Downloadable Version

 

Notice of Privacy Practices 

Connections Child and Family Center 

25511 Budde Rd, Ste 1303, Spring, TX 77380 

Notice of Privacy Practices

I. Use and Disclosure of Protected Health Information 

Connections Child and Family Center will not disclose information to anyone about you/your child without your express written consent. Records and information collected will be retained or released following state laws regarding confidentiality of mental health records. Written permission is required to release treatment records or documents.

II. Limits of Privacy or Confidentiality 

We may use or disclose PHI without your consent or authorization in only the following circumstances: 

Child Abuse: If we have cause to believe that a child has been, or may be, abused, neglected, or sexually abused, we must make a report of such within 48 hours to the Texas Department of Protective and Regulatory Services, the Texas Youth Commission, or to any local or state law enforcement agency. 

Abuse of the Elderly and Disabled: If we have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, we must immediately report such to the Department of Protective and Regulatory Services. 

Sexual Misconduct by a therapist: If you report to us any situation that constitutes sexual misconduct by a current or former therapist, then we are required to inform the licensing authority of the offending therapist. 

Regulatory Oversight: If a complaint is filed against a therapist with a regulatory authority, they have the authority to subpoena confidential mental health information relevant to that complaint. 

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 we will not release information, without written authorization from you or your personal or legally appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case**** 

Serious Threat to Health or Safety: If we determine that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, we may disclose relevant confidential mental health information to medical or law enforcement personnel. 

Worker’s Compensation: If you file a worker’s compensation claim, we may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.

III. Certain Uses and Disclosures Allowing you the Opportunity to Object 

  1. Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations. 
  2. Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us.

IV. Client’s Rights 

  1. ***Right to Request Restrictions ***-You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request. 
  2. ***Right to Inspect and Copy ***- You have the right to inspect or obtain a copy (or both) of PHIs in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so. 

V. Questions and Complaints 

If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint to Lauren Pasqua, Psy.D at 25511 Budde Rd, Ste 1301, Spring, TX 77380 

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request. 

EFFECTIVE DATE OF THIS NOTICE 

This notice went into effect on October, 24, 2017 

Acknowledgement of Receipt of Privacy Notice 

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. 

By signing, I acknowledge that I have received and read a copy of Privacy Practices and understand my rights. I also acknowledge that I have read and understand the limits to privacy or confidentiality.