HIPAA, The Health Insurance Portability and Accountability Act was enacted by congress to protect your personal health information.  It is a set of regulations about how healthcare information is stored, shared, and how disclosures are made.  It is intended to protect your private medical information.  The State of Texas and the Texas State Board of Examiners of Licensed Professional Counselors, Social Workers, Marriage and Family Therapists, and Psychologists code of ethics have long-established standards which in most cases meet and in some cases exceed HIPAA standards.  This office has and will continue to comply with all ethical and legal guidelines in the state of Texas that apply to mental health counseling, and with the newly enacted Federal HIPAA regulations. 

 

The following outlines circumstances in which your personal health information may be used.

1. In accordance with HIPPA, your information may only be released with your consent. 

2. Your demographic information, as well as diagnosis, is used in secure electronic billing.  Billing staff is informed of dates of service, diagnosis, demographic information, and health insurance information. For clients who chose to file insurance claims, please be aware that in order for you to be reimbursed by your health care company, I will be required to diagnose a mental health condition. Any diagnosis made may become part of your medical / insurance record.

3. All of our sessions will become part of your clinical record.  Our communication is privileged.  I will keep confidential anything you say to me, with the following exceptions: 1) you authorize me to tell someone else, as in the case with insurance reimbursement, or consultation with another professional, 2) I am ordered by the court to disclose your information, 3) I determine that you are a danger to yourself or to others, 4) If during session I become aware that there is physical abuse, sexual abuse, or neglect to a child or an aged adult, I am required to report to the State of Texas Protective Services. 5) I must also disclose to the proper authorities if there has been sexual abuse perpetrated by a minister or therapist, or if there has been a life-threatening felony unreported. I keep your client file in dual locked storage.  I maintain records for a period of five years for adults and five years beyond the age of 18 for children.  All electronic data is password protected.

4. In the event any unpaid balance for services of your patient account have not been taken care of within 180 days, and no payment plan or alternate arrangement has been agreed upon, demographic information, date of service, service provided, charges paid and unpaid will be turned to a professional collection service, or reported to credit agencies.

5. When requesting additional authorizations from your insurance company (particularly HMO’S) I will be required in most cases to support my request with clinical information. 

6. To ensure that I am providing quality of care, insurance companies may from time to time audit me.  In the event of this, an agent of the insurance company may request access to your chart to ensure that essential paperwork is enclosed such as initial assessment, visit log, demographic information, client contract, explanation of confidentiality, treatment plan and discharge notes. 

7. I may hire a medical professional to audit charts to prepare for such mentioned audits and or to provide support services as needed.  No other Quality Improvement etc will be performed on your file, by anyone other than myself.    Any business agent such as a medical billing service, medical secretary, or auditor is bound to strict confidentiality and is punishable by law for any infringement upon confidentiality clauses.

 

Thank you for choosing me as your provider.  I appreciate the trust and the opportunity to work with you.  If you have any questions please feel free to speak with me.  Please ask questions.  Once you have read and have an understanding of the above information on health insurance claims and HIPAA please sign and Date below.

 

 

____________________________________       __________________________

Client Signature or Legal Guardian                      Date

 

___________________________________         _____________________________

Printed Name                                                      Relationship to Client

 

 

If you have any further questions regarding HIPAA you may visit www.hhs.gov/ocr/hipaa or call directly 1-866-627-7748 or email questions to ocrprivacy@os.dhhs.gov