HIPPA
Notice of Privacy Policy to Protect Your
Health Information
Victor E. Loos, Ph.D., LSSP / Center for Family Consultation
2524 Nottingham St. Houston, Texas 77005 (713) 526-4751
Health Information
Victor E. Loos, Ph.D., LSSP / Center for Family Consultation
2524 Nottingham St. Houston, Texas 77005 (713) 526-4751
This notice describes how mental health information about you may be used and disclosed and how you can get access to this information.
Please review it carefully. I may use or disclose your protected health information (information that could identify you), for treatment, payment, and office administration. To help clarify these terms, here are some definitions:
Treatment
is when I provide, coordinate or manage your mental health care and other services related to such care. An example of treatment would be when I consult with another health care provider, such as your family physician.
Payment
is when I obtain reimbursement for your health care. Examples of payment are when I disclose your information to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Office Administration
is any activity that relates to the performance and operation of my practice. Examples are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. Please note: you may communicate with our office via phone, secure voice mail, personal visit, mail, or fax (which is received in a private, secure location). For reasons of confidentiality and security, we do not use e-mail. No billing, credit card, personal information, clinical information, or appointment details are sent or accepted via e-mail.
Disclosures Requiring Specific Authorization
I may use or disclose your protected health information for purposes other than the three previously listed (treatment, payment, office administration) when your specific authorization is obtained. A specific authorization is written permission that permits only a specific disclosure. You may revoke all such specific authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
Disclosures Which Require No Specific Authorization
I may use or disclose your protected health information without a specific authorization in the following circumstances:
Child/ Elderly/Disabled Abuse:
If I have cause to believe that a child, elderly person, or disabled person has been, or may be, abused, neglected, exploited or sexually abused, I am legally required to make a report within 48 hours to the appropriate state or local agency.
Health Oversight:
If a complaint is filed against me with the licensing board, they have the authority to subpoena confidential mental health information from me relevant to that complaint.
Judicial 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, I will not release information, without written authorization from you or your representative, unless I am court ordered.
Serious Threat to Health or Safety:
If I determine that there is a probability of imminent physical injury by you to yourself or others, I may disclose relevant confidential mental health information to medical or law enforcement personnel.
Worker’s Compensation:
If you file a worker’s compensation claim, I may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.
Please review it carefully. I may use or disclose your protected health information (information that could identify you), for treatment, payment, and office administration. To help clarify these terms, here are some definitions:
Treatment
is when I provide, coordinate or manage your mental health care and other services related to such care. An example of treatment would be when I consult with another health care provider, such as your family physician.
Payment
is when I obtain reimbursement for your health care. Examples of payment are when I disclose your information to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Office Administration
is any activity that relates to the performance and operation of my practice. Examples are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. Please note: you may communicate with our office via phone, secure voice mail, personal visit, mail, or fax (which is received in a private, secure location). For reasons of confidentiality and security, we do not use e-mail. No billing, credit card, personal information, clinical information, or appointment details are sent or accepted via e-mail.
Disclosures Requiring Specific Authorization
I may use or disclose your protected health information for purposes other than the three previously listed (treatment, payment, office administration) when your specific authorization is obtained. A specific authorization is written permission that permits only a specific disclosure. You may revoke all such specific authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
Disclosures Which Require No Specific Authorization
I may use or disclose your protected health information without a specific authorization in the following circumstances:
Child/ Elderly/Disabled Abuse:
If I have cause to believe that a child, elderly person, or disabled person has been, or may be, abused, neglected, exploited or sexually abused, I am legally required to make a report within 48 hours to the appropriate state or local agency.
Health Oversight:
If a complaint is filed against me with the licensing board, they have the authority to subpoena confidential mental health information from me relevant to that complaint.
Judicial 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, I will not release information, without written authorization from you or your representative, unless I am court ordered.
Serious Threat to Health or Safety:
If I determine that there is a probability of imminent physical injury by you to yourself or others, I may disclose relevant confidential mental health information to medical or law enforcement personnel.
Worker’s Compensation:
If you file a worker’s compensation claim, I may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.
Patient's Rights
Right to Request Restrictions
You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations
You have the right to request and receive confidential communications of your protected health information by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.)
Right to Inspect and Copy
You have the right to inspect or obtain a copy (or both) of your protected health information in my mental health and billing records used to make decisions about you for as long as your protected health information is maintained in the record. I may deny your access to such information under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
Right to Amend
You have the right to request an amendment of your protected health information for as long as it is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
Right to an Accounting
You generally have the right to receive an accounting of disclosures of your protected health information for which you have neither provided consent nor authorization. On your request, I will discuss with you the details of the accounting process.
Right to a Paper Copy
You have the right to obtain a paper copy of this notice from me upon request.
You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations
You have the right to request and receive confidential communications of your protected health information by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.)
Right to Inspect and Copy
You have the right to inspect or obtain a copy (or both) of your protected health information in my mental health and billing records used to make decisions about you for as long as your protected health information is maintained in the record. I may deny your access to such information under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
Right to Amend
You have the right to request an amendment of your protected health information for as long as it is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
Right to an Accounting
You generally have the right to receive an accounting of disclosures of your protected health information for which you have neither provided consent nor authorization. On your request, I will discuss with you the details of the accounting process.
Right to a Paper Copy
You have the right to obtain a paper copy of this notice from me upon request.
Therapist's Duties
I am required by law to maintain the privacy of your protected health information and to provide you with a notice of my legal duties and privacy policy. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you with a Revised Notice Form.
Complaints
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I will provide you with the address upon request.
Download PDF or MS Word Version of HIPAA
Complaints
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I will provide you with the address upon request.
Download PDF or MS Word Version of HIPAA