Please refer to the Informed Consent Form for my standard office policies. I have provided my Privacy Practices below in accordance with HIPPA requirements.
Both forms (links to the left) may be completed and brought with you to your first appointment.
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.
Understanding Your Protected Health Information (PHI)
When you visit, a record is made of your symptoms, assessments, test results, diagnoses, treatment plan, and other mental health or medical information. Your record is my physical property, the information within which belongs to you. Being aware of what is in your record will help you to make more informed decisions when authorizing disclosure to others. In using and disclosing your protected health information (PHI), it is my objective to follow the Privacy Standards of the Federal Health Insurance Portability and Accountability Act (HIPAA) and requirements of Texas law.
Your mental health and/or medical record serves as
- a basis for planning your care and treatment
- a means of communication among the health professionals who may contribute to your care
- a legal document describing the care you received
- a means by which you or a third-party payer can verify that services billed were actually provided
- a source of information for public health officials charged with improving the health of the nation
- a source of data for facility planning
- a tool with which I can assess and continually work to improve the care I render and the outcomes I achieve.
-Maintain the privacy of your protected health information (PHI) as required by law and provide you with notice of legal duties and privacy practices with respect to the protected health information that is collected and maintained about you.
-Abide by the terms of this notice currently in effect. I have the right to change this notice of privacy practices and to make the new provisions effective for all protected health information that I maintain, including that obtained prior to the change. Should my information practices change, I will post new changes and provide you with a copy, upon request.
-Notify you if I am unable to agree to a requested restriction.
-Accommodate reasonable requests to communicate with you about protected health information by alternative means or at alternative locations, e.g. you may not want a family member to know that you are being seen. At your request, I will communicate with you, if needed, at a different location.
-Use or disclose your health information only with your authorization except as described in this notice.
Your Protected Health Information (PHI) Rights
-Review and obtain a paper copy of the notice of privacy practices upon request and of your health information, except that you are not entitled to access, or to obtain a copy of, psychotherapy notes and a few other exceptions may apply. Copy charges may apply.
-Request and provide written authorization and permission to release information for purposes of outside treatment and health care operations. This authorization excludes psychotherapy notes that may have been made with your permission by your mental health clinician.
-Revoke your authorization in writing at any time to use, disclose, or restrict health information except to the extent that action has already been taken.
-Request a restriction on certain uses and disclosures of protected health information, but I am not required to agree to the restriction request. You should address your restriction request in writing. I will notify you within 10 days if I cannot agree to the restriction.
-Request that I amend your health information by submitting a written request with the reasons supporting the request. I am not required to agree to the requested amendment.
-Obtain an accounting of disclosures of your health information for purposes other than treatment, payment, health care operations and certain other activities for the last six years.
-Request confidential communications of your health information by alternative means or at alternative locations.
Disclosures for Treatment, Payment and Health Operations
I, Janet M. Kinney, will use your PHI, with your consent, in the following circumstances:
Treatment: Information obtained by your psychologist/counselor or from a nurse, physician, dentist or other member of your health care team will be recorded in your record and used to determine the management and coordination of treatment that will be provided for you.
For payment: I will send a bill to your insurance company. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis to obtain reimbursement for your health care or to determine eligibility or coverage.
Disclosure to others: If you give me a written authorization, you may revoke it in writing at any time, but that revocation will not affect any use or disclosures permitted by your authorization while it was in effect. We will not use or disclose your health information without your authorization, except as described below to report serious threat to health or safety or child and adult abuse or neglect.
II. I will use your PHI, without your consent or authorization, in the following circumstances:
Child Abuse: If I have reasonable cause to suspect that a child known to me in the course of professional duties has been abused or neglected, or have reason to believe that a child known to me in the course of my professional duties has been threatened with abuse or neglect, and that abuse or neglect of the child will occur, I must report this to the relevant county department, child welfare agency, police, or sheriff’s department.
Adult and Domestic Abuse: If I believe that a vulnerable adult (ex. incapacitated or facility resident) is the victim of abuse, neglect or domestic violence or the possible victim of other crimes, I will report such information to the relevant county department or state official.
Serious Threat to Health or Safety: If I have reason to believe, exercising best judgment and my professional care and skill, that you may cause serious harm to yourself or another person, I will take steps, without your consent, to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition in order to protect you or another person from harm. This may include instituting commitment proceedings.
Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and I will not release the information without written authorization from you or your personal or legally-appointed representative, or a subpoena/court order. The privilege does not apply when you are being evaluated by a third party or where the evaluation is court ordered.
As required by law for national security and law enforcement: I may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. I may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence and other national security activities. I may disclose health information for law enforcement purposes as required by law or in response to a valid court order.
Law/Health Oversight: As required by law I may disclose your health information. For example, if the Texas Board of Examiners of Psychologists requests that I release records to them in order to investigate a complaint against a provider, I must comply with such a request.
Worker’s Compensation: I may disclose health information to the extent authorized by you and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law; I may be required to testify.
For More Information or to report a problem
If you have questions and would like additional information, please ask.
If you are concerned that your privacy rights have been violated, or if you disagree with a decision I have made about access to your health information, or if you would like to make a request to amend or restrict the use or disclosure of your health information, please contact me. If you believe that your privacy rights have been violated, you can also file a complaint with the Secretary of the U.S. Department of Health and Human Services:
Office for Civil Rights
U.S. Department of Health & Human Services
150 S. Independence Mall West - Suite 372
Philadelphia, PA 19106-3499
(215) 861-4441; (215) 861-4440 (TDD) Fax: (215) 861-4431
You may also visit this web site for forms: http://www.hhs.gov/ocr/privacyhowtofile.htm
I respect your right to the privacy of your health information. There will be no retaliation in any way for filing a complaint with the U.S. Department of Health and Human Services.