Notice of Privacy Practices
*Click here to download the Notice of Privacy Practices*
ACCORDANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
(HIPAA), THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED, AS WELL AS HOW YOU MAY GAIN ACCESS TO THIS INFORMATION. PLEASE
REVIEW CAREFULLY AND SIGN THE CONSENT.
Protecting Your Personal and
will explain how we handle your medical/mental health information.
Applicable federal and state laws require us to maintain the privacy of
clients’ personal and health information. In this Notice, your
personal or protected health information is referred to as “health information”
or “PHI” and includes information regarding your health care and treatment with
identifiable factors, such as your name, age, address, income or other
financial information. Because state and federal laws, combined with our
professional ethics, are very complicated, some parts of this notice are very
detailed and may seem difficult to understand. Please know that we are
committed to protecting the privacy of your health and personal information and
are available to answer any questions you may have.
We Protect Your Health Information
We protect your health information by treating all of your health
information that we collect as confidential (for exceptions to confidentiality
see Authorization for Evaluation and Treatment), by training all staff in
federal and state confidentiality policies and practices per HIPAA, by
restricting access to your health information only to those office staff that
need to know your health information in order to provide our services to you,
and by maintaining physical, electronic, and procedural safeguards to comply
with federal and state regulations guarding your health information.
and Disclosures for Treatment, Payment, and Health Care Operations
We may use or disclose your protected health information for treatment,
payment, and health care operations purposes if you have given consent to
receive evaluation or treatment services.
Payment, and Health Care Operations Clarification of Terms
Treatment- when our office
provides, coordinates, or manages your health care and other services related
to your health care. An example of treatment would be when our office consults
with another health care provider, such as your family physician.
Payment- when you provide
reimbursement for the services you receive in the office. An example of payment
would be when our office discloses your PHI to your health insurer to obtain
reimbursement for your health care or to determine eligibility or coverage.
Operations- activities that relate to the performance and operation of our office.
Examples of health care operations are quality assessment and improvement
activities, business related matters such as audits and administrative
services, case management and care coordination, and conducting training and
educational programs or accreditation activities.
Use- activities within
the office such as sharing, employing, applying, utilizing, examining, and
analyzing information that identifies you.
outside of the office, such as releasing, transferring, or providing access to
information about you to other parties.
and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside Treatment, Payment, or
Health Care Operations when your authorization is obtained. An “authorization”
is written permission above and beyond the general consent that permits only
specific disclosures. In those instances when the office is asked for
information for purposes outside of Treatment, Payment, or Health Care
Operations, we will obtain an authorization from you before releasing this
Specific authorization is also obtained before releasing your psychotherapy
notes. Psychotherapy notes are notes made about treatment and are given a
greater degree of protection than PHI.
You may revoke all such authorizations at any time, provided each
revocation is in writing. After that time, we will not use or disclose your
information for the purposes originally agreed upon. However, we cannot take back any information already
disclosed with your permission or that we had used in our office.
and Disclosures Not Requiring Consent or Authorization
The laws allow us to use or disclose PHI without your consent or
authorization in some cases. Here
are some examples of when this might occur:
When Required by
Law- Suspected child abuse must be reported. Also, if you are involved in a lawsuit or legal proceeding
and the provider receives a subpoena, discovery request, or other lawful
process, some of you PHI may have to be released. This will occur only after trying to tell you about the
request, consulting your lawyer, or trying to get a court order to protect the information
being requested. Finally, some information has to be disclosed to governmental
agencies that check on providers to see that privacy laws are being obeyed.
Enforcement Purposes- Information may be released if your provider is
asked to do so by a law enforcement official to investigate a crime or
For Public Health
Activities- Some of your PHI might be disclosed to agencies that investigate
diseases or injuries.
Decedents- PHI might be disclosed to coroners, medical examiners, or funeral
directors, and to organizations relating to organ, eye, or tissue donations or
Government Functions- PHI of military personnel and veterans may be
disclosed to government benefit programs relating to eligibility and
enrollment. PHI may also be
disclosed to Workers Compensation and Disability Programs, to correctional
facilities if you are an inmate, and for national security reasons.
To Prevent a
Serious Threat to Health or Safety- If we believe that there is a serious
threat to your health or safety or that of another person or the public, the
provider can disclose some of your PHI.
This disclosure will only be provided to persons who can prevent the
Rights and Provider’s Duties
Rights to Request
Restrictions- You have the right to request that we limit what is told to people
involved in your care or the payment of your care, such as family members and
friends. We may not be able
to accept your request; however, if accepted we will uphold it except in case
of emergency or if it is against the law.
Right to Receive
Confidential Communications by Alternative Means/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 being seen at the office. On your request,
communications will be sent to an alternate address.)
Right to Inspect
and Copy- You have the right to inspect and/or obtain a copy of your records. A
reasonable fee may be charged for copying. Access to your records may be
limited or denied under certain circumstances, but in most cases you have a
right to request a review of that decision. On your request, we will discuss
with you the details of the request and denial process.
Right to Amend- You have the
right to request in writing an amendment of your health information for as long
as PHI records are maintained. The request must identify which information is
incorrect and include an explanation of why you think it should be amended. If
the request is denied, a written explanation stating why will be provided to
you. You may also make a statement disagreeing with the denial, which will be
added to the information of the original request. If your original request is
approved, we will make a reasonable effort to include the amended information
in future disclosures. Amending a record does not mean that any portion of your
health information will be deleted.
Right to an
Accounting- You generally have the right to receive an accounting of disclosures of
PHI. If your health information is disclosed for any reason other than
treatment, payment, or operation, you have the right to an accounting for each
disclosure of the previous six (6) years. The accounting will include the date,
name of person or entity, description of the information disclosed, the reason
for disclosure, and other applicable information. If more than one (1)
accounting is requested in a twelve (12) month period, a reasonable fee may be
Paper- If you received this notice electronically (e.g., accessing a website)
you have the right to obtain a paper copy of the notice from the office upon
providers and administrators:
Provider is required by law to maintain the privacy of PHI and to
provide you with this notice of legal duties and privacy practices.
The providers and administrators reserve the right to change the privacy
policies and practices and terms of this Notice at any time, as permitted by
applicable law. We reserve the right to make the changes in our privacy
practices and the new terms of our Notice effective for all health information
that we maintain, including health information we created or received before we
made the changes. Unless we notify you of such changes, however, the office is
required to abide by the terms currently in effect.
For questions regarding this Notice of our Privacy Practices, or if you
are concerned that your privacy rights may have been violated, please contact Michelle
M. Forrester, Ph.D. You may also make a written complaint to the US Department
of Health and Human Services, whose address can be provided upon request. If
you choose to make a complaint with the US Department of Health and Human
Services, or with us, we will not retaliate in any way.
Michelle M. Forrester, Ph.D., PC
Licensed Psychologist # 2-5359
9601 Katy Freeway, Suite 175
Houston, TX 77024
Phone (713) 598-3559
9601 Katy Freeway, Suite 175 • Houston, TX 77024