|TEXAS NOTICE FORM
of Psychologists’ Policies and Practices to Protect the Privacy
of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment,
and Health Care Operations
I may use or disclose your protected health information
(PHI), for treatment, payment, and health care operations purposes
with your consent. To help clarify these terms, here are some definitions:
· “PHI” refers to information in your health
record that could identify you.
· “Treatment, Payment and Health Care Operations”
– Treatment is when I provide, coordinate or manage your health
care and other services related to your health care. An example
of treatment would be when I consult with another health care provider,
such as your family physician or another psychologist.
- Payment is when I obtain reimbursement for your healthcare. Examples
of payment are when I disclose your PHI to your health insurer to
obtain reimbursement for your health care or to determine eligibility
- Health Care Operations are activities that relate to the performance
and operation of my practice. Examples of health care operations
are quality assessment and improvement activities, business-related
matters such as audits and administrative services, and case management
and care coordination.
· “Use” applies only to activities within my
[office, clinic, practice group, etc.] such as sharing, employing,
applying, utilizing, examining, and analyzing information that identifies
· “Disclosure” applies to activities outside
of my [office, clinic, practice group, etc.], such as releasing,
transferring, or providing access to information about you to other
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment,
and health care operations when your appropriate authorization is
obtained. An “authorization” is written permission above
and beyond the general consent that permits only specific disclosures.
In those instances when I am asked for information for purposes
outside of treatment, payment and health care operations, I will
obtain an authorization from you before releasing this information.
I will also need to obtain an authorization before releasing your
psychotherapy notes. “Psychotherapy notes” are notes
I have made about our conversation during a private, group, joint,
or family counseling session, which I have kept separate from the
rest of your medical record. These notes are given a greater degree
of protection than PHI.
You may revoke all such authorizations (of PHI or psychotherapy
notes) 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.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization
in the following circumstances:
§ Child Abuse: If I have cause to believe that a child has
been, or may be, abused, neglected, or sexually abused, I 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.
§ Adult and Domestic Abuse: If I have cause to believe that
an elderly or disabled person is in a state of abuse, neglect, or
exploitation, I must immediately report such to the Department of
Protective and Regulatory Services.
§ Health Oversight: If a complaint is filed against me with
the State Board of Examiners of Psychologists, they have the authority
to subpoena confidential mental health information from me 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 I 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 I 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, 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.
IV. Patient's Rights and Psychologist's Duties
· 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 PHI 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 PHI and psychotherapy notes
in my mental health and billing records used to make decisions about
you for as long as the PHI is maintained in the record. I may deny
your access to PHI 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 PHI for as long as the PHI 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 PHI for which you have
neither provided consent nor authorization (as described in Section
III of this Notice). 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 the notice from me upon request, even if you have
agreed to receive the notice electronically.
· I am required by law to maintain the privacy of PHI and
to provide you with a notice of my legal duties and privacy practices
with respect to PHI.
· 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
V. Questions and Complaints
If you have questions about this notice, disagree
with a decision I make about access to your records, or have other
concerns about your privacy rights, you may contact me through my
If you believe that your privacy rights have been
violated and wish to file a complaint with me/my office, you may
send your written complaint to:
Joann Murphey, Ph.D.
13300 Old Blanco Rd., #260
San Antonio, Texas 78216
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.
You have specific rights under the Privacy Rule.
I will not retaliate against you for exercising your right to file
VI. Effective Date, Restrictions and Changes to
This notice will go into effect on April 14, 2003.
Patient/Legal Guardian (signature)