Notice of Privacy Practices
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.
Your Rights
When it comes to your health information, you have certain rights. This section explains your
rights and some of our responsibilities to help you.
You have the right to inspect and copy your protected health information – This means you may
inspect and obtain a copy of protected health information about you that is contained in your patient
record. In certain cases, we may deny your request. You may be charged a reasonable, cost-based
fee.
You may have the right to have us amend or correct your protected health information – You can
ask us to correct health information about you that you think is incorrect or incomplete. We may
say “no” to your request, but we’ll tell you why in writing within 60 days.
You have the right to request confidential communications – You can ask us to contact you in a
specific way (for example, home or office phone) or to send mail to a different address. We will
say “yes” to all reasonable requests.
You have the right to request a restriction of your protected health information – This means you
may ask us, in writing, not to use or disclose any part of your protected health information for the
purposes of treatment, payment or healthcare operations. You may also request that any part of
your protected health information not be disclosed to family members or friends who may be
involved in your care or for notification purposes as described in this Notice of Privacy Practices.
In certain cases, we may deny your request for a restriction.
You have the right to receive a copy of this Notice of Privacy Practices – We are required to follow
the terms of this notice. We reserve the right to change the terms of our notice, at any time. If
needed, new versions of this notice will be effective for all protected health information that we
maintain at that time. Upon your request, we will provide you with a revised Notice of Privacy
Practices if you call our office and request that a revised copy be sent to you in the mail or ask for
one at the time of your next appointment.
You have the right to choose someone to act for you – If you have given someone medical power
of attorney or if someone is your legal guardian, that person can exercise your rights and make
choices about your health information. We will make sure the person has this authority and can
act for you before we take any action.
You have the right to file a complaint if you feel your rights are violated – You can complain if
you feel we have violated your rights by contacting us using the information on page 1. You can
file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights
by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-
696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against
you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a
clear preference for how we share your information in the situations described below, talk to us.
Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead
and share your information if we believe it is in your best interest. We may also share your
information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
Our Uses and Disclosures
We typically use or share your health information in the following ways:
For Treatment – We may use and disclose your protected health information to provide, coordinate,
or manage your health care and any related services. We will also disclose protected health
information to other physicians who may be involved in your care and treatment. We may use or
disclose your protected health information, as necessary, to contact you to remind you of your
appointment.
For Payment – Your protected health information will be used, as needed, to obtain payment for
our health care services. This may include certain activities that your health insurance plan may
undertake before it approves or pays for the health care services we recommend for you such as:
making a determination of eligibility or coverage for insurance benefits, reviewing services
provided to you for medical necessity, and undertaking utilization review activities.
For Healthcare Operations – We may use or disclose, as needed, your protected health information
in order to support the business activities of our practice. This includes, but is not limited to
business planning and development, quality assessment and improvement medical review, legal
services, and auditing functions. It also includes education, provider credentialing, certification,
underwriting, rating, or other insurance related activities. Additionally, it includes business
administrative activities such as customer service, compliance with privacy requirements, internal
grievance procedures, due diligence in connection with the sale or transfer of assets, and creating
de-identified information.
As Required by Law – We may use or disclose your protected health information to the extent that
the law requires the use or disclosure.
For Health Oversight – We may disclose protected health information to a health oversight agency
for activities authorized by law, such as audits, investigations, and inspections.
In Cases of Abuse or Neglect – We may disclose your protected health information to a public
health authority that is authorized by law to receive reports of child abuse or neglect. In addition,
we may disclose your protected health information if we believe that you have been a victim of
abuse, neglect or domestic violence to the governmental entity or agency authorized to receive
such information. In this case, file disclosure will be made consistent with the requirements of
applicable federal and state laws.
For Legal Proceedings – We may disclose protected health information in the course of any
judicial or administrative proceedings, in response to an order of a court or administrative tribunal
(to the extent such disclosure is expressly authorized), in certain conditions in response to a
subpoena, discovery request or other lawful process.
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health
information.
• We will let you know promptly if a breach occurs that may have compromised the privacy
or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy
of it.
• We will not use or share your information other than as described here unless you tell us we
can in writing. If you tell us we can, you may change your mind at any time. Let us know in
writing if you change your mind.
For Records Requests
Please contact us directly-
Finding Freedom Therapy, PLLC
4099 McEwen Rd, Ste 610
Dallas, TX 75244
Phone: 972-674-9166
Fax: 469-574-0361
For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
We can change the terms of this notice, and the changes will apply to all information we have
about you. Any new notice will be available upon request, in our office, and on our website.