Noel C Gonzalez Psychotherapy + Consultation
281-501-3683
TREATMENT:
Notice of Privacy Policy
PAYMENT:
OFFICE ADMINISTRATION:
Treatment is when I provide, coordinate or manage your mental health care and other services related to such care. An example of treatment would be when I consult with another health care provider, such as your family physician or psychiatrist.
This notice described how mental health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. I may use or disclose your protected health information (information that could identify you) for treatment, payment and office administration. To help clarify these, here are some definitions.
Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your information to your health insurance when I provide you with documentation for you to obtain reimbursement for your health care or to determine eligibility or coverage.
Office administration is any activity that related to the performance and operation of my practice. Example are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
DISCLOSURES REQUIRING SPECIFIC AUTHORIZATION:
I may use or disclose yoru protected health information for purposes other than the three previously listed (treatment, payment, office administration) when your specific authoriation is obtain. A specific authorization is written permission that permits only a specific discloure. You may reovel all such specific authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that 91) I have relied on that authoircation, or (2) if the authorization was obtained as a condition of obtain insurance overage, and the law provides the insurer the right to contest the cliam uner the policy.
I may use or disclose your protected health information without a specific authorization in the following circumstances:
- Child/Elderly/Disabled Abuse
If I have cause to believe that a child, elderly person, or disabled person has been, or may be abused, neglected, exploited or sensually abused, I am legally required to make a reported within 48 hours to the appropriate state or local agency.
- Health Oversight:
If a complaint is filed against me with the licensing board, they have the authority to subpoena confidential mental health information form me relevant to that complaint.
- Judicial 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. I will not release information, without written authorization from you or your representative, unless I am court ordered.
- Serious Threat to Health or Safety:
If I determine that there is a probability of imminent physical injurty by you to yourself or others. I may disclose relevant confidential mental health information to medical or law enforcement personnel.
DISCLOSURES WHICH REQUIRE NO SPECIFIC AUTHORIZATION:
PATIENT'S RIGHTS:
- Right to Receive Confidential ComRight to Request Restrictions
You have the right to request restriction on certain uses and disclosure of protected health information about you. However, I am not required to agree to a restriction you requested.
- Right to Receive Confidential Communications by Alternative Means and at Alternative Locations
You have the right to revues and receive confidential communication of your protected health information by alternative means and at alternative locations (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bill to another address).
- Right to Inspect and Copy
You have the right to inspect or obtain a copy (or both) of your protected health information in my mental health and billing records used to make decision about you for as long as your protected health information is maintained in the record. I may deny your access to such information under certain circumstanced, 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 Amend
You have the right to request an amendment of your protected health information in the record. I 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 your protected health information for which you have neither provided consent nor authorization. On your request, I will discuss with you the details of the accounting process.
- Right to a Paper Copy
You have the right to obtain a paper copy of thi notice from me upon request.
THERAPIST'S DUTIES:
- I am required by law to maintain the privacy of your protected health information and to provide you with a notice of my legal duties and privacy practices.
- Ireserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am requrited to abide by the terms currently in effect.
- If I revise my polices and procedures, i will provide you with a Revised Notice Form.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I will provide you with the address upon request.
Dr. Noel C Gonzalez
401 Northwood Street
Houston, Texas 77009
281.501.3683
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