If you believe that the evaluator has violated your privacy rights, you have the right to file a compliant in writing with the evaluator/privacy officer via the address outlined above or with the Secretary of Health and Human Services at 200 Independence Avenue, SW Washington DC 20201 or by calling (202) 619-0257.
The effective date of this Notice is September 2013, and this Notice was last updated in January 2018.
Signed this ____________ day of __________________, 2018.
The following additional notifications are required in order to ensure that you have a thorough understanding of how your information may or may not be used or transmitted during the course of a court-ordered evaluation:
You have the following rights regarding PHI that is maintained about you. To exercise any of these rights, please submit your request in writing via your attorney after your evaluation has been completed to the evaluator’s privacy officer located at the evaluator’s address and contact information.
Right of access to inspect and copy: Once your court-ordered evaluation is complete, you have the right, which may be restricted only in exceptional circumstances or via court order, to inspect and copy any PHI information related to you or your child/ren that has not already been attached to your evaluation and produced to the court and/or your attorney or clients who represent themselves. The evaluator may charge a reasonable, cost-based fee for the copies, and if the records are maintained electronically, you may also request an electronic copy of your PHI. You may not request that this information be provided to another person aside from your attorney of record.
Right to amend: Once your court-ordered evaluation is completed and filed with the court, you have the right to ask that the PHI be amended if you feel that the PHI that I have about you is incorrect or incomplete. I am not required to agree with your amendment, and if your amendment is directly related to information that was produced to me, it would be most appropriate for you to seek amendment of this information from the provider who produced the PHI to the evaluator. If I deny your request for an amendment, you have the right to file a statement of disagreement with the evaluator that will be forwarded to the court and the attorneys of record or to clients who represent themselves.
Right to an accounting of disclosures: You have the right to request an accounting of certain of the disclosures that I make of your PHI or your child/ren’s PHI. The evaluator may charge a reasonable fee for this request, and within a court-ordered evaluation, your PHI or your child/ren’s PHI will only be disclosed as outlined in your Informed Consent and Advisement Form to the court, the attorneys, to clients who represent themselves, and to the individuals for whom releases were signed and have not been revoked.
Right to request restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI. I am not required to agree to your request, though the court will be notified if an attempt is made to restrict the evaluator’s access to necessary PHI required as part of the standards of practice and the Texas Family Code in relation to the court-ordered evaluation.
Breach of notification: If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself. Once your evaluation is completed, I maintain your records under lock and key for five years until those records are destroyed in the evaluator’s presence.
Right to a copy of this notice: You have a right to a copy of this notice, which can be found online via the evaluator’s website. NOTE: The current law requires that I also notify you as to your Right to Request Confidential Communication. This notice states that you have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request. During an evaluation, you are asked to provide a preferred telephone number and email address to the evaluator for communication purposes. The evaluator will contact you as needed via one of these means primarily for administrative purposes, and as noted, your information acquired during an evaluation is not confidential.
NOTE: The current law requires that I also notify you as to your Right to Request Confidential Communication. This notice states that you have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request. During an evaluation, you are asked to provide a preferred telephone number and email address to the evaluator for communication purposes. The evaluator will contact you as needed via one of these means primarily for administrative purposes, and as noted, your information acquired during an evaluation is not confidential.
NOTE: The laws related to the maintenance policies of your PHI changed in 2013, and these laws require that I disclose this information to you, though this information does not apply to the evaluator’s process. The reasons that each item do not apply will be outlined in italicize below each item identified:
For treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of proving, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization. (The process of a court ordered evaluation is not treatment, and the evaluator does not provide treatment services in her practice.)
For payment: We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection. (Payment for a court-ordered evaluation is payable directly to the evaluator by check or money order. The evaluator does not bill insurance, and her services are not covered by insurance. The only payment that may be necessary and related to your PHI information is related to any costs that your current or previous providers may require you to pay to produce your records to the evaluator for the court-ordered process as required by the Texas Family Code and the standards of practice. As noted in the release forms that you will sign, you are responsible for all costs, if any, related to the records acquired for your evaluative process.)
Without authorization: Following is a list of the categories of uses and disclosures permitted by HIPAA without authorization. Applicable law and ethical standards permit us to disclose information about you without your authorizations in a limited number of situations.
Research: PHI may only be disclosed after a special approval process or with your authorization. (The evaluator does not conduct research within her practice.)
Fundraising: We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive. (You will never receive fundraising communications from the evaluator.)
Verbal permission: We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission. (The evaluator will not speak to your family members during a court-ordered evaluation process unless they have completed a personal reference form or a written witness statement for you and a telephone call to them is warranted. Should a family member contact the evaluator, she will ask that they place any and all information to the evaluator in writing, and any questions answered will be process driven only with your PHI not being discussed or disclosed.)
For the evaluation: During the course of an evaluation, your PHI and/or your child/ren’s PHI may be acquired as part of the evaluation process as required by the standards of practice and the Texas Family Code. This information will be used for the purpose of ensuring a thorough evaluation of your family in order to provide an accurate assessment to the court related to your child/ren and his/her best interest. This information, once acquired, may be reproduced to the court, the attorneys of record, and/or to the clients who represent themselves, and this is clearly outlined in the Releases of Information that you will be required to sign during the course of the evaluative process. This information may also be utilized anonymously in consultation with other clinical professionals to assist the evaluator in completing your case with appropriate peer review, and I may disclose your actual PHI or your child/ren’s PHI to another mental health professional or consultant with your appropriate authorization only.
Required by law: Under the law, I must disclose your PHI to you upon your request, though this information will not be produced until the evaluation process has been completed in order to ensure the evaluator’s neutrality. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.
Without authorization: Following is a list of the categories of uses and disclosures permitted by HIPAA without authorization. Applicable law and ethical standards permit me to disclose information about you without your authorizations in a limited number of situations.
With authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked in writing at any time, except to the extent that I have already made a use or disclosure based upon your authorization or an applicable court order related to your family law matter.
This notice describes how your medical information may be used and/or disclosed and how you can get access to this information. Please review this notice carefully before signing.
As outlined in the Informed Consent and Advisement Form related to your court-ordered evaluation, the process of such an evaluation is not confidential, and the information acquired during the course of that evaluation, which can include your Protected Health Information (PHI), can be produced to the court and to the attorneys of record or to clients who represent themselves upon completion of that evaluation.
As a mental health professional, I am required to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices related to your PHI. I am required to abide by the terms of this Notice of Privacy Practices at all times, and while I reserve the right to change the terms of my Notice of Privacy Practices at any time, any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. Should I change this policy at any time during the course of your evaluation, you will be provided with a copy of the revised Notice of Privacy Practices and asked to sign that new document. Should your evaluation be completed before such a revision occurs, you will not be provided such a copy since my services with your family at that time will no longer be in process. You can access my current Notice of Privacy Practices at any time on my website.
Your health record contains personal information about you and your health, and while the process of an evaluation does not involve the creation of a health record, the process does entail the necessity of the evaluator acquiring PHI related to you and/or your children. This information about you may identify you and relate to past, present, and future physical or mental health or condition and related health care services and is thus referred to as your PHI. This Notice of Privacy Practices describes how I may use or disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (HIPAA), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the evaluator’s code of ethics, which are located on the evaluator’s website via a link to the Texas State Board of Examiners for Professional Counselors. It also describes your rights regarding how you may gain access to and control your PHI.