Restoring Connections Therapy

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION (PHI) MAY BE USED AND DISCLOSED, YOUR RIGHTS REGARDING THAT INFORMATION, AND HOW YOU CAN ACCESS IT. PLEASE READ IT CAREFULLY.

Our Commitment to Your Privacy

Protecting your privacy and maintaining your trust are fundamental to our practice. As your therapist, we understand that the information you share is deeply personal and confidential.

Federal law, including the Health Insurance Portability and Accountability Act (HIPAA), requires me to protect your Protected Health Information (PHI), provide you with this Notice of Privacy Practices, and follow the privacy practices described in this notice.

As a general rule, I will not release information about you without your written authorization unless disclosure is required or permitted by law.

What Is Protected Health Information?

Protected Health Information (PHI) includes information that identifies you and relates to your physical or mental health, the care you receive, or payment for your care. This includes information contained in your clinical record, billing records, appointment history, and communications related to your treatment.

How Your Information May Be Used or Disclosed

Treatment

I may use or disclose your PHI to provide, coordinate, or manage your mental health treatment.

Examples include:

  • Consulting with another licensed healthcare provider regarding your care.
  • Coordinating care with another provider at your request.
  • Making referrals for additional services.

Only the information necessary for your treatment will be shared.

Payment

If you choose to use insurance or another third-party payer, information may be disclosed as necessary to verify benefits, obtain authorization, submit claims, or collect payment.

If you pay privately and do not request insurance reimbursement, your information generally will not be shared with an insurance company.

Health Care Operations

Your information may be used for legitimate business activities necessary to operate the practice, including:

  • Professional consultation
  • Practice management
  • Required audits

Whenever practical, only the minimum necessary information will be used.

Uses and Disclosures Required or Permitted by Law

There are situations in which I may be legally required or legally permitted to disclose information without your written authorization.

These include:

  • Reporting suspected child abuse or neglect.
  • Reporting abuse, neglect, or exploitation of certain vulnerable adults when required by law.
  • Responding to a valid court order or other legal process.
  • Complying with mandatory reporting requirements under federal or Texas law.
  • Preventing or reducing a serious and imminent threat to your safety or the safety of another person.
  • Certain law enforcement requests when required by law.
  • Workers’ compensation claims, when applicable.

Whenever possible, I will discuss these situations with you before information is released unless I am prohibited by law from doing so.

Uses Requiring Your Written Authorization

Except as described above, your written authorization is required before I disclose your Protected Health Information.

Examples include:

  • Communicating with family members or friends who are not involved in your care.
  • Releasing records to schools, employers, attorneys, or other third parties.
  • Coordinating care with another provider when not otherwise permitted by HIPAA.

You may revoke your authorization at any time in writing unless I have already acted in reliance upon it.

Psychotherapy Notes

If I maintain psychotherapy notes that are kept separate from your clinical record, those notes receive additional protection under HIPAA and generally will not be disclosed without your written authorization except as permitted or required by law.

Routine progress notes, treatment plans, assessments, diagnoses, billing records, and other documentation that become part of your clinical record are not psychotherapy notes.

Appointment Reminders and Communication

I may contact you regarding:

  • Appointment reminders
  • Scheduling changes
  • Billing questions
  • Administrative matters

These communications may occur by telephone, voicemail, secure client portal, email, or text message according to your communication preferences.

Please understand that while reasonable safeguards are used, standard email and text messaging may involve some privacy risks. Secure messaging through the client portal is recommended whenever possible.

Electronic Health Record

This practice uses SimplePractice, a HIPAA-compliant electronic health record and secure client portal, for scheduling, documentation, billing, secure messaging, client forms, and telehealth services.

SimplePractice provides services under a Business Associate Agreement as required by HIPAA.

Your Rights

You have the right to:

  • Inspect and receive a copy of your clinical record, subject to applicable law.
  • Request restrictions on certain uses or disclosures.
  • Request confidential communications by alternative means or at alternative locations.
  • Receive an accounting of certain disclosures.
  • Receive a paper or electronic copy of this Notice.
  • File a complaint if you believe your privacy rights have been violated.

I will not retaliate against you for exercising any of these rights.

How to Request Access to Your Health Information

You have the right to request access to your Protected Health Information (PHI) maintained by this practice, subject to certain limitations under applicable federal and state law.

To request a copy of your records, please submit a written request through the secure Client Portal or contact the practice directly using the contact information provided on this website.

Your request should include:

  • Your full name;
  • Your date of birth;
  • Your current contact information; and
  • A description of the records you are requesting.

Before providing records, this practice may take reasonable steps to verify your identity to help protect the privacy and security of your health information.

Requests for access to records will be reviewed and processed within the timeframe required by applicable law. If a fee is permitted for copying, preparation, or delivery of records, you will be informed of any applicable charges before the records are provided.

Please note that certain information, including psychotherapy notes as defined by HIPAA, may not be included in a standard medical record request and may have additional protections under federal law.

If you have questions about requesting access to your records, please contact the practice.

Changes to This Notice

I reserve the right to revise this Notice at any time.

Any revised Notice will apply to all Protected Health Information maintained by this practice and will be available in the office and on the practice website.

Questions or Privacy Concerns

If you have questions about this Notice or your privacy rights, please contact the practice directly using the contact information listed on this website.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with this practice or with:

U.S. Department of Health and Human Services
 Office for Civil Rights

Filing a complaint will not affect your care or services in any way.

Acknowledgment

Clients are asked to acknowledge receipt of this Notice of Privacy Practices. Your acknowledgment confirms only that you received this Notice; it does not waive any of your rights.

TELEHEALTH & ELECTRONIC COMMUNICATION POLICY

This practice uses electronic communication and telehealth technology to provide services while maintaining appropriate protections for your privacy and confidentiality. Please review this policy regarding the use of electronic systems in your care.

Electronic Health Record and Client Portal

This practice uses SimplePractice, a HIPAA-compliant electronic health record and client portal, for:

  • Maintaining clinical records
  • Completing intake forms and documentation
  • Scheduling appointments
  • Secure client communications
  • Billing functions
  • Telehealth services

Information maintained within the electronic health record is protected as required by applicable privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA).

Electronic Communication

Electronic communication methods, including email and text messaging, may involve privacy risks. While reasonable safeguards are used to protect your information, no electronic communication system can guarantee complete confidentiality.

Clients are encouraged to use the secure SimplePractice Client Portal when communicating information related to their care whenever possible.

By choosing to communicate electronically, you acknowledge that electronic communications may carry some level of privacy risk.

Text Messaging

Text messaging may be used for administrative purposes, such as appointment reminders or scheduling communications, if you have provided permission to receive text messages.

Standard message and data rates may apply.

Text messaging should not be used to communicate urgent mental health concerns or emergency situations.

You may withdraw consent to receive text messages at any time.

Telehealth Services

Telehealth services are provided through the secure SimplePractice platform when clinically appropriate.

Telehealth involves the use of electronic communication technology to provide mental health services when the therapist and client are not physically in the same location.

Before participating in telehealth services, clients should understand that:

  • Telehealth requires access to appropriate technology, including a device with audio and video capability and a reliable internet connection.
  • Electronic communication and technology may involve potential privacy and security risks.
  • Technical difficulties may interrupt or prevent a session.
  • Clients should participate from a private location whenever possible to protect confidentiality.

Location During Telehealth Sessions

Because professional licensure laws apply based on the client’s location at the time services are provided, clients must be physically located in a jurisdiction where the therapist is authorized to provide services during telehealth appointments.

Clients should inform the practice if their location changes.

Emergency Situations

Electronic communication and telehealth services are not a substitute for emergency services.

Do not use text messaging, email, the client portal, or website contact forms for emergencies or urgent safety concerns.

If you are experiencing an emergency, call 911 or seek immediate assistance through emergency or crisis resources available in your area.

Consent for Electronic Communication and Telehealth

By choosing to participate in telehealth services or communicate electronically, you acknowledge that:

  • You understand the potential benefits and limitations of telehealth.
  • You understand the potential privacy risks associated with electronic communication.
  • You have had the opportunity to ask questions about these services.
  • You consent to receive services through approved electronic platforms when clinically appropriate.

Questions regarding telehealth or electronic communication may be discussed with the practice at any time.

GOOD FAITH ESTIMATE NOTICE

Your Right to Receive a Good Faith Estimate

Under the federal No Surprises Act, clients who are uninsured, self-pay, or who choose not to submit claims to insurance have the right to receive a Good Faith Estimate explaining the expected cost of their mental health services.

A Good Faith Estimate provides an estimate of the charges you may reasonably expect for scheduled services based on information available at the time the estimate is created.

What Is Included in a Good Faith Estimate?

A Good Faith Estimate may include:

  • The expected type of service(s) to be provided
  • The expected frequency and duration of services when reasonably predictable
  • The estimated charges associated with those services

Because mental health treatment is individualized, the length and frequency of treatment may change based on your clinical needs, treatment goals, and progress.

Your Estimate May Change

Your Good Faith Estimate is based on what is known and reasonably expected at the time it is prepared.

The estimate does not include unexpected services or changes in treatment that may become clinically appropriate during the course of therapy.

If your treatment needs change significantly, you may receive an updated estimate reflecting the expected costs of future services.

If Your Bill Is Higher Than Your Good Faith Estimate

If you receive a bill that is substantially higher than your Good Faith Estimate, you have the right to contact this practice to discuss the charges.

You may:

  • Ask for an explanation of the difference between the estimate and the billed amount;
  • Request that the bill be reviewed for accuracy;
  • Discuss payment options or possible financial arrangements.

You may also have the right to initiate a federal dispute resolution process through the U.S. Department of Health and Human Services (HHS) if your billed charges are at least $400 more than your Good Faith Estimate for the same services.

How to Request a Dispute Review

To learn more about your rights under the No Surprises Act or to begin the federal dispute process, visit:

Centers for Medicare & Medicaid Services (CMS)
No Surprises Act Information: https://www.cms.gov/nosurprises

You may also contact the U.S. Department of Health and Human Services at:

Phone: 1-800-368-1019

Please note that a fee may apply to submit a dispute request. Additional information about eligibility requirements and the dispute process is available through CMS.

Keep Your Good Faith Estimate

Please keep a copy of your Good Faith Estimate for your records. You may need it if you receive a bill that is significantly higher than the estimated amount.

Questions

If you have questions about your Good Faith Estimate or the expected cost of services, please contact the practice before beginning services or at any time during treatment.

Professional Licensing and Consumer Complaints

I am a Licensed Marriage and Family Therapist (LMFT) practicing in accordance with the laws, rules, and ethical standards governing licensed mental health professionals in the State of Texas.

The Texas Behavioral Health Executive Council (BHEC) oversees the regulation of behavioral health professionals in Texas, including Licensed Marriage and Family Therapists.

If you have questions regarding professional licensure, regulatory standards, or the licensing process, you may contact BHEC directly:

Texas Behavioral Health Executive Council
Website: https://bhec.texas.gov/
Contact Information: https://bhec.texas.gov/contact-us/

If you have concerns regarding professional conduct or believe a licensed mental health professional has violated applicable standards, you may submit a complaint through the appropriate regulatory process.

You may also contact the Texas Office of the Attorney General Consumer Protection Division regarding consumer concerns:

Texas Office of the Attorney General
Consumer Protection Division
Website: https://www.texasattorneygeneral.gov/consumer-protection

Filing a complaint with a regulatory agency is independent of this practice and will not affect your access to services.

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