Your Information. Your Rights. My Responsibility.

This notice describes how personal health information (PHI) about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this Notice of Privacy Practices, please contact the specified contact information listed at the end of this document.

Your Rights

You have the right to: 

• Get a copy of your paper or electronic health record
• Correct your paper or electronic health record
• Request confidential communication
• Ask me to limit the information I share
• Get a list of those with whom I’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that I use and share information as I: 

• Collaborate and consult with other professionals on your behalf
• Tell family and friends about your condition
• Provide you mental health care
• Provide disaster relief or emergency mental health treatment

Our Uses and Disclosures

I may use and share your information as I: 

• Treat you
• Run my practice
• Coordinate treatment and comply with health plan requirements
• Bill for your services and/or collect overdue payments
• Comply with mandatory reporting laws
• Respond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.

Get an electronic or paper copy of your health record 

• You can ask to see or get an electronic or paper copy of your health record and other health information I have about you. Ask me how to do this. 
• I will provide a copy or a summary of your health information, usually within 14 days of your request. I may charge a reasonable, cost-based fee.

Ask me to correct your health record

• You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this.
• I may say “no” to your request, but will tell you why in writing within 60 days.

Request confidential communications

• You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. 
• I will say “yes” to all reasonable requests.

Ask me to limit what I use or share

• You can ask me not to use or share certain health information for treatment, payment, or business operations. I am not required to agree to your request, and may say “no” if it would negatively affect your care or my ability to practice.
• If you pay for a service out-of-pocket in full, you can ask me not to share that information for the purpose of payment or business operations with your health insurer. I will say “yes” unless a law requires me to share that information.

Get a list of those with whom I’ve shared information

• You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why.
• I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). I’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.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• I will make sure the person has this authority and can act for you before I take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel I have violated your rights by contacting me using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• I will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions.

In these cases, you have both the right and choice to tell me to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief or emergency situation

If you are not able to tell me your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest.

In these cases I never share your information unless you give me written permission:

• Requests from family, friends, or others
• Requests for copies of your records (unless accompanied by a subpoena)
• Most sharing of psychotherapy notes

Our Uses and Disclosures

How do I typically use or share your health information? 

I typically use or share your health information in the following ways.

Treat you

Although it is not my practice to do so without first informing you, I can use your health information and share it with other professionals for consultation.

Example: I may consult with another therapist about whether or not a particular treatment may be helpful, considering your diagnosis and history.

Although it is not my practice to do so without first informing you, I can use your health information and share it with other healthcare professionals who are treating you.

Example: I may ask your psychiatrist or primary care doctor about your overall health condition.

Run my business

I can use and share your health information to run my practice, improve your care, and contact you when necessary.

Example: I use health information about you to manage your treatment outcomes and monitor trends within my practice.

Example: I use health information about you to justify services in the event of an audit. 

Bill for your services

I can use and share your health information to bill and get payment from health plans or other entities. 

Example: I give information about you, such as a diagnosis, to your health insurance plan so it will pay for your services. 

Example: I can give information about you, such as your address, to a collection agency if you acquire an outstanding balance.

How else can I use or share your health information? 

I am allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as mandatory reporting for potential child abuse. I have to meet many conditions in the law before I can share your information for these purposes. For more information please reference the Consent for Services document.

Help with public health and safety issues

I can share health information about you for certain situations such as: 

• Reporting suspected child abuse or neglect
• Preventing or reducing a serious threat to an identified person’s health or safety

Comply with the law

I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that I am complying with federal privacy law.

Respond to lawsuits and legal actions

Although it is not my practice to do so without first discussing the situation with you, I can share health information about you in response to a subpoena or if required to do so by a judge.

My Responsibilities

• I am required by law to maintain the privacy and security of your protected health information. 
• I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• I must follow the duties and privacy practices described in this notice and give you a copy of it. 
• I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me so, you may change your mind at any time. Let me know in writing if you change your mind. 

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

I can change the terms of this notice, and the 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.

This notice was last updated on 01/01/2024.

Privacy Officer Contact

If you have any questions or concerns about this notice or about your privacy while receiving services, please contact us:

Privacy Official: Tori Prophet
832.263.1592
5900 Balcones Drive # 16286, Austin, TX 78731
[email protected]