THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR INFORMATION IS IMPORTANT TO US.

 

OUR LEGAL DUTY

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We are required by law to:

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Maintain the privacy and security of your protected health information.

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Notify you promptly if a breach occurs that may have compromised the privacy or security of your information.

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Abide by the terms of this notice and provide you with an updated copy if there are significant changes.

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This notice is effective as of December 18, 2024. We reserve the right to change the terms of this notice, and any changes will apply to all the information we have about you. The new notice will be available upon request, in our office, and on our website.

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USES & DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

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1. We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes. To help clarify these terms, here are some definitions:

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- "PHI" refers to information in your health record that could identify you.

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- "Treatment, Payment and Health Care Operations"

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Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or other practitioner.

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Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

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Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters, such as audits and administrative services, and case management and care coordination.

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- "Use" applies only to activities within Restoring Connections Counseling, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

 

- "Disclosure" applies to activities outside of Restoring Connections Counseling, such as releasing, transferring, or providing access to information about you to other parties.

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2. We may disclose to a family member, other relative, a close personal friend of yours, or any other person identified by you, the health information directly relevant to such person's involvement with your care or payment related to your health care.

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3. Contacting You. We may use and disclose health information to reach you about appointments and other matters. We may contact you by mail, telephone or email. We may leave voice messages at the telephone number you provide us with, and we may respond to your email address.

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USES AND DISCLOSURES REQUIRING AUTHORIZATION

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We may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission that is above and beyond the general consent that permits only specific disclosures. In those instances, when we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your counseling notes or any information related to reproductive health care. "Counseling notes"are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. Information about reproductive health care includes all information relating to the health of a person in all matters relating to the reproductive system and to its functions and processes. These counseling notes and reproductive health care information are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI, counseling notes, or reproductive health information) at any time, provided each revocation is in

writing. You may not revoke an authorization to the extent that (1) we 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.

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USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION

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We may use or disclose PHI without your consent or authorization in the following circumstances:

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- Child Abuse: If we have cause to believe that a child has been, or may be, abused, neglected, or sexually abused, we 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.

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- Adult and Domestic Abuse: If we have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, we must immediately report such to the Texas Department of Protective and Regulatory Services.

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- Health Oversight: If a complaint is filed against us with the State Board of Examiners, the board has the authority to subpoena confidential mental health information from us relevant to that complaint.

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- 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 under state law, and we 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.

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- Serious Threat to Health or Safety: If we 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, we may disclose relevant confidential mental health information to medical or law enforcement personnel.

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- Worker's Compensation: If you file a worker's compensation claim, we may disclose records relating to your diagnosis and treatment to your employer's insurance carrier.

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- Health-Related Services. We may use and disclose health information about you to send you mailings about health-related products and services available Restoring Connections Counseling.

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PATIENT RIGHTS

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- Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI. We are not required to agree to all requests, except in the case where you pay for services out-of-pocket in full and request that the information not be disclosed to your health plan. We are required to agree to your request to restrict disclosure of your health information to a health plan if the disclosure is for

payment or health care operations and the information pertains solely to a health care item or service for which you have paid out-of-pocket in full. You may revoke the authorization, in writing, at any time, but we cannot take back any uses or disclosures of your health information already made with your authorization.

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- Right to Receive Confidential Communications in a Particular Manner: You have the right to request that we communicate with you about your health information in a particular manner (e.g., at work or by mail). We will accommodate reasonable requests.

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- Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in our mental health and billing records used to make decisions about you

for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.

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- Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a paper copy of this Notice at any of our

facilities or by calling 940-312-1461.

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- Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

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- 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 previously). On your request, we will discuss with you the details of the accounting process.

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-Right to Notification of a Breach: You have the right to be notified in the event of a breach of your unsecured protected health information. If a breach of your unsecured protected health information occurs, we will notify you promptly in accordance with federal and state laws.

 

QUESTIONS OR COMPLAINTS

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For more information about our privacy policy or have questions or concerns, please contact us.

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If you believe your privacy rights have been violated, you can file a complaint with us or with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

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To file a complaint with us, contact:

Megan Blanton

Contact Officer

2681 MacArthur Blvd, Ste 302

Lewisville, Texas 75067

940-312-1461

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To file a complaint with the U.S. Department of Health and Human Services, send your complaint to:

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Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Washington, D.C. 20201

1-877-696-6775

or use the web form at https://ocrportal.hhs.gov

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