Notice of Policies and Practices to Protect the Privacy of Your Health Information

This notice describes how medical information about you may be used, disclosed, and accessed. Please review this notice carefully before signing. If you have any questions, please ask your counselor for clarification.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”) and regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules. It also describes your rights regarding how you may gain access to and control your PHI. 

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request, or providing one to you at your next appointment.

How we may use and disclose health information about you:
For Treatment: Your PHI may be used and disclosed by those involved in your care for the purpose of providing your treatment and related services. Disclosures include consultations with clinical supervisors and other treatment team members.


Disclosure of PHI to parties outside of Annie’s Counseling or Greater Dallas Support Alliance is not permitted except in the following instances:
•    You disclose abuse, neglect, or exploitation of a child, elder, or disabled person
•    I determine you are a danger to yourself or others
•    I am court ordered through a subpoena
•    You disclose sexual contact with another health professional 
•    Medical emergencies
•    You direct me in writing to release your records
•    I am otherwise required by law to disclose such information


Written authorization: Written authorization can be revoked at any time, except to the extent that we have already made a use or disclosure based on prior authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.


For payment: With your written authorization, we may use and disclose PHI so that we can receive payment for the treatment services provided to you. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services to determine medical necessity, or utilization review activities.


Should non-payment necessitate a collection process, we will disclose the minimum amount of PHI required for collection purposes.


Third party vendors: Annie’s Counseling uses third party vendors for data storage of client PHI. Annie’s Counseling has entered agreements with each vendor in order to protect your PHI.


Release of information to family: We may disclose information to family members or friends only with your written consent or as necessary to prevent serious harm.

Legally authorized representative: Legally authorized representatives, often a parent or legal guardian, has the right to access the PHI of the person for whom they provided consent to treat except when:
•    A parent has voluntarily agreed to the client’s confidentiality
•    Provider has a reasonable belief that the legally authorized representative has abused or neglected the client, or could endanger the client.


Deceased clients: We may disclose PHI regarding deceased clients as mandated by state or federal law, or to a family member or friend based on your prior consent.


Oversight: If required, we may disclose PHI to a health oversight agency for the purpose of audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program, and peer review organizations performing utilization and quality control.


Fundraising and research: For the purpose of fundraising and/or research, only non-identifying, aggregated PHI will be shared. Non-aggregated PHI will only be shared with written authorization.


Surveys: Some of our grants that provide funding for services ask that we have those receiving services from the grant complete surveys throughout treatment. We will protect confidentiality with surveys, unless otherwise noted by you, the client, in written form.


Your rights regarding your PHI (for counseling clients):

You have the following rights regarding PHI we maintain about you. To use any of these rights, please submit your requesting in writing to Katherine Foutz, LMSW, LCDC, Privacy Officer for Annie's Counseling at PO Box 1350 Forney, TX 75126.

  • Right of access to inspect and copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.

  • Right to amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.

  • Right to disclosures. You may request a record of disclosures of your PHI outside of the organization. We may charge a reasonable fee if you file more than one request in any 12 month period.

  • Right to request restrictions. You have the right to request restrictions or limitations on the disclosures of your PHI for the purpose of treatment, payment, or health care operations. If your limitation prevents us from collecting payment from an insurer or third party, you are responsible for the service fee.

  • Right to request how we communicate with you. You have the right to request that we communicate with you about health matters in certain way.

  • Breach notification. If there is a breach in of your PHI concerning you, we may be required to notify you of this breach, including what happened and how you can protect yourself.

  • Copy of this notice. You have a right to a copy of this notice.


This policy applies to all counseling sessions, both in person and via telehealth. 


If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer Katherine Foutz at Annie's Counseling PO Box 1350 Forney, TX 75126 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257.

We will not retaliate against you for filing a complaint.

Last updated June 2020