Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Therapist

Client Information

/ Middle Initial

( optional )
 

( MM-DD-YYYY )







( for Text Message Reminders )

Bill To Contact

/ Middle Initial







Emergency Contact

First Name
Last Name
Phone
Mobile
Relation
Email

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

INFORMATION ABOUT SERVICES

Information about your Counselor/Life Coach

You have been made aware of your therapist/counselor/coach's qualifications and have chosen to engage in counseling/coaching with him or her. You are aware that your counselor and or Life Coach holds either an LPC license with the Texas State Board of Examiners of Professional Counselors or a certification to practice as a Life Coach. Credentials are posted in each practitioners' office and are always available upon request.

**The terms therapist and counselor will be used interchangeably throughout this document.**

Nature of Counseling

Please understand you must be honest and willing to share personal information about yourself if counseling is to be effective.  You understand that counseling may at times be difficult and unpleasant, depending on the nature of the issues that are being addressed. You also understand that for counseling to be effective, you must be an active participant that completes assignments when given by your counselor.

Please understand that your relationship with your counselor is strictly professional and that your counselor will not acknowledge you in public unless the contact is initiated by you (and your counselor will not engage in an extended conversation with you in a public place nor acknowledge in what respect they know you, again unless you initiate this). Please understand your counselor will not attend any social events with you or engage in any activities outside of counseling at the counseling office that may be disrupted to the therapeutic relationship.

Social Media

See COMMUNICATION/SOCIAL MEDIA POLICY

Assessment & Evaluation

Please understand your first session will be a diagnostic evaluation, in which your counselor will gather personal information for the purpose of determining issues that need to be addressed and recommendations for how to address such issues. Please understand your evaluation may result in a diagnosis if required by your insurance company or another third party payer. Please understand your counselor may, at times, utilize testing instruments (i.e. Beck Depression Inventory, SASSI, etc.) to best determine your counseling needs.

Course of Counseling & Treatment Planning

Please understand the number, frequency, and duration of your counseling sessions will be determined based on your specific needs. Please understand that you will collaborate with your counselor to develop a treatment plan and agree to work toward your treatment goals.

Family Involvement

Please understand you may request family involvement in your counseling and agree to discuss this with your counselor before scheduling any such session(s).

Confidentiality & Records

You have been made aware of the confidentiality/privacy policies of Authentic Balance Counseling and all associates.  Please understand your counselor may not disclose information about your counseling without your express written consent, except in those situations identified in the Confidentiality/Privacy Notice.

In very rare instances, I may also keep Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. While insurance companies can request and receive a copy of your Clinical Agreement REV 2017 0524 3 Record, they cannot receive a copy of your Psychotherapy Notes without your written, signed   Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. Please be advised that generally I do not keep psychotherapy notes. Please note that while I do take notes during session, these notes are shredded and do not become part of your treatment records.

Possible exceptions to confidentiality include but are not limited to the following situations: abuse or neglect of minors, elders, or disabled persons; abuse of patients in mental health facilities (681.33 TAC, Ch.681); criminal prosecutions (611.004 Texas Health & Safety Code, Ch. 611); child custody cases ( 611.006 Texas Health & Safety Code, Ch. 611); situations where the therapist has a duty to disclose, or where, in the therapist's judgment, it is necessary to warn or disclose ( 611.004 Texas Health & Safety Code, Ch. 611); fee disputes between the therapist and the client (611.006 Texas Health & Safety Code, Ch. 611); or the filing of a complaint with the licensing board (611.006 Texas Health & Safety Code, Ch. 611).

If you have any questions regarding confidentiality, you should bring them to the attention of the therapist/coach at any point during your treatment. Please understand your counselor will maintain a record of your counseling, which will be kept for seven (6) years after termination of counseling if you are an adult. Your record will be kept for seven (6) years past your 18th birthday if you are a minor.

Confidentiality for Marital or Couple Therapy

When I conduct marital or couple therapy it is critical that all parties understand and agree that neither party shall for any reason attempt to subpoena my testimony or my records to be presented in a deposition or court hearing of any kind for any reason, such as a divorce case.

Both parties acknowledge that the goal of psychotherapy, either individual or marital or couples therapy, is for the sole purpose of the amelioration of psychological distress and that the process of psychotherapy depends on trust and openness during the therapy sessions.

Therefore, it is understood by both parties that if they request my services as a psychotherapist, they are expected not to use information given to me during the therapy process against the other party in a judicial setting of any kind, be it civil, criminal, or circuit.

Your signature below reflects that you agree to the terms set forth above as it pertains to Marital or Couple Therapy.

Contacting Me

See COMMUNICATION/SOCIAL MEDIA POLICY

Termination of Services

Please understand you may choose to terminate counseling services at any time and be aware that your counselor may recommend termination of counseling services and provide referrals if they feel they are practicing outside of their scope.

Payment for Services/Insurance

Payment is expected at the time services are rendered, and you will be provided a receipt for services.  We accept most major credit cards, and cash, we do not accept checks, Authentic Balance Counseling and its associates are in many cases considered an out-of-network provider.  Please note many insurance companies do reimburse for out-of-network mental health services, but you will have to verify what your particular plan covers.

Payment for Services/Insurance cont.

If you have a Health Savings Account (HSA), Flexible Spending Arrangement (FSA), Medical Savings Account (MSA), or Health Reimbursement Arrangement (HRA), you may be able to pay for therapy, consultation, and psychological assessment services from such accounts. Utilizing one of these options can in many cases make your services tax-deductible, again you will need to verify this information.  Your receipt for services may be submitted for many HSA, FSA, MSA, HRA plans for reimbursement through your out-of-network benefits. Please be sure to call your health insurance carrier to verify your benefits for Out-of-Network and Outpatient Mental Health coverage. Within contract guidelines, the undersigned therapist will look to you for full payment of your account, and you will be responsible for payments of all charges including NSF Bank charges.

You acknowledge and agree to pay Authentic Balance Counseling for services provided by our licensed professional counselors.

Initial Diagnostic Evaluation:  $125.00

ETT Diagnostic Evaluation: $125.00

Individual Session:  $125.00

Couples Session: $150.00

Family Session: $175.00

New Client Phone Consultation (lasting more than 10 minutes & less than 30 minutes): $75.00

In the event disclosure of your records or testimony is required by law, payment will be expected from you, regardless of whose attorney subpoenas your involvement. Client records will not be released without written consent, unless court-ordered to do so. Please note: a subpoena does not constitute a court order.

For legal proceedings:  Please note even though you are responsible for the testimony fee, it does not mean that my testimony will be solely in your favor. I can only testify to the facts of the case and to my professional opinion. Your signature below also waives your counselor's involvement in any legal matters if she/he deems it more appropriate to not participate.

The following fees also apply:

Preparation time (including submission of records): $150/hr (charged in 5 minute increments)

Client/Attorney Phone calls: $150/hr (charged in 10 minute increments)

Depositions: $450/hour

Mileage: $0.75/mile

Filing a document with the court: $100

The minimum charge for a court appearance: $650/hr. (2 hour minimum)

All attorney fees and costs incurred by the therapist as a result of the legal action.

Payment for Services/Documentation Request 

Insurance companies do not reimburse for completion of FMLA or disability paperwork. I am willing to send medical records, but I will not complete any forms unless I have adequate information from you. I will not do any disability paperwork for any individuals who have been in therapy for less than 5 sessions. If you request any letters, forms, or any other paperwork to be completed, such as FMLA or disability forms, please be advised that there is a fee for paperwork. My fee is $150.00 per hour. FMLA paperwork generally requires a minimum of 30 minutes to complete, (suggesting a minimum cost of $75.00) due to the need for supporting clinical documentation. Short-term disability often takes longer to complete, and may require additional assessments beyond my regular intake evaluation. This includes but is not limited to any letters of support, paperwork, forms, or reports, such as those related to FMLA, short-term or long-term disability, or Social Security Disability, including time to complete, copies of records, and faxing or mailing.

Crisis Situations  

We have limited our practice to clients who are not in need of 24-hour care.  If you are in need of 24-hour care, please inform us so that we can refer you to a professional colleague.  In the event of a crisis, every effort will be made to return your call & schedule if necessary. However, please understand that your therapist may be in sessions & unable to return your call until later in the business day. Should you need immediate assistance or experience a crisis after hours or on the weekend, please call 911 or contact the National Suicide and Prevention Hotline at 1-800-273-TALK (8255). 

Authorization to Release Information

This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the practice, authorized practice employees or your assigned counselor to release your protected health information to a person or organization that you choose. You can revoke this authorization at any time by submitting a request in writing to the practice, authorized practice employee or your assigned counselor. Revoking this authorization will not affect any action taken prior to receipt of your written request.

Duty to Warn/Duty to Protect 

In the event that your therapist believes you (or your child if your child is the client) is at risk of harming themselves or someone else, you give your permission in the Emergency Contact section of your intake paperwork for your therapist to contact anyone who is in a position to prevent said harm, including the person who is in danger, if applicable. Further, you give your permission for those persons to be contacted in addition to any law enforcement or medical personnel.

Scheduling & Cancellations 

You agree to attend all of your scheduled sessions and to call at least 24 hours ahead of time, if you are NOT be able to attend your session for any reason. Please understand you will be required to keep a credit card on file and it may be charged the full session fee, based on your appointment classification (individual, couple or family) if you cancel less than 24 hours before your scheduled appointment or do not attend your scheduled session without calling. Insurance companies will not pay for missed appointments. Please be aware that this also applies to Employee Assistance Program (EAP) sessions.


PLEASE NOTE:

Please understand your counselor/coach will make every effort to work with your scheduling needs, as possible within your counselor's schedule & office availability. *Please note established clients will have first option for first and last appointment of the day selection(s).

By reviewing and signing the Client Statement of Understanding & Client Intake Form(s), you the undersigned client, acknowledge that you have both read and understand all the terms, conditions, & information contained in the 1) Client Understanding, 2) Client Intake Form, 3) Authorization for Credit Card Billing, Information About Services, Communication/Social Media and HIPPA Policy. You acknowledge that you have been provided with sufficient opportunity to ask questions and seek clarification of anything contained in your initial client paperwork that is unclear to you.

="margin-top:>
( Type Full Name )
COMMUNICATION/SOCIAL MEDIA POLICY

COMMUNICATION/SOCIAL MEDIA POLICY

This document outlines Authentic Balance Counseling's office policies related to the use of Social Media. Please read it to understand how we conduct ourselves, as a counseling/coaching practice on the internet and how you can expect us to respond to the various interaction that may occur between us on the internet. If you have any questions about anything within this document, we encourage you to bring them up when you meet with your counselor/coach. As new technology develops and the internet changes, there may be times when we will need to update this policy. If we do so, we will notify you in writing of any policy changes, and offer a printed copy of the updated policy or you can view it at www.authenticbalancecounseling.com.

Licensed Professional Counselors do not disclose client confidences except by written authorization or waiver, or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law.

E-mails, Cell Phones, Computers, and Faxes are Not Private

No form of client communication is 100 percent guaranteed to be private. Conversations can be overheard; emails can be sent to the wrong recipients and phone conversations can be listened to by others. But in today's age of email Facebook, Twitter, Instagram and other social media, psychotherapists have to be more aware than ever of the ethical pitfalls they can fall into by using these types of communication. Although they add convenience and expedite communication, it is very important to be aware that computers and email and cell phone communication can be accessed relatively easily by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Emails, in particular, are vulnerable to such unauthorized access because servers have unlimited and direct access to all emails that go through them. The email that we use is as secure as possible, using encryption software, but still consider that emails and data on all computers may not be encrypted; it is always a possibility that faxes can be sent erroneously to the wrong address, and computers, including laptops, may be stolen. Our computers are equipped with a firewall virus protection and passwords, and we also password protect and back up all confidential information from our computers on a regular basis.

If you need to cancel or change an appointment time, a phone call or SMS (text) message may get that information to your counselor/coach faster. However, the preferred method of rescheduling appointments is through the use of our online scheduling system https://authenticb.mytherabook.com/appointments/new, when you initially get your appointment reminder message. Please notify your counselor/coach in writing if you decide to avoid or limit, in any way, the use of emails, cell phones, SMS (text), faxes, or storage of confidential information on computers. If you communicate confidential or private information via SMS(text) or email, we will assume that you have made an informed decision, and will view it as your agreement to take the risk that such communication may be intercepted, and we will honor your desire to communicate on such matters via email.

Contacting Me

I am often not immediately available by telephone. While I am usually in my office between 9:30 AM and 7:30PM Tuesday and Thursday, I will not answer the phone when I am with a patient. You are welcome to leave a voicemail for me, which I check regularly. I will make every effort to return your call within 72 hours, with the exception of weekends, holidays, and other days that I am not in my office (Monday, Wednesday or Friday). If you are difficult to reach, please inform me of times when you will be available. Again because texting may not secure be a secure methods of communication you do so at your own risk, responsibility, and liability. Please understand if you text me, I may not respond if the content is not regarding an appointment cancellation or change 24-hours prior to your scheduled appointment time.

Please do not use email or faxes for emergencies. Due to computer or network problems, emails may not be deliverable, and your counselor/coach may not check your emails or faxes daily. We prefer that you use email to arrange or modify appointments only if you are having a problem with our online scheduling system. If you email your counselor/coach content related to your sessions, please note that email is not completely secure or confidential. If email communication outside of your session requires more than 5 minutes to read or respond to; we may consider saving it for review during your appointment time.

Please DO NOT send forwarded messages regardless of how inspirational they may seem to our professional email address. Our professional e-mail addresses are used for work related issues, and we do not want to risk obtaining a virus spread by forwarded emails.

If you choose to communicate with your counselor/coach by email, be aware that all emails are retained in the logs of ours and your internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. You should also know that any emails we receive from you and any responses that we send to you become part of your legal record and may be revealed if your records are summoned by a legal entity.

Social Media Should Be Considered Public Communication:

Messaging on social networking sites such as Twitter, Facebook, Google+, or LinkedIn is not secure. It could compromise your confidentiality to use wall postings, @replies, or other means of engaging with us online if we have an already established client/therapist or client/coach relationship. It may also create the possibility that these exchanges become part of your legal medical record and will need to be documented and archived in your chart. Also, we may not read these messages in a timely fashion, if at all. If you need to contact us between sessions, the best way to do so is by phoning your counselor/coach directly. You may also email your counselor/coach directly as a way to receive a quick resolution for administrative issues such as quickly changing appointment times. See the email section above for more information regarding email interactions.

Friending May Expose Our Professional Relationship and Undermine Your Privacy

This social network policy serves as your notification that being liked as friends or contacts on these sites can compromise your confidentiality and your respective privacy. As in any other public context, you have control over your description of the nature of our acquaintance, if you choose to disclose a professional relationship. For example, if your counselor saw you out in public and you did not acknowledge them, they would follow your lead and do the same. If you introduce them to your friends, they would likely agree with your description of how you know them. They will not confirm or deny any professional relationship between yourself and clients on any social network sites. We reserve the right to discontinue any social network connection without prior notification, and we encourage you to do the same. We DO NOT allow the use of social network sites for any communication about our therapeutic/working relationship, including scheduling issues, due to the lack of privacy protections. If there are things from your online life that you wish to share with us, please bring them into our sessions where we can view and explore them together, during the therapy time.

Location-based Services Reveal Your Location

If you use location-based services on your mobile phone, please be aware of the privacy issues related to using these services. We have not placed our practice as a check-in location on any of the various LBS sites such as Foursquare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a client due to check-ins at our office. Please be aware of this risk if you are intentionally "checking-in" from our office or if you have a passive LBS app enabled on your phone.

I Do Not Use Search Engines to Learn About You

It is NOT a regular part of our practice to search for clients on Google or Facebook or other search engines. Extremely rare exceptions may be made during a crisis. If we have reason to suspect that you are in danger and you have not been in touch with us via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations, and if we ever resort to such means, we will fully document it and discuss it with you when we meet next.

Fanning/Liking Your Professional Page May Imply Endorsement

We keep various social media pages for our professional practice to allow people to share our blog posts and practice updates and information. All of the information shared on these pages is available on our website. You are welcome to view our social media pages and read or share articles posted there, and comment on them. However, referrals from other clients are one of our best sources of business. Our website, Facebook Fan page, Instagram, Twitter, and Pinterest are intended to let others know who Carole Gilmore, LPC is as a mental health professional, who Authentic Balance Counseling is as a counseling practice and to make it easier to refer individuals who might benefit from our services. We will not confirm or deny any professional relationship between clients on any social network site. This social media policy was constructed to inform you of the risks involved with associating on a social network. National licensing boards and associations agree and state that Professional Counselors (currently does not pertain to coaches) should not use their professional relationships with clients to further their own interests. We will not ask you to "like" our page or endorse us on other business pages. However, it is your right and option to do so.

Tweeting and Following Promote Your Professional Services

Our practice periodically publishes a blog on our website and as a standalone site www.Carolecounsels.com and may post news about services offered in our practice, such as upcoming workshops and presentations on Twitter and other social media sites. We have no expectation that you as a client will want to follow our blog or Twitter stream. However, if you use an easily recognizable name on Twitter and we happen to notice that you've followed us there, we may briefly discuss it and its potential impact on our working relationship. Our primary concern is your privacy. If you share this concern, there are more private ways to follow us on Twitter (such as using an RSS feed or a locked Twitter list), which would eliminate your having a public link to our content. Please use your discretion in choosing whether or not to follow us.

Business Review Sites Are Ineffective Paces to Voice Your Complaints

You may find our psychotherapy practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business had added itself to the site. If you should find our listing on any of these sites, please know that our listing is NOT a request for a testimonial, rating, or endorsement from you as our client. Of course, you have the right to express yourself on any site you wish. But due to confidentiality, we cannot respond to any review on any of these sites whether it is positive or negative. We urge you to take your own privacy as seriously as we take our commitment of confidentiality to you. You should also be aware that if you are using these sites to communicate with us about your

Business Review Sites Are Ineffective Paces to Voice Your Complaints cont.

feelings about your treatment, there is a good possibility that we may never see it. Approaching your counselor/coach directly with your concerns is always the more effective option. If we are working together, we hope that you will bring your feelings and reactions about your treatment directly to your designated counselor/coach. This can be an important part of your session(s), even if you decide we are not a good fit. None of this is meant to keep you from sharing that you are a client of ours, you may share this information wherever and with whoever you like. Confidentiality means that we cannot tell people that you are our client and our Code of Ethics prohibits our Licensed Professional Counselors (not our coaches) from requesting testimonials. But you are more than welcome to tell anyone you wish that you are working with one of our counselors/coaches or how you feel about the treatment we provided you, in any forum of your choosing.

Reviews and Testimonials

If you do choose to write something on a business review site, we hope you will keep in mind that you may be sharing personally revealing information in a public forum. We urge you to create a pseudonym that is not linked to your regular email address or friend networks for your privacy and protection. If you feel we have done something harmful or unethical and you do not feel comfortable discussing it with us, please know you can have the services of our licensed counselors reviewed by the Texas State Board of Examiners of Professional Counselors. Ultimately, however, our preference is that you discuss all concerns you have about your treatment directly with us so that we may reach a resolve.

Thank you for taking the time to review our Communication/Social Media Policy. If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the internet, please bring them to our attention so that we can discuss them.

( Type Full Name )
PRIVACY POLICY

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.

When you receive treatment or counseling services from Authentic Balance Counseling we will obtain and create "protected health information" (PHI) about you. Health information includes any information that relates to (1) your past, present, or future physical or mental health or condition; (2) the health care/counseling provided to you; and (3) the past, present, or future payment for your health care.

The following notice tells you about your duty to protect your PHI, your privacy rights, and how we may use or disclose your health information. In summary, your PHI will not be disclosed, except as permitted or required under federal law (42 CFR & 45 CFR), state law (Chapter 611 - Health and Safety Code), or as authorized in writing by you and your guardian, if applicable.

Counselor's Obligations

The law requires us to protect the privacy of your PHI. This means that we will not disclose any health information without your written authorization, except in the ways outlined in this notice. This protection applies to all health information we have about you, no matter when or where you received or sought services. We will not tell anyone if you sought, are receiving, or have ever received services from us, unless the law allows us to disclose that information.

We will ask you for your written permission (authorization or consent) to use or disclose your health information. There are times when we are allowed to use or disclose your health information without your permission, as explained in this notice. If you give us your permission to use or disclose your health information, you may revoke it at any time. If you revoke your permission, we will not be liable for using or disclosing your health information before we knew you revoked your permission. To revoke your authorization, submit a written statement, signed by you, to Authentic Balance Counseling, 3900 S. Stonebridge Dr. #604, McKinney 75070.

We are required to give you this notice of our legal duties and privacy practices, and our counselors must do what this notice says. We will ask you to sign an acknowledgement that you have received this notice (ACKNOWLEDGEMENT OF RECEIPT). We may change the contents of this notice and, if we do, we will have copies of the new notice in our office. The new notice will apply to all health information we have, no matter when we obtained or created the information.          

Authentic Balance Counseling, may use and disclose Personal Health Information (PHI) about you with your consent in the following circumstances:

Treatment

Authentic Balance Counseling and its associates may use and disclose your PHI to provide, coordinate, or manage your health care and related services, including the disclosure of your PHI to health care providers outside of Authentic Balance Counseling. For example, we may use and disclose your PHI when referring you to another health care provider. We also may disclose your PHI to individuals who may be involved in your care after you terminate from Authentic Balance Counseling and its associates.

Payment

Authentic Balance Counseling and its associates may use and disclose your PHI to bill and collect payment for the services provided to you. For example, Authentic Balance Counseling and its associates may share your PHI with your health plan(s) to request coverage and obtain payment approval before providing services to you (in non-emergency situations). Authentic Balance Counseling and its associates may send a bill to you or to a third-party payee, and this bill may include PHI such as your diagnosis and treatment services received. Authentic Balance Counseling and its associates also may share portions of your PHI, as necessary, with billing departments, insurance companies, and other health care providers.

Health Care Operations

Authentic Balance Counseling and its associates may use and disclose PHI to perform business activities - i.e., "health care operations." This includes:

Activities to improve health care, evaluating programs, and developing procedures;

Reviewing the competence, qualifications, performance of health care professionals and others;

Business office functions, such as billing, aggregate data gathering, or other functions that assist counseling staff in managing administrative case duties;

Conducting training programs;

Resolving internal grievances;

Conducting accreditation, certification, licensing, or credentialing activities;

Providing professional review, legal services, or auditing functions; and

 Engaging in business planning and management or general administration.

Minimum Necessary Standard

When using, or disclosing your PHI or when requesting your PHI from another covered entity, Authentic Balance Counseling and its associates will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations.

However, the minimum necessary standard will not apply in the following situations:

Disclosures to or requests by a health care provider for treatment;

Uses or disclosures made to you;

Uses or disclosures made under an authorization signed by you and your guardian (when applicable);

Disclosures made to the Secretary of the U.S. Department of Health and Human Services;

Uses or disclosures that are required by law; or

Uses or disclosures that are required for our licensed counselor's compliance with legal regulations.

Substance Abuse Services

If you receive substance abuse counseling from Authentic Balance Counseling, you have the highest level of privacy protection allowable by federal law (CFR 42). This law generally requires that Authentic Balance Counseling cannot disclose PHI that would identify you as a substance abuser or a patient of substance abuse counseling without your written consent. There are some exceptions to this requirement. Authentic Balance Counseling may use or disclose PHI that would identify you as a substance abuser or a patient of substance abuse services without your consent or authorization as follows:

As required by a court order;

To medical personnel in a medical emergency;

To qualified personnel for research, audit, or program evaluation;

To comply with State law mandating the reporting of suspected child abuse or neglect;

To communicate with law enforcement personnel about a crime or threatened crime on the premises of the offices of Authentic Balance Counseling or other therapists practicing on the premises.

Federal and State laws prohibit re-disclosure of information about alcohol or drug abuse treatment without your permission. Federal rules restrict any use of information about alcohol or drug abuse treatment to criminally investigate or prosecute any alcohol or drug abuse patient.

Communicable Diseases

Authentic Balance Counseling will not disclose information about you related to testing for Human Immunodeficiency Virus (HIV) without your specific written permission, unless the law requires me to disclose the information.

If you have one of the several specific communicable diseases (for example, tuberculosis, syphilis, or HIV/AIDS), Authentic Balance Counseling and its associates will treat PHI about your disease as confidential and will disclose such PHI without your written consent only in limited circumstances as permitted or required by law.

Authentic Balance Counseling will not use or disclose your health information without your consent or authorization, except as described in this Notice or as otherwise required by law.

Authentic Balance Counseling and its associates may use and disclose PHI about you without your consent or authorization in the following circumstances:

In general, Authentic Balance Counseling and its associates are required by law to obtain your written consent or authorization before using or disclosing your PHI that does not identify you as a substance abuser or a patient of substance abuse services. However, there are exceptions to this requirement, as described below:

Treatment

Your PHI may also be released to the health care professional who referred you to Authentic Balance Counseling. A responsible professional associated with Authentic Balance Counseling may disclose your PHI, as necessary, to a physician or health care provider who provides you with emergency medical services.

Other Permitted Uses and Disclosures

Also, Authentic Balance Counseling and its associates may use or disclose PHI that does not identify you as a substance abuser or a patient of substance abuse services without your consent or authorization as follows:

To address a serious threat to health or safety. Authentic Balance Counseling and its associates may use or disclose your health information to medical or law enforcement personnel if you or others are in danger and the information is necessary to prevent physical harm;

In judicial and administrative proceedings. Authentic Balance Counseling and its associates may also disclose your health information in any criminal or civil proceeding if a court or administrative judge has issued an order or subpoena that requires us to disclose it.

To report known or suspected child and elder abuse or neglect;

For purposes of filing a petition for involuntary commitment or a petition for an adjudication of incompetency and the appointment of a guardian;

Other Permitted Uses and Disclosures cont.

To Authentic Balance Counseling's legal counsel, if such information is relevant to litigation, to the operations of Authentic Balance Counseling, or to the provision of services provided by Authentic Balance Counseling and its associates.

Requests for PHI/Health Records

Although your health records are the physical property of Authentic Balance Counseling and its associates you have certain rights with regard to the information contained therein.

1. You have the right to inspect and copy your PHI upon the submission of a written request. Again, this right is not absolute and applies only in certain situations, Authentic Balance Counseling and its associates can deny access - for example, if a licensed health care professional believes that access to such information could cause harm to your physical or mental well-being.

2. If Authentic Balance Counseling denies you access to your PHI, we will explain why and what your rights are, including how to seek review. If Authentic Balance Counseling grants access to your PHI, we will give you instructions on any additional steps, if needed, for you to have access to the information. Authentic Balance Counseling reserves the right to charge a reasonable fee for making copies of the requested PHI.

3. You have the right to request in writing amendment of your PHI.

Authentic Balance Counseling and its associates may deny your request if:

Authentic Balance Counseling or its associates did not create the record, unless you provide a reasonable basis to believe that the originator of the PHI is no longer available to act on the request.

The records are not available for your access, as discussed above.

The record is accurate and complete.

The PHI that is the subject of your request is not maintained by or for Authentic Balance Counseling.

If Authentic Balance Counseling denies your request for amendment, we will notify you why and how you can submit a written statement disagreeing with the denial (which may be rebutted by Authentic Balance Counseling) and how you can complain to the licensing authority about the denial.

Requests for PHI/Health Records cont.

If Authentic Balance Counseling grants the request, we will make the correction(s) and distribute the correction(s) to those who need it and those you identify to us (in writing) that you want to receive the corrected information.

1. You have the right to request how and where Authentic Balance Counseling contacts you about PHI. For example, you may request that we contact you at your work address or phone number. Your request must be in writing. Authentic Balance Counseling is required to accommodate all reasonable requests.

2. You have the right to obtain an accounting of certain disclosures by Authentic Balance Counseling of your PHI. However, Authentic Balance Counseling and its associates are not required to provide an accounting for:

Disclosures to persons involved in the individual's care or disclosures for other notification purposes as provided in 164.510 of the HIPAA Privacy Rules (uses and disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for the care of the individual, of the individual's location, general condition, or death).

National security or intelligence purposes under 164.512(k)(2) (disclosures not requiring consent, authorization, or an opportunity to object, see Chapter 16).

Correctional institutions or law enforcement officials under 164.512(k)(5) (disclosures not requiring consent, authorization, or an opportunity to object).

Disclosures of PHI made before the compliance date, April 14, 2003.

Disclosures of PHI made to carry out treatment, payment or health care operations;

Disclosures of PHI made to you about your PHI;

Disclosures of PHI incidental to a permissible disclosure;

Disclosures of PHI made under your written authorization.

Authentic Balance Counseling must respond to the request for accounting within 60-days of the request by providing the accounting or by granting itself a one-time 30-day extension in which to provide the accounting. The accounting will include:

Date of each disclosure

Name and address, if known, of the organization or person who received the protected health information

Brief description of the information disclosed

Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the disclosure or, in lieu of such statement, a copy of the written request for disclosure, where permitted by law.

The first accounting in any 12-month period is free. Thereafter, Authentic Balance Counseling reserves the right to charge reasonable retrieval and copying fees.

You have the right to obtain a paper copy of this Notice at any time by contacting Authentic Balance Counseling and its associates. Authentic Balance Counseling and its associates will provide a copy of this Notice no later than the date you first receive services from them, except in emergency situations, and then Authentic Balance Counseling and its associates will provide the Notice to you as soon as reasonably practicable after the emergency treatment situation.

You have the right to revoke your consent or authorization to use or disclose health information by the instructions on the consent or authorization form, except to the extent that we have already acted in reliance on the consent or authorization.

Complaint Process

If you believe that Authentic Balance Counseling has violated your privacy rights, you have the right to file a complaint. You may complain by contacting:

Texas Department of State Health Services

1100 West 49th Street

Austin, TX 78756

1-800-832-9623

OR

United States Department of Health and Human Services

200 Independence Avenues, SW

Washington D.C. 20201

1-800-368-1019

You must file your complaint within 180 days of when you knew or should have known about the event that you think violated your privacy rights.

Further Information

If you have questions, you may contact Authentic Balance Counseling at (972) 546-2874 during normal business hours.

A ClientCopy of this Notice will be provided at Intake or is available upon request at any time.

( Type Full Name )