HIPAA NOTICE OF PRIVACY PRACTICES
Effective Date: September 10, 2015

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. 
OUR OBLIGATIONS: 
We are required by law to :

Maintain the privacy of protected healthcare information
Give you this notice of our legal duties and privacy practices regarding health information about you.
Follow the terms of our notice that is currently in effect.

You may request a copy of this Notice from your AFT therapist, or you can view a copy of it in the office or on the website, which is located at www.ackermanfamilytherapy.com.

HOW WE WILL USE AND DISCLOSE YOUR PHI
The following describes the ways we may use and disclose health information that identifies you ("Health Information"). Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer. 
Consenting to treatment authorizes the following disclosures: 

FOR TREATMENT. We may use and disclose Health Information for your treatment and to provide you with related services. We may disclose your Health Information to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, we may disclose your PHI to her/him in order to coordinate your care. 

FOR PAYMENT. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment. We could also provide Health Information to business associates, such as billing companies, debt collections agencies, claims processing companies, and others that process claim payments for my office.

FOR HEALTH CARE OPERATIONS. AFT may disclose Health Information to facilitate the efficient and correct operation of the practice. Examples: Quality control - we might use Health Information in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. We may also provide Health Information to our attorneys, accountants, consultants, and others to make sure that AFT is in compliance with applicable laws. Health Information may also be shared for the purposes of training and supervising our staff and providing backup care in the care of your therapist's absence.

APPOINTMENT REMINDERS, TREATMENT ALTERNATIVES, and HEALTH RELATED BENEFITS and SERVICES. We may use and disclose Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. 

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort. 

RESEARCH. Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information. 

SPECIAL SITUATIONS WHERE USED AND DISCLOSURE DO NOT REQUIRE YOUR CONSENT: 
EMERGENCIES. Your consent is not required if you need emergency treatment provided that we attempt to get your consent after treatment is rendered. In the event that we try to get your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain) but we think that you would consent to such treatment if you could, we may disclose your Health Information.

AS REQUIRED BY LAW. We will disclose Health Information when required to do so by international, federal, state or local law. This includes mandatory reporting when we see evidence of, are told about, or suspect abuse, neglect, or endangerment of children, elderly, or disabled persons. This also includes mandatory reporting if we are informed that another licensed counselor has engaged in sexual activity with a client.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat. 

BUSINESS ASSOCIATES. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

MILITARY AND VETERANS. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military. 

WORKERS' COMPENSATION. We may release Health Information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. 

PUBLIC HEALTH RISKS. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

HEALTH OVERSIGHT ACTIVITIES. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

DATA BREACH NOTIFICATION PURPOSES. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

LAWSUITS AND DISPUTES. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. 

LAW ENFORCEMENT. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person's agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. 

CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties. 

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. 

PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations. 

INMATES OR INDIVIDUALS IN CUSTODY. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.

CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT: 
INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

DISASTER RELIEF. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES
The following uses and disclosures of your Protected Health Information will be made only with your written authorization:
1. Uses and disclosures of Protected Health Information for marketing purposes; and
2. Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation. 

YOUR RIGHTS:
You have the following rights regarding Health Information we have about you:
Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to Samantha Salazar, M.A, LPC (Records Manager). We are not required to give you access directly to our records management system as that would potentially compromise the privacy of other clients. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

Please note that we follow the allowances made in the Texas State Law regarding record retention and records more than 5 years old may have already been destroyed.

RIGHT TO AN ELECTRONIC COPY OF ELECTRONIC MEDICAL RECORDS. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request within 15 days, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

RIGHT TO GET NOTICE OF A BREACH. You have the right to be notified upon a breach of any of your unsecured Protected Health Information. If the breach affects more than 500 people, a general notice will be made via local media and on our website.

RIGHT TO AMEND. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request (including the reason for the request), in writing, to Samantha Salazar, M.A., LPC (Records Manager). You will receive a response within 60 days of our receipt of your request. We may deny your request, in writing, if we find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of our records, or (d) written by someone who is no longer associated with this company. Our denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and AFT's denial be attached to any future disclosures of your Health Information. If we approve your request, we will make the change(s) to your Health Information. Additionally, we will tell you that the changes have been made, and will advise all others who need to know about the change(s) to your Health Information.

RIGHT TO AN ACCOUNTING OF DISCLOSURES. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Samantha Salazar, M.A., LPC (Records Manager). AFT will respond to your request for an accounting of disclosures within 60 days of receiving your request.

RIGHT TO REQUEST RESTRICTIONS. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to Samantha Salazar, M.A., LPC (Records Manager). We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us "out-of-pocket" in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Out-of-Pocket-Payments. If you paid out-of-pocket in full (or in other words, you have requested that we not bill your health plan) for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request. You may choose to not use your insurance even if your insurance plan would otherwise cover the services requested.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to your therapist and/or Samantha Salazar, M.A., LPC (Records Manager). Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests. 

RIGHT TO A PAPER COPY OF THIS NOTICE. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, www.Ackermanfamilytherapy.com. To obtain a paper copy of this notice, you may either download and print a copy from the website or you may ask your therapist for a copy. Please note that due to the location of the printer/copier, your therapist may not have a paper copy available during your session, but will make arrangements to have a copy available as soon as is reasonably possible.

CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner.

COMPLAINTS:
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. 

To file a complaint with our office, contact Samantha Salazar, M.A., LPC (Privacy Officer), Ackerman Family Therapy, PLLC, sam@ackermanfamilytherapy.com or submit written complaints by mail or in person at the office where you received services.

If you believe that a therapist has behaved in an unethical or illegal manner, you may file a complaint with the Licensing board in the state where you received services.
Texas State Licensing Board: 1-800-942-5540
Complaints Management and Investigative Section 
P.O. Box 141369 
Austin, Texas 78714-1369 

All complaints must be made in writing. You will not be penalized for filing a complaint.

Office Policies and Informed Consent for Therapy Services
This form provides you, the client, with information that is additional to the HIPAA Notice of Privacy Practices.

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law as explained in the Notice of Privacy Practices.

LITIGATION LIMITATION: AFT therapists do not conduct assessments for child custody nor are we equipped to provide mental stability assessment for legal purposes. We do not provide expert witness services. By signing this consent, you are agreeing that, should there be legal proceedings neither you nor your attorney(s), nor anyone else acting on your behalf will call on any AFT therapist to testify in legal proceedings, nor will a disclosure of the records be requested for legal purposes unless otherwise agreed upon in writing during the initial session. 

If the therapist is ordered to appear in court, a fee of $600 is due immediately. If records are subpoenaed or an attorney requires a phone call or meeting related to the records, you will be charged $150 for each hour of preparation, communication, and/or travel, plus all legal fees incurred by AFT in response to the subpoena. If there is no prior written agreement, you will also owe a $1,000 breach of contract fee.

CONSULTATION: AFT therapists consult regularly with other professionals regarding clinical work. These meetings are held in confidential spaces, each client's identity remains anonymous and the other professionals are bound by the same confidentiality laws described in the Privacy Practices.

COMMUNICATIONS: The most secure means of communicating with your therapist is via phone call or sending a message through the secure client portal. By default, the client portal will send reminders via text message and via email. If you do not want reminders, please ask your therapist to change the settings on your account. 

AFT therapists do not accept friend requests from current or former clients on social networking sites, such as Facebook because we believe that adding clients as friends on these sites and/or communicating via such sites is likely to compromise the client's privacy and confidentiality. For this same reason, we request that clients not communicate with AFT therapists via any interactive or social networking web sites. Additional information is provided in the consent for unencrypted communications.

RECORDS AND YOUR RIGHT TO REVIEW THEM: AFT retains clinical records only as long as is mandated by Texas law. If you have concerns regarding the treatment of your records, please discuss them with Samantha Salazar, M.A., LPC (records custodian). As a client, you have the right to review or receive a summary of your records at any time, or request that your records be released to another agency or individual. If the AFT therapist and/or the records custodian assesses that releasing such information might be harmful in any way, AFT will provide the records to an appropriate and legitimate mental health professional of your choice. 

When more than one client is involved in treatment, such as in cases of couple and family therapy, AFT will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact your therapist between sessions, please leave a message on that therapist's direct voicemail (the phone numbers are listed at www.ackermanfamilytherapy.com) your call will be returned as soon as possible. Ms. Salazar checks her messages a few times during the daytime only. If you have an emergency indicate it clearly in your message and if you need to talk to someone right away call 9-1-1 for medical or police emergencies or 800-273-TALK (8255) for mental health emergencies. You may also go to an emergency room such as Bellaire Behavioral Hospital. 

Please do not use email, text message, or faxes for emergencies as these communications may not be received in a timely manner. 

PAYMENTS: Clients are expected to pay the standard session fee at the beginning of each session unless other arrangements have been made via a fee adjustment agreement or confirmation of insurance coverage.
Please notify your therapist if any problems arise during the course of therapy regarding your ability to make timely payments. 
AFT may keep your credit card on file for the purpose of collecting patient responsibility amounts and other fees. 
If your account is overdue (unpaid) for more than 10 days and there is no written agreement on a payment plan, AFT may use legal or other means (courts, collection agencies, etc.) to obtain payment. 

The standard fee for a 45-minute session is $125. Assessment sessions have higher fees (eg. $165 for 45-minute appointments, $295 for 90-minute appointments). 
Specific therapists may offer lower fees.

AFT provides direct billing for BCBS PPO plans. If you have another type of insurance, each session invoice (available on the client portal) includes all the information necessary should you choose to submit claims for reimbursement.

Acceptable forms of payment include: cash, checks, credit cards.
Health Care Savings Account cards may be used to pay for counseling sessions. Returned checks incur a $50 late payment fee. 

If you believe AFT has overcharged your credit card, please contact the therapist so that we can investigate the situation. If we have made an error we will issue a refund. If you have the credit card company reverse the charge without contacting us first, you will incur a $75 fraud investigation fee.

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for re-scheduling or canceling an appointment. Your card on file will be charged $75 if you contact us with less than 24 hours notice but more than 2 hours notice. The full session fee (as shown on the invoice) will be charged for less than 2 hours notice and for sessions missed without notification. 
Insurance companies do not cover or reimburse for missed sessions or late cancellation fees. 

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. 

Your therapist will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. 

During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Your therapist may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. 

Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. 

Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and perhaps frustrating. 
There is no guarantee that psychotherapy will yield positive or intended results. 

During the course of therapy, your therapist is likely to draw on various psychological approaches according to the problem that is being treated and his/her assessment of what will best benefit you. These approaches include, but are not limited, to cognitive-behavioral, family systems, EMDR (eye-movement desensitization and reprocessing), and psycho-education. 

AFT therapists are not medical doctors and do not provide medication or prescriptions.

TERMINATION: After the first couple of meetings, your therapist will assess if s/he can be of benefit to you. If at any point during psychotherapy the therapist assesses that progress has stopped, that there is an unresolvable conflict of interest, that there has been a breach of contract, or that you require a different therapeutic approach or higher level of care, the therapist will initiate case closure and provide any appropriate referrals. You also have the right to terminate therapy at any time. Your financial responsibilities to AFT continue until all outstanding claims and/or balances are paid in full regardless of therapy termination date. 

DUAL RELATIONSHIPS: Therapy never involves sexual or any other dual relationship that impairs your therapist's objectivity, clinical judgment or can be exploitative in nature. Your therapist will assess carefully before entering into non-sexual and non-exploitative dual relationships with you. It is important to realize that in some communities, particularly small towns, military bases, university campus, etc., multiple relationships are either unavoidable or expected. Your therapist will never acknowledge working therapeutically with anyone without the client's written permission. 
Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advise your therapist if the dual relationship becomes uncomfortable for you in any way. Your therapist will always listen carefully and respond to your feedback and will discontinue the dual relationship if it is interfering with the effectiveness of the therapy or your welfare and, of course, you may do the same at any time. 
Therapists do not provide counseling services to friends. The difference between friendship and other dual relationships is somewhat subjective, but in general, the therapist would seek emotional support from a friend but should not do so with a client.