Effective November 1, 2011

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.  YOU WILL SIGN THIS DOCUMENT AT YOUR FIRST VISIT.

When you receive treatment or benefits from San Antonio Compassionate Counseling and Behavioral Center, PLLC, create and maintain information about your health, treatment, and payment for services. We will not use or disclose your information without your written authorization (permission) except as described in this notice.

How We May Use and Disclose Your Health Information

We may use and disclose your health information without your authorization for treatment, payment, and health care operation purposes. Examples include but are not limited to:

• Using or sharing your health information with other health care providers involved in your treatment or with a pharmacy that is filling your prescription.
  
• Using or sharing your health information with your health plan to obtain payment for services or using your health information to determine your eligibility for government benefits in a health plan.
  
• Using or sharing your health information to run our business, to evaluate provider performance, to educate health professionals, or for general administrative activities.
  

We may share your health information with our business associates who need the information to perform services on our behalf and agree to protect the privacy and security of your health information according to agency standards.

We may use or share your health information without your authorization as authorized by law for our patient directory, to family or friends involved in your care, or to a disaster relief agency for purposes of notifying your family or friends of your location and status in an emergency situation.

We may use and disclose your health information without your authorization to contact you for the following activities, as permitted by law and agency policy: providing appointment reminders; describing or recommending treatment alternatives; providing information about health-related benefits and services that may be of interest to you; or fundraising.

We may also use and disclose your health information without your authorization for the following purposes:

• For public health activities such as reporting diseases, injuries, births or deaths to a public health authority authorized to receive this information, or to report medical device issues to the FDA;
  
• To comply with workers compensation laws and similar programs;
  
• To alert appropriate authorities about victims of abuse, neglect, or domestic violence; if the agency reasonably believes you are a victim of abuse, neglect, or domestic violence we will make every effort to obtain your permission, however, in some cases we may be required or authorized to alert the authorities;
  
• For health audits, investigations, and inspections of San Antonio Compassionate Counseling and Behavioral Center, PLLC.
  
• For research approved by an Institutional Review Board or privacy board; for preparing for research such as writing a research proposal; or for research on decedents information;
  
• To create or share de-identified or partially de-identified health information (limited data sets);
  
• For judicial and administrative proceedings such as responding to a subpoena or other lawful order;
  
• For law enforcement purposes such as identifying or locating a suspect or missing person;
  
• To coroners, medical examiners, or funeral directors as needed for their jobs;
  
• To organizations that handle organ, eye or tissue donation, procurement, or transplantation;
  
• To avert a serious threat to health or public safety;
  
• For specialized government functions such as military and veteran activities, national security and intelligence activities, and for other law enforcement custodial situations;
  
• For incidental disclosures such as when information is overheard in a waiting room despite reasonable steps to keep information confidential; and
  
• As otherwise required or permitted by local, state, or federal law.
  

We will always obtain your authorization to use or share your information for marketing purposes, to use or share a summary of your psychotherapy notes, if there is payment from a third party, or for any other disclosure not described in this notice or required by law. You have the right to cancel your authorization, except to the extent that we have taken action based on your authorization. You may cancel your authorization by writing to the privacy officer per below.

Your Privacy Rights

Although your health record is the property of San Antonio Compassionate Counseling and Behavioral Center, PLLC, you have the right to:

• Inspect and copy your health information, including lab reports, upon written request and subject to some exceptions. We may charge you a reasonable, cost-based fee for providing records as permitted by law.
  
• Receive confidential communications of your health information, such as requesting that we contact you at a certain address or phone number. You may be required to make the request in writing with a statement or explanation for the request.
  
• Request amendment of your health information in our records. All requests to amend health information must be made in writing and include a reason for the request.
  
• Request an accounting (a list) of certain disclosures of your health information that we make without your authorization. You have the right to receive one accounting free of charge in any twelve-month period.
  
• Request that we restrict how we use and disclose your health information for treatment, payment, and health care operations, or to your family and friends. We are not required to agree to your request, except when you request that we not disclose information to your health plan about services for which you paid with your own money in full.
  
• Obtain a paper copy of this notice upon request.
  

Our Duties

We are required to provide you with notice of our legal duties and our privacy practices with respect to your health information. 

We must maintain the privacy of information that identifies you and notify you in the event your health information is used or disclosed in a manner that compromises the privacy of your health information.

We are required to abide by the terms of this notice. We reserve the right to change the terms of this notice and to make the revised notice effective for all health information that we maintain. We will post revised notices on our public website at www.dshs.texas.gov and in waiting room areas. You may request a copy of the revised notice at the time of your next visit.

Complaints

If you believe your HIPAA privacy rights have been violated please submit your complaint in writing. To report an offense allegedly occurring in Texas, file the complaint with the Region VI office located in Dallas.

Region IV Office for Civil Rights

1301 Young Street, Suite 1169

Dallas, Texas 75202

San Antonio Compassionate Counseling and Behavioral Center, PLLC will not retaliate against you for filing a complaint.

Written Acknowledgement of receipt and understanding of HIPAA Rights

NOTICE:  YOU WILL SIGN THIS DOCUMENT DURING YOUR FIRST VISIT WITH YOUR COUNSELOR.  YOUR SIGNATURE ON THIS DOCUMENT INDICATES YOU HAVE READ IT AND ALSO SERVES AS AN ACKNOWLEDGEMENT YOU HAVE RECEIVED THE HIPAA NOTICE DESCRIBED ABOVE.