Privacy Policy - HIPAA & Communication Consent

Community Counseling Center

Notice of Privacy Practices

Effective Date: April 3, 2024

THIS NOTICE DESCRIBES HOW MEDICAL AND MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED — AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1. Our Legal Duties

We are required by law to:

  • Keep your protected health information (PHI) private and secure.

  • Provide you with this Notice of Privacy Practices (NPP) about how we may use and disclose your PHI.

  • Follow the terms of this NPP.

  • Notify you if there is a breach of your unsecured PHI.

  • No health information or private information shall be shared with third parties without written consent.
    We may change our policies and practices in the future. Any updated notice will apply to all your PHI and will be available at our office and on our website.

2. How We May Use and Share Your PHI

Without your authorization, we are allowed to use and disclose your PHI for:

  • Payment: Handling billing, insurance claims, or eligibility verification.

We may also disclose PHI without authorization when required or permitted by law, such as:

  • Reporting abuse, neglect, or domestic violence; public health reporting; legal orders; law enforcement; organ donation; health oversight; to avert serious threats to health or safety, etc.

  • Note on Mental Health Information: Texas law imposes stricter protections for mental health (including psychotherapy notes), substance abuse, genetic, and certain disease-related information. We will not share your info without legal authority or your explicit permission.

3. Your Rights Regarding Your PHI

You have the right to:

  1. Receive Confidential Communications: Ask us to contact you in a certain way or at another location, and we’ll accommodate reasonable requests.

  2. Request Restrictions: Ask us to restrict how we use or share your info for treatment, payment, or operations. We aren’t required to agree, but we will accommodate reasonable requests.

  3. Inspect and Copy: View and copy the PHI we maintain about you. We may charge a reasonable fee.

  4. Amend: Request corrections if you believe there is an error in your records.

  5. Accounting of Disclosures: Ask for a list of the times we’ve shared your PHI—with whom and why (not including disclosures for treatment, payment or operations). You get one free accounting per year.

  6. Copy of This Notice: Obtain a paper copy of this NPP upon request.

  7. Revoke Authorization: You may revoke any authorization you've given us (except to the extent we’ve already relied on it).

4. How to File a Complaint

If you believe your privacy rights have been violated, you may:

  • File a complaint with Community Counseling Center — no retaliation will be taken against you.

  • File a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, Region VI (e.g., Dallas, TX). You may also file with the Texas Health and Human Services Commission or other applicable state authorities.

5. Uses Requiring Authorization

We must obtain your written authorization before using or disclosing PHI for purposes such as:

  • Disclosure of psychotherapy notes (if maintained separately)
    Other uses and disclosures not described in this notice will only occur with your written authorization.

Text and Email Communications

6. No mobile opt-in data will be shared with third parties or affiliates. An additional consent outside of our privacy policy will be required to opt in or out of email or text communications.

7. Acknowledgment of Receipt

For in-person or electronic service, we will provide this notice at your first visit and request that you sign a form acknowledging receipt. If we can’t obtain a signature, we will document our efforts and reasons.

Signature __________________________________________

Date___________________

_____________________________________________________________________________________________________

Communication Consent

You will be asked to sign either accepting or opting out of communication with our office by either email and/or text messages. Each new patient packet will have the consent included with it. You may opt out or in at any time in writing.

Client Communication Consent Form

Client Name: _________________________________________
Phone Number: ________________________________________
Email Address: _________________________________________

We want to keep in touch with you in a way that’s convenient, timely, and respectful of your preferences. Please indicate your consent to receive communications from our office. Please note that no mobile opt-in data will be shared with ANY third parties:

✅ Communication Preferences

Please check the boxes below to indicate your preferences:

☐ I DO NOT wish to receive text messages or emails from Community Counseling Center

☐ Text Messages (SMS)
I give permission to receive appointment reminders, updates, and other non-marketing communications via text message.

☐ Emails
I give permission to receive appointment reminders, updates, newsletters, and other non-marketing communications via email.

🔒 Consent & Privacy

  • Your contact information will be used solely for communication between you and our office.

  • We will never share your information with third parties without your consent.

  • You can opt out of communications at any time by notifying us in writing or following unsubscribe instructions in emails.

✍️ Client Authorization

By signing below, I acknowledge that I have read and understood this consent form. I voluntarily give my permission to be contacted by the methods I selected above.

Client Signature: ___________________________
Date: ________________