| Your privacy is protected by the Health Insurance Portability and Accountability Act
NOTICE OF PRIVACY PRACTICES FOR PERSONAL THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Summary This Notice describes how your personal health information (PHI) is protected, and how RestoreFx may use and disclose this information. PHI includes personally identifiable information that relates to your past, present, or future health, treatment, or payment for health care services. RestoreFx’s employees and professional staff are required to comply with this privacy policy, and have access to this information only when there is an appropriate reason to do so, such as to confer with other health care providers or to submit claims for these services. Under the Health Insurance Portability and Accountability Act (HIPAA), you are afforded privacy rights regarding the use and disclosure of your health information. These include: a right to be informed of the potential uses and disclosures of your protected health information, and to limit those uses and disclosures of this protected health information; a right to receive this written notice that explains how we may use and disclose your protected health information, your rights under HIPAA’s privacy rule, and RestoreFx’s responsibilities as a covered entity under HIPAA; a right to a paper copy of this notice, or to have your legally designated representative receive a copy of this notice; you are asked to acknowledge receipt of this notice; a right to amend your record, to restrict what information from your record is disclosed to others, and to receive an accounting of disclosures of this information that were made without your authorization, other than for treatment, payment or health care operations; a right to have your complaints about my policies and procedures recorded in these records. As a health care provider, RestoreFx is making a good faith effort to see that you or your representative have received and acknowledged this notice of privacy practices. If you are seen for emergency treatment, you will receive this notice as soon as practically possible afterward. I. Disclosures for Treatment, Payment, and Health Care Operations RestoreFx may use or disclose your protected health information (PHI), for certain treatment, payment, and health care operations purposes without your authorization. To help clarify these terms, here are some definitions: PHI refers to information in your health record that could identify you. Treatment is when RestoreFx or another healthcare provider diagnoses or treats you. An example of treatment would be when RestoreFx consults with another health care provider, such as your family physician or another psychologist, regarding your treatment. Payment is when RestoreFx obtains reimbursement for your healthcare. Examples of payment are when RestoreFx discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. Health Care Operations is when RestoreFx discloses your PHI to your health care service plan (for example your health insurer), or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination. Use applies only to activities within RestoreFx’s office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. Disclosure applies to activities outside of RestoreFx’s office, such as releasing, transferring, or providing access to information about you to other parties. Authorization means written permission for specific uses or disclosures. All authorizations to disclose must be on a specific, legally required form. II. Uses and Disclosures Requiring Authorization RestoreFx may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances when RestoreFx is asked for information for purposes outside of treatment and payment operations, RestoreFx will obtain an authorization from you before releasing this information. You may revoke or modify all such authorizations of PHI at any time, provided each revocation is in writing; however, the revocation or modification is not effective until RestoreFx receives it. You may not revoke an authorization to the extent that (1) RestoreFx has relied on that information; 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 Child Abuse: Whenever RestoreFx, in her professional capacity, has knowledge of or observes a child RestoreFx knows or reasonably suspects, has been the victim of child abuse or neglect, RestoreFx must immediately report such to a police department or sheriff’s department, county probation department, or county or state welfare department. Adult and Domestic Abuse: If RestoreFx, in their professional capacity, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if RestoreFx is told by an elder or dependent adult that he or she has experienced these, or if RestoreFx reasonably suspects such, they must report the known or suspected abuse immediately to the local ombudsman or the local law enforcement agency. Health Oversight: If a complaint is filed against RestoreFx with the State Board that licenses a profession, the Board has the authority to subpoena confidential mental health information from RestoreFx relevant to that complaint. Serious Threat to Health or Safety: If you communicate to RestoreFx a serious threat of physical violence against an identifiable victim, RestoreFx must make reasonable efforts to prevent harm, which may include communicating that information to the potential victim, and the police. If RestoreFx has reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, RestoreFx may release relevant information as necessary to prevent the threatened danger. Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that RestoreFx has provided you, RestoreFx must not release your information without: 1) your written authorization or the authorization of your attorney or personal representative; or The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. RestoreFx will inform you in advance if this is the case. IV. Patient’s Rights and Provider’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, RestoreFx is 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. (For example, you may not want a family member to know that you are seeing RestoreFx and may request that she not telephone your residence). Right to Inspect and Copy You have the right to inspect or obtain a copy (or both) of PHI in RestoreFx’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. RestoreFx may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, RestoreFx 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. RestoreFx may deny your request. On your request, RestoreFx 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, RestoreFx 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 RestoreFx upon request, even if you have agreed to receive the notice electronically. Duties of Provider: RestoreFx is required by law to maintain the privacy of PHI and to provide you with a notice of their legal duties and privacy practices with respect to PHI. RestoreFx reserves the right to change the privacy policies and practices described in this notice. Unless RestoreFx notifies you of such changes, however, they are required to abide by the terms currently in effect. If RestoreFx revises their policies and procedures, RestoreFx will provide you with a written copy of the revised policies and procedures at the earliest possible opportunity following this revision, in person or by mail. V. Complaints For complaints against psychology staff contact Dr. Jordan (512) 293-3807, or: Krista Jordan, Ph.D. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. RestoreFx will provide the appropriate address upon request. For complaints against medical staff, such as physicians, as well as other licensees and registrants of the Texas Medical Board, please contact: Texas Medical Board Complaints regarding non-compliance with the Physical Therapy Practice Act, or regarding any licensee under the Act, should be directed to: Texas Board of Physical Therapy Examiners For complaints against our behavior health staff, please contact: Texas State Board of Social Work Examiners Texas State Board of Examiners of Psychologists Texas State Board of Examiners of Professional Counselors VI. Effective Date, Restrictions, and Changes to Privacy Policy This notice went into effect January 1, 2009. RestoreFx reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that RestoreFx maintains. RestoreFx will provide you with a revised notice by mail, at the earliest opportunity following the revision. |