This notice describes how medical information about you may be used, disclosed, and safeguarded, and how you can obtain access to this information. Please review it carefully.

Greater Heights Holistic Psychiatry has a legal duty to safeguard your protected health information (“PHI”) and keep it private. PHI constitutes information created or noted by this office that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or payment for such health care. This notice is required to explain when, why, and how your PHI would be used and/or disclosed by this office. Use of PHI is when information is shared, applied, utilized, examined, or analyzed within the office; disclosure of PHI is when information is released, transferred, given, or otherwise revealed to a third party outside of this office. With some exceptions, your PHI will not be used or disclosed more than is necessary to accomplish the purpose for which the use or disclosure is made. Following the privacy practices described in this notice is legally required. Any changes to these practices will apply to PHI already on file. Before any changes to policies are made, this notice may be modified and a new copy of it will be posted in the office and on the website. You may also request a copy of this notice from our office.

Your PHI may be used and disclosed for many different reasons. Some of the uses or disclosures will require your prior written authorization; however, others will not.

Uses and disclosures related to treatment, payment, or office health care operations do not require your prior written consent:

- For treatment. Your health information may be used to give you medical treatment or services. Your PHI may be disclosed to pharmacists and their assistants, and other professionals involved in your care to put in place a treatment plan and to carry out that plan. For example, your PHI may be provided to clarify medication instructions with a pharmacy, obtain prior authorization for certain medications from insurance entities, or disclose health information to physicians who provide follow-up care to you.

- For health care operations. Your PHI may be disclosed to facilitate the efficient and correct operation of this medical practice. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, conducting business or arranging for other related activities.

- To obtain payment for treatment. Your PHI may be used and disclosed to bill and/or collect payment for the treatment and services provided to you.

- Minors. If you are an unemancipated minor (i.e., not legally authorized to act as adult) under Texas law, there may be circumstances in which we disclose health information about you to a parent, guardian, or other person acting in loco parentis, in accordance with our legal and ethical responsibilities.

- Parents. If you are a parent of an unemancipated minor and are acting as the minor’s personal representative, we may disclose health information about your child to you in certain circumstances. If we are legally required to obtain your consent as your child’s personal representative in order for your child to receive care from us, we may disclose health information about your child to you. In some circumstances, we may not disclose health information about an unemancipated minor to you. If your child is legally authorized to consent for treatment, we may not disclose health information about your child to you without your child’s written permission.

- Other disclosures. Your consent is not required if you need emergency treatment. In the event that this office tries to get your consent, but you are unable to communicate (e.g., unconscious), but it is reasonable to assume that you would consent to such treatment if you could, your PHI may be disclosed.

- Required by law. This office may make a disclosure to the appropriate officials when a law requires reporting information to government agencies, law enforcement personnel, and/or administrative proceedings.

- Disclosure may be compelled by a party to a proceeding before a court or an administrative agency pursuant to its lawful authority, or if a search warrant is lawfully issued to a law enforcement agency.

- Health and safety codes and federal regulations. Disclosure may be compelled by the patient or the patient’s representative pursuant to Texas Health and Safety Codes or to corresponding federal statutes or regulations, such as the privacy rule that requires this notice.

- To avoid harm. PHI may be provided to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person including yourself or the public. This includes when disclosure is necessary to prevent the threat of danger from occurring.

- Child/elder abuse and neglect. Disclosure may be mandated by the Texas child abuse and neglect reporting law or the Texas elder/dependent adult abuse reporting laws.

- Threat of violence. Disclosure may be compelled or permitted by the fact that you tell this office of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.

- Public health. Disclosure may be permitted to public health officials if required.

- Health oversight activities. This office may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization.

- Specific government functions. PHI may be disclosed as a matter of national security.

- Worker’s compensation purposes. In certain circumstances, PHI may be provided in order to comply with workers’ compensation laws.

- Appointment reminders and health-related benefits/services. PHI may be used to provide appointment reminders.

- If disclosure is otherwise specifically required by law.
I hereby acknowledge that the HIPPA Clinic Policies have been made available to me for review. I am aware that the policies for this practice may change from time to time and that the current copy of the policy is always available upon request from the GHHP staff. I understand that the clinic is not responsible for providing me the updated policy and it is my responsibility to request GHHP staff in writing.

If you are filling this form electronically, then type your name in this field will be equivalent to signing your name on a paper document.