texas State Board of Examiners of Professional Counselors
Complaints Management & Investigative Section
P.O. Box 141369
Austin, TX 78714-1369
Ph: (800) 942-5540
I will not retaliate against you for exercising your right to file a complaint.
The Effective Date of this Notice is June 4, 2013
Email /Texting / Credit & Debit Card ‘Square’ Consent Form
Email & Texting
HIPAA regulations and my professional Code of Ethics both require that I keep your Protected Health Information private and secure, and indeed I want to do so. Email and texting are very convenient ways to handle administrative issues such as scheduling or billing receipts. However, both of these mediums of communicating are not 100% secure.
Some of the potential risks you might encounter if we email or text include:
- Delivery of an email or text to an incorrectly typed address or phone number.
- Email accounts can be ‘hacked’ giving a 3rd party access to email content and addresses.
- Phone companies keep a copy of text messages (including those that are deleted off your phone) in their files.
- Email providers (Gmail, Comcast, Yahoo) keep a copy of each email on their servers where it might be accessible to employees, etc.
I will avoid using email or texting to discuss clinical issues (i.e. the important things we talk about in session).
If you are comfortable doing so, I am happy to use email and / or texting to handle administrative matters such as appointment reminders and scheduling or billing issues. If you are not comfortable using email and or texting because of the potential risks, we may handle administrative issues via phone calls.
Use of Square for Credit & Debit Card Payments
I use the company ‘Square’ to process your credit and debit card payments. The company uses secure technologies for these financial transactions.
However, Square may send email or text receipts, which are not 100% secure, as noted above. Square may automatically send a receipt to the email or text message on file for your card if you have previously requested a receipt from another merchant using Square. If you want to avoid receiving an automatic receipt, choose alternate payment options of check or cash, or contact Square to change your preferences.
Finally, for rare circumstances, I have an option of sending you an invoice for services that you may pay online through Square. Please keep in mind that taking advantage of invoicing also means that you will receive the notice and receipt via unsecured email.
Please indicate your preferences & Sign the small form.