HIPPA Policy Statement

Cobblestone Counseling, PLLC
256 Ed English Dr., Building 4, Ste. C
Shenandoah, TX 77385
832.510.5611 mobile / 936.271.2774 fax
[email protected]



I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Suzanna Adelizi, Licensed Marriage and Family Therapist-Associate may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your general 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 we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when your counselor consults with another health care provider such as your family physician or mental health professional.
-Payment is when we obtain reimbursement for your health care. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
-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 the practice of Cobblestone Counseling, PLLC, such as using information that identifies you.

 “Disclosure” applies to activities outside the practice of Cobblestone Counseling, PLLC, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes 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 specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment, and health care operations, we will obtain an authorization from you before releasing this information. We will need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation regarding a private, group, joint, or family counseling session. 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.

I will also obtain an authorization from you before using or disclosing:

 PHI in a way that is not described in this Notice

 PHI for marketing purposes

 Psychotherapy notes

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, 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 or Disabled: 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 Texas Department of Protective and Regulator Services.

 Sexual Misconduct by a Therapist: If you report to me any situation that constitutes sexual misconduct by a current or former therapist, then I am required to inform the licensing agency of the offending therapist.

 Regulatory Oversight: Disclosures may be made to the U.S. Department of Health and Human Services in the course of their oversight of mental health professionals. If a complaint is filed against a therapist with a regulatory authority, the regulatory body has the authority to subpoena confidential mental health information relevant to that complaint. The federal government may also require disclosure for specialized functions such as determining fitness for military duties, eligibility for VA benefits, national security and intelligence, for public health purposes relating to disease or FDA-regulated products, or to a coroner or medical examiner, for example, for identification or cause of death.

 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.

 Workers’ Compensation: If you file a workers’ compensation claim, I may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.

IV. Client’s Rights and Our Professional Duties

Client’s Rights

 Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of PHI about you. However, we are not required to agree to a restriction you request.

 Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket: You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.

 Right to Be Notified if There is a Breach of Your Unsecured PHI: You have the right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

 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 want a family member to know that you are seeking our services. Upon request, I will send bills and other correspondence to another address.

 Right to Inspect and Copy: You have the right to inspect or obtain a copy of both PHI and psychotherapy notes in your counselor’s 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 you 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 Access Electronically Stored Health Records: You have a right to request a copy of any of your health records that are stored in electronic form and to receive a copy of such record no later than 15 business days after the date that I receive your written request. You will receive the record copy in electronic form, unless you agree to accept the record in another form,

 Right to Amend: You have the right to an amendment of PHI for as long as the PHI is maintained in the record. We 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.

Our Professional Duties

 I am required by law to maintain the privacy of PHI and to provide you with a notice of our 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, I am required to abide by the terms in effect.

 If I revise my policies and procedures, I will post a current copy in our offices. A current copy will also be available on my website, and you may request a personal copy.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision we make about access to your record, or have other concerns about your privacy rights, you may contact Suzanna Adelizi, LMFT-A at (832) 510-5611 or (832) 631-6348. If you believe your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint to Suzanna Adelizi, LMFT-A at Cobblestone Counseling, PLLC, 256 Ed English Dr., Building 4, Suite C, Shenandoah, TX 77358 . You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Ms. Adelizi can provide you with the appropriate address on request. You have specific rights under the Privacy Rule. We will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on February 1, 2019. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice in our lobby and on our website. You may request a personal copy at any time.