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.
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 The Texas Behavioral Health Executive
Council.
The Texas Behavioral Health Executive Council investigates and
prosecutes professional misconduct committed by marriage and
family therapists, professional counselors, psychologists,
psychological associates, social workers, and licensed
specialists in school psychology. Although not every complaint
against or dispute with a licensee involves professional
misconduct, the Executive Council will provide you with
information about how to file a complaint.
Texas Behavioral Health Executive Council
George H.W. Bush State Office Bldg.
1801 Congress Ave., Ste. 7.300
Austin, Texas 78701
Enforcement@bhec.texas.gov
1-800-821-3205
Further Information
If you have questions, you may contact Authentic Balance
Counseling at (972) 546-2874 during normal business hours.
A Client Copy of this Notice will be
provided at Intake or is available upon request at any
time.