I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health

care operations purposes with your consent. To help clarify these terms, here are some definitions:

• “PHI´ refers to information in your health record that could identify you.

• “Treatment, Payment and Health Care Operations”

– Treatment is when I provide, coordinate, or manage your health care and other services related

to your healthcare. Payment is when I obtain reimbursement for your healthcare. Health Care

Operations are activities that relate to the performance and operation of my practice.

• “Use” applies only to activities within my [office, clinic, practice group, etc.] such as sharing,

employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of my [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

I 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 above and

beyond the general consent that permits only specific disclosures. In those instances when I am asked

for information for purposes outside of treatment, payment, and health care operations, I will obtain

an authorization from you before releasing this information.

You may revoke all such authorizations at any time, provided each revocation is in writing. You

may not revoke an authorization to the extent that (1) I 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.

III. Uses and Disclosures with Neither Consent nor Authorization

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

§ Child Abuse: If I have cause to believe that a child has been, or may be, abused, neglected, or

sexually abused, I 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 I have cause to believe that an elderly or disabled person is in a

state of abuse, neglect, or exploitation, I must immediately report such to the Department of

Protective and Regulatory Services.

§ Health Oversight: If a complaint is filed against me with the State Board of Examiners of

Psychologists, they have the authority to subpoena confidential mental health information from

me 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 under state law, and I will not release information, without written

authorization form 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 I 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, I may disclose relevant confidential mental health information to medical

or law enforcement personnel.

§ Worker’s Compensation: If you file a worker’s compensation claim, I may disclose records

relating to your diagnosis and treatment to you employer’s insurance carrier.

IV. Patient’s Rights and Psychologist’s Duties

Patient’s Rights

• Right to Request Restrictions – You have the right to request restrictions on certain uses and

disclosures of protected health information about you. However, I am not required to agree to a

restriction you request.

• Right to Receive Confidential Communications by Alternative Means and at Alternative

Locations – You have the right to request and receive confidential communications of PHI by

alternative means and at alternative locations.

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and

psychotherapy notes in my mental health and billing records used to make decisions about you

for as long as the PHI is maintained in the record. I may deny your access to PHI under certain

circumstances, but in some cases you may have this decision reviewed. On your request, I will

discuss with you the details of the request and denial process.

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is

maintained in the record. I may deny your request. On your request, I will discuss with you the

details of the amendment process.

• 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, I will discuss with you the details of the accounting process.

• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon

request.

Psychologist’s Duties

• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal

duties and privacy practices with respect to PHI.

• I reserve the right to change the privacy policies and practices described in this notice. Unless I

notify you of such changes, however, I am required to abide by the terms currently in effect.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to your records, or

have other concerns about your privacy rights, you may contact me by mail or phone.

If you believe that your privacy rights have been violated and wish to file a complaint with my

office, you may send your written complaint to my current address. You may also send a written

complaint to the Secretary of the U.S. Department of Health and Human Services. You have specific

rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on 4/13/03. I will limit the uses or disclosures that I make in compliance

with state law. I reserve the right to change the terms of this notice and to make the new notice provisions

effective for all PHI that I maintain.