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Notice of Privacy Practices

*Click here here to download the Notice of Privacy Practices*


Protecting Your Personal and Health Information

This notice 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.  

How 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.  

Uses 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.  

Treatment, 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.

Health Care 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.

Disclosure- activities outside of the office, such as releasing, transferring, or providing access to information about you to other parties.  

Uses 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 information. 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.  

Uses 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.  

For Law Enforcement Purposes- Information may be released if your provider is asked to do so by a law enforcement official to investigate a crime or criminal. 

For Public Health Activities - Some of your PHI might be disclosed to agencies that investigate diseases or injuries.  

Relating to Decedents- PHI might be disclosed to coroners, medical examiners, or funeral directors, and to organizations relating to organ, eye, or tissue donations or transplants.  

For Specific 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 danger.  

Patient Rights and Provider’s Duties 

Patient Rights: 

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 charged.  

Electronic vs. 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 request.  

Duties of 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.  

Questions and Complaints

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

Phone: 713-598-3559

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