TEXAS NOTICE FORM
Notice of Psychologists’ and Counselors’ Policies and Practices to Protect Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL, COUNSELING, AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
The Austin Center for Therapy and Assessment (ACTA) may use or disclose your protected health information (PHI), for treatment, payment, and healthcare operations purposes with your consent. To help clarify these terms, here are some definitions:
“PHI” refers to information in yours or your child's health record that could identify you or your child.
“Treatment, Payment, and Healthcare Operations”
Treatment is when ACTA provide, coordinate or manage your healthcare and other services related to your healthcare. An example of treatment would be when ACTA consults with another healthcare provider, such as your family physician, healthcare specialist, or another psychologist.
Payment is when ACTA obtains reimbursement for your healthcare. Examples of payment are when ACTA professionals disclose your PHI to your health insurer to obtain reimbursement for your healthcare or to determine eligibility or coverage.
Health Care Operations are activities that relate to the performance and operation of the ACTA practice. Examples of healthcare operations are quality assessment and improved activities, business-related matters such as audits and administrative services, and case management and care coordination.
"Use" applies only to activities within ACTA (office, clinic, practice group, etc) such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
"Disclosure" applies to activities outside our office (clinic, practice group, etc.), such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
ACTA may use or disclose PHI for purposes outside of treatment, payment, and healthcare operations when your appropriate authorization is obtained. An “authorization”is written permission above and beyond the general consent that permits only specific disclosures. In those instances when ACTA professionals are asked for information for purposes outside of treatment, payment and healthcare operations, ACTA professionals will obtain an authorization before releasing your psychology/counseling notes. “Psychology/Counseling notes” are notes ACTA licensed professionals have made about our conversation during a private, group, joint, or family counseling session, which ACTA professionals have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or psychology/counseling notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) ACTA professionals 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 policy.
III. Uses and Disclosures with Neither Consent nor Authorization
ACTA may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: If ACTA licensed mental health professionals have cause to believe that a child has been, or may be abused, neglected, or sexually abused, said professional must make a report of such 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 ACTA licensed mental health professionals have cause to believe that an elderly or any person is in a state of abuse, neglect, or exploitation, said professional must immediately report such to the Department of Protective and Regulatory Services.
Health Oversight: If a complaint is filed against the mental health professionals with the State Board of Examiners of Psychologists and/or Texas State Board of Examiners of Professional Counselors, they have the authority to subpoena confidential mental health information from ACTA relevant to that complaint.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged understate law, and ACTA will not release information, without written authorization from you or your personal or legally appointed 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.
Serious Threat to Health or Safety: If ACTA licensed mental health professionals 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, said professional may disclose relevant confidential mental health information to medical or law enforcement personnel.
Worker’s Compensation: If you file a worker’s compensation claim, ACTA professionals may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.
Comply with the Law: If state or federal law requires it, including the Department of Health and Human Services to see that we are complying with federal privacy law, ACTA professions may disclose records.
Hospital Directory: ACTA does not create or manage a hospital directory.
IV. Patient’s Rights and Psychologist/Counselor’s Duties
Right to Request Restrictions- You have the right to request restrictions on certain uses and disclosures of protected health information about you; You can ask us not to use or share certain health information for treatment, payment, or our operations. However, ACTA professionals are not required to agree to a restriction request, and we may deny your request it if may affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree to this restriction unless a law requires us to share that information.
Right to Receive Confidential Communications by Alternative Means at Alternative Locations- 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 an ACTA professional. Upon your request, ACTA will send your bills to another address.)
Right to Inspect and Copy- You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. You can ask for an electronic or paper copy and we will typically provide you with a copy or summary within 30 days of your request. ACTA may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, ACTA professionals will discuss with you the details of the request and denial process.
Right to Amend- You have the right to request an amendment or correction of PHI for as long as the PHI is maintained in the record if you believe that the information is incorrect or incomplete. ACTA professionals may deny your request. On your request, an ACTA professional will discuss with you the details of the amendment process. If we deny your request, you will receive a written explanation within 60 days as to why we have made the denial.
Right to an Accounting- You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, an ACTA professional will discuss with you the details of the accounting process. You can ask for a list of the times we have shared your PHI for the six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). Upon request, we will provide one accounting per year for free, but we will charge a reasonable, cost- based fee if you ask for another one within 12 months.
Right to a Paper Copy- You have the right to obtain a paper copy of this notice from ACTA upon request, even if you have agreed to receive the notice electronically.
Right to Choose Someone to Act for You- If you have given someone power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure that the person has this authority and can act for you before we take any action.
Right to File a complaint if You Feel Your Rights are Violated: You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can also 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/. We will not retaliate against you for filing a complaint.
ACTA psychologists and counselors are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
ACTA psychologists and counselors will never use or share your information for the following cases unless you give us written permission: external marketing purposes, sale of your information, and most sharing of psychotherapy notes.
ACTA psychologists and counselors will share information with your family, close friends, or others involved in your care with your written consent.
ACTA professionals are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
ACTA professionals reserve the right to change the privacy policies and practices described in this notice. Unless an ACTA professional notifies you of such changes; however, said ACTA professional is required to abide by the terms currently in effect.
If ACTA revises its policies and procedures, ACTA will provide you with a written copy of that revision either in person during a scheduled appointment at our office or through the mail at the address you specify for receipt of mail if you are still an active patient of ACTA.
The effective date of this policy is 11/27/2013.
Privacy Officers: Aron Bautista & Olivia Weekley