THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY
Breakthrough Psychological Solutions, PLLC (referred hereto as “BPS”) is required by law to maintain the privacy of certain health information about you, and to inform you of its practices with respect to the privacy of that information. This Notice of Privacy Practices is being provided to inform you of the ways that BPS may use the personal information it collects about you and how it may disclose that information. Federal and state laws require health care providers to protect the privacy of information about your health, your healthcare, and payment for your health care, if that information identifies you or could be used to identify you. The law permits us to use or disclose your protected health information only for certain specific purposes, unless you give us a written authorization permitting us to make other uses and disclosures. This notice describes the purposes for which we may use or disclose protected health information about you. The law also gives you certain rights with respect to your protected health information. This notice provides a summary of those rights.
USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
Treatment - As it pertains to BPS, treatment means providing psychological services, to include individual therapy, group therapy, and psychological assessment. Treatment also includes coordination and consultation with your physician and other healthcare providers. As BPS provides these services to you, information obtained during this process will be recorded in our records. BPS may use this information, in coordination with your healthcare providers, to determine the best course of treatment for you.
Payment - We may use and disclose health information for activities required to obtain payment from you or your insurance carrier for the services provided to you by BPS. These activities include eligibility determination, pre-certification, billing and collection activities, obtaining documentation required by your insurer, and when applicable, disclosure of limited information to consumer reporting agencies.
30 Crocus Petal St., The Woodlands, TX 77382 (409) 344-3581(409) 344-3581 (972) 692-7303 fax psychbreakthrough.com
Health Care Operations - Health care operations include review of your protected health information by members of BPS's professional staff to ensure compliance with all federal and state regulations. This information will then be utilized to continually improve the quality and effectiveness of the services provided to you by BPS. Healthcare operations also include BPS's business management and general administrative activities.
OTHER USES AND DISCLOSURES THAT DO NOT REQUIRE AUTHORIZATION
- We may use or disclose protected health information when the use or disclosure is required by law.
- We may use or disclose protected health information to avert a serious threat to your health or safety, or the health and safety of others.
- We may disclose protected health information to a legally-authorized government authority, such as a social service or protective services agency, if we reasonably believe you or other mandated individuals are a victim of abuse, neglect or domestic violence.
- We may disclose protected health information to agencies authorized by law to conduct health oversight activities, such as licensing, inspections, and audits.
- We may disclose protected health information in response to court orders or subpoenas.
- Unless you object, we may disclose to a member of your family, other relative, or a close personal friend, or any other person identified by you, the protected health information directly relevant to that person's involvement with your health care or payment for your health care.
- We may use your health information to contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.
USES AND DISCLOSURES WITH YOUR AUTHORIZATION
We will obtain your authorization for any use or disclosure of your protected health information for purposes other than those summarized above. You may revoke your authorization at any time, except to the extent we have acted in reliance on the authorization, by sending a written notice of revocation to the address on the last page of this notice.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You may request additional restrictions to the use or disclosure of your protected health information for treatment, payment or health care operations. However, we are not required to agree to the requested restrictions.
We normally contact you by telephone or mail at your home address. You may request that we contact you at some other address or telephone number, or by some other method, such as e-mail. We will accommodate reasonable requests.
You may inspect and obtain a copy of protected health information that is used to make decisions about your care or payment for your care. We may deny a request to inspect records only in a few limited circumstances. If you request copies of records, we may charge you a reasonable fee for the copies.
You have the right to request amendment of the protected health information we maintain about you. We may deny your request if we determine that the record is accurate and complete, or if we did not create the record, unless the creator of the record is no longer available, or if you do not have a right to access the record. If we deny your request, you have the right to submit a statement disagreeing with our decision and to have the statement attached to the record.
You may request an accounting of certain disclosures we have made of your protected health information after April 14, 2003. The accounting is not required to include disclosures for treatment, payment, or health care operations, disclosures to persons involved in your health care or payment, disclosures for notification purposes, or disclosures with your written authorization. You may receive one accounting free of charge within a twelve-month period. We may charge a reasonable fee for all subsequent requests during the same twelve-month period.
You have the right to obtain a paper copy of this notice upon request. We reserve the right to change the terms of this notice, and to make the new notice provisions effective for all protected health information that we maintain.
If you have questions or would like additional information please write or call:
Breakthrough Psychological Solutions, PLLC • Attn: Compliance Officer • 30 Crocus Petal St. • The Woodlands, TX 77382 • 409-344-3581
If you believe your rights have been violated, you may file a written complaint at the address above, or you may also file a complaint with the Texas State Board of Examiners of Psychologists by writing or calling:
Enforcement Division • Texas State Board of Examiners of Psychologists • 333 Guadalupe, Tower 2, Room 450 • Austin, Texas 78701 • 512-305-7709
This Notice of Privacy Practices is effective July 1, 2012.