Pierce Counseling | 1300 Bay Area Blvd. Suite B200 Houston, TX 77058 | 832.794.

3209

HIPAA Notice of Privacy Practices Effective January 1, 2013 THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMAITON. PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by me, whether electronically, on paper, or orally, are kept properly confidential. HIPAA gives you, the client, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. I am required by law to give you a notice of privacy practices and maintain the privacy of your confidential information. This notice is intended to let you know of my legal duties, your rights, and my privacy practices with respect to such information. I am required to abide by the terms of the notice currently in effect. I reserve the right to change the terms of this notice and/or my privacy practices and to make the changes effective for all protected health information that I maintain, even if it was created or received prior to the effective date of the notice revision. If I make a revision to this notice, I will make the notice available at my office upon request on or after the effective date of the revision and I will post the revised notice in a clear and prominent location. My Privacy Commitment to You I am a Marriage and Family Therapist, licensed by the State of Texas through the State Board of Examiners of Marriage and Family Therapists, and therefore create and maintain treatment records that contain individually identifiable and protected health information about you (PHI). This notice applies to the information and records I have about your psychotherapy, mental health status, and care you receive at my office. Your records are kept secured so that they are not readily available to those who do not need them. If you need or desire further information related to this Notice or its contents, or if you have any questions about this Notice or its contents, please feel free to contact me. I will do my best to answer your questions and to provide you with additional information. Use and Disclosure of PHI for the Purpose of Providing Services Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow me to use and disclose your health information for these purposes. I may use and disclose your health records only for each of the following purposes: For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services, including communication with referral sources and for consultations. For Payment. I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection. For Health Care Operations. I may use or disclose, as needed, your PHI in order to support necessary business activities including, but not limited to, review of treatment procedures, quality assessment activities, licensing, and conducting or arranging for other business activities. For training or teaching purposes PHI will be disclosed only with your authorization. I may also contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Pierce Counseling | 1300 Bay Area Blvd. Suite B200 Houston, TX 77058 | 832.794.3209

For Supervision or Consultation. I periodically discuss cases with colleagues for the purpose of consultation. This is an established practice in the field of psychotherapy and is beneficial to your treatment. I make every effort to keep identifying information private and my colleagues are bound to the same standards of confidentiality as I am. To Avert a Serious Threat to Health or Safety. I may use and disclose confidential information about you when necessary to prevent a serious threat to your health and safety or the health and safety of another person. I also may disclose information relative to the disclosure of past or present knowledge of child abuse or abuse of the elderly. With Verbal Permission. I may use or disclose your information to family members that you have directly involved in your treatment with me with your verbal permission. I will not disclose information to any family member that is not participating in treatment at your request without your written consent. For Lawsuits and Disputes. If you are involved in a lawsuit or dispute, I may disclose information about you in response to a court or administrative order. Subject to all legal requirements, I may also disclose information about you in response to a subpoena from a judge. As Required by Law. I will disclose health information about you when required by federal, state, or local law or when I am ethically bound to do so. You may revoke your written authorization at any time, provided that the revocation is in writing and except to the extent that I have taken action in reliance on your written authorization. Your right to revoke an authorization is also limited if the authorization was obtained as a condition of obtaining insurance coverage for you. Your Privacy Rights You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to me, (the Privacy Officer) at 1300 Bay Area Blvd. Ste B200, Houston, Tx 77058: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. I am, however, not required to agree to a requested restriction. If I do agree to a restriction, I must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. (as long as this is deemed by your therapist to be in your (or, in the case of treatment of a minor, the minor clients) best interest and will do no harm. An appropriate charge for copies or mailing may be assessed. The right to receive an accounting of disclosures of protected health information. This is applicable for a six year period from the effective date of this notice. Exemptions include: disclosure for treatment, payment or healthcare operations, disclosures pursuant to a signed release, disclosure made to you (the client), and disclosures for national security or law enforcement. The right to obtain a paper copy of this notice from me upon request. The right to amend information in my records by making a request to do so in a writing that provides a reason to support the requested amendment. This right to amend is not absolute, I am permitted to deny the requested amendment for specified reasons. You may file a disagreement statement if denied, which will be filled, along with the denial, with your record. For more information about HIPAA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 1301 Young Street, Suite 1169 Dallas, TX 75202 Toll Free: (800) 368-1019

You have recourse if you feel that your privacy protections have been violated. Please contact my office, you can also file a complaint with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of my office. I will not retaliate against you for filing a complaint. Complaints must be filed in writing and include the manner in which you believe the violation occurred, the approximate date of the violation, and any details you believe to be pertinent to the incident.