HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your Rights

You have the right to:

Get a copy of your mental health record within 30 days of your request.
Request corrections to your record if you believe information is incorrect or incomplete.
Request confidential communications in a specific way, such as by phone or email only.
Request restrictions on use and disclosure of certain health information.
Get a list of those with whom we have shared your information in the past six years.
Get a copy of this notice at any time.
File a complaint with our practice or with the U.S. Department of Health and Human Services Office for Civil Rights.

Your Choices

For certain health information, you have the right to tell us your choices regarding how we share your information, including:

Sharing information with family, close friends, or others involved in your care. We will only share this information if you give us written permission or if you are present and agree.
Sharing information in a disaster relief situation.
Marketing purposes or sale of your information. We will never use your information for marketing purposes or sell your information without your written permission.

Our Uses and Disclosures

We may use and share your information in the following ways:

Treatment. We may share your information with other healthcare providers involved in your treatment.
Payment. We may share your information to bill and receive payment from your insurance company or other payers.
Operations. We may use your information to improve our services, train staff, and manage our practice.

We are also required by law to share your information in the following circumstances:

When required by state or federal law.
When necessary to prevent a serious and imminent threat to health or safety.
When required by law enforcement or court order.
When reporting suspected abuse, neglect, or domestic violence as required by Texas law.

Psychotherapy Notes

We will never share your psychotherapy notes without your written permission, except as required by law.

Our Responsibilities

Counseling Forward PLLC is 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.

Changes to This Notice

We may change the terms of this notice at any time. The new notice will be effective for all health information we maintain. You may request a copy of the current notice at any time.

Questions or Complaints

Counseling Forward PLLC

2631 Gattis School Rd Suite 200

Round Rock, TX 78664

(737) 688-0017

deissyr@counseling-forward.com

U.S. Department of Health and Human Services

Office for Civil Rights

200 Independence Avenue SW, Washington, DC 20201

1-877-696-6775 | www.hhs.gov/ocr/privacy/hipaa/complaints