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Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION
PLEASE REVIEW IT CAREFULLY.
1. PURPOSE: As an independent mental health practitioner, I follow the privacy practices described in this Notice. I keep your mental health information in records that will be maintained and protected in a confidential manner, as required by law. Please note that in order to provide you with the best possible care and treatment all employees involved in the health care operations of this practice may have access to all or some of your records.
2. WHAT ARE TREATMENT and HEALTH CARE OPERATIONS?
Your treatment includes sharing information among health care providers who are involved in your treatment For example, if you are seeing both a physician (psychiatrist) and a psychotherapist, they may share information in the process of coordinating your care. Treatment records may be reviewed as part an on-going process directed toward assuring the quality of care.
3. HOW WILL THIS PRACTICE USE MY PROTECTED HEALTH INFORMATION?
Your personal mental health record will be retained by me for approximately ten years after your last clinical contact.; or, in the case of a child, for 10 years after their 18th birthday. After that time has elapsed, the record will be shredded or burned or otherwise destroyed in a way that protects your privacy. Until the records are destroyed they may be used, unless you ask for restrictions on a specific use or disclosure, for the following purposes:
• Appointment reminders;
• Notification when an appointment is cancelled or rescheduled;
• As may be required by law;
• For public health purposes such as reporting of child or elder abuse or neglect; reporting reactions to medications; infectious disease control; notifying authorities of suspected abuse, neglect, or domestic violence (if you agree or as required by law);
administration and management of this practice;
· Mental health oversight activities (e.g., audits, inspections, or investigations of administration and management of this practice;
· For billing and collections;
• Lawsuits and disputes (I will attempt to provide you advance notice of subpoena before disclosing information from your record.);
• Law enforcement (e.g., in response to a court order or other legal process) to identify or locate an individual being sought by authorities; about victim of a crime under restricted circumstances; about a death that may be the result of criminal conduct; about criminal conduct that occurred on the premises; when emergency circumstances occur relating to a crime;
• To prevent a serious threat to health or safety;
• To carry out treatment and health care operations functions through medical transcription services;
• To military command authorities if you are a member of the armed forces or a member of a foreign military authority;
• National security and intelligence activities;
• Protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations.
• Alcohol and drug abuse information has special privacy protections. I will not disclose any information identifying an individual as being a client or provide any mental health or medical information relating to a client1s substance abuse treatment unless: (i) the client consents in writing; (ii) a court order requires disclosure of the information; (iii) medical personnel need the information to meet a medical emergency; (iv) qualified personnel use the information for the purpose of conducting research, management audits, or program evaluation; or (v) it is necessary to report a crime or a threat to commit a crime or to report abuse or neglect as required by law.
4. YOUR AUTHORIZATION IS REQUIRED FOR OTHER DISCLOSURES, Except as described previously, I will not use or disclose information from your record unless you authorize (permit) in writing for me to do so. You may revoke your permission, which will be effective only after the date of your written revocation.
5. YOU HAVE RIGHTS REGARDING YOUR PROTECTED MENTAL HEALTH INFORMATION. You have the following rights regarding your mental health information, provided that you make a written request to invoke the right on the form provided to you for that purpose.
• Right to request restriction. You may request limitations on your mental health information I may disclose, but I am not required to agree to your request. If I agree, I will comply with your request unless the information is needed to provide you with emergency treatment.
• Right to confidential communications. You may request communications in a certain way or at a certain location, but you must specify how or where you wish to be contacted.
• Right to inspect and copy. You have the right to inspect and copy your mental health information regarding decisions about your care; however, psychotherapy notes may not be inspected and copied. I may charge a fee for copying. mailing! and supplies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed mental health professional chosen by me. I will comply with the outcome of the review.
• Right to request clarification of record. If you believe that the information I have about you is incorrect or incomplete you may ask in writing to add clarifying information. I am not required to accept the information that you propose.
• Right to accounting of disclosures. You may request a list of the disclosures of your mental health care operations in the last six (6) years, but not prior to April 14, 2003.
• Right to a copy of this Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. You may print out a copy of this notice from this website.
6. REQUIREMENTS REGARDING THIS NOTICE.
I am required to provide you with this Notice that governs my privacy practices. I may change policies or procedures in regard to privacy practices. If and when changes occur, the changes will be effective for mental health information I have about you as well as any information I receive in the future. Any time you come in for an appointment, you may ask for and receive a copy of the Privacy Notice that is in effect at the time.
7. COMPLAINTS.
If you believe your privacy rights have been violated, you may file a complaint with me, the appropriate state regulatory agency (see list below), or the Secretary of the Department of Health and Human Services. You will not be penalized or retaliated against in any way for making a complaint.
Contact: Call this office if:
• you have a complaint;
• you have any questions about this notice
• you wish to request restrictions on uses and disclosure for health care treatment or operations; or
• you wish to obtain any of the forms mentioned to exercise your individual rights described above
STATE REGULATORY AGENCIES:
· For psychologists: Texas State Board of Examiners of Psychologists
· For social workers: Texas State Board of Social Worker Examiners
· For licensed professional counselors: Texas State Boards of Examiners of Professional Counselors
· For Marriage and Family Therapists: Texas State Board of Examiners of Marriage and Family Therapists
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