THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO ME.

OUR LEGAL DUTY

I am required by applicable federal and state law to maintain the privacy of your health information. I am also required to give you this Notice about privacy practices, my legal duties, and your rights concerning your health information. I must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect January 1, 2016, and will remain in effect until I replace it.

I reserve the right to change my privacy practices and the terms of the Notice at any time, provided such changes are permitted by applicable law. I reserve the right to make the changes in my privacy practices and the new terms of my Notice effective for all health information that we maintain, including health information I created or received before I made the changes. Before I make a significant change in my privacy practices, I will change this Notice and make a new Notice available upon request.

You may request a copy of our notice at any time. For more information about my practices, or for additional copies of this Notice, please contact me using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

I use and disclose health information about you for treatment, payments, to obtain managed care authorizations, and other healthcare operations. For example:

         Treatment: I may use or disclose your health information to a physician or other healthcare provider providing treatment for you.

         Payment: I may use and disclose your health information to obtain payment for services I provide to you.

Healthcare Operations: I may use or disclose your healthcare information to provide quality assessment and improvement activities, to review the competence or qualifications of healthcare professionals, for evaluation of practitioner and provider performance, for conducting training programs, accreditation, certification, licensing, or credentialing activities.

Your Authorization: In addition to my use of your health information for treatment, payment or healthcare operations, you may give me written authorization to use your health information or to disclose it to anyone for any purpose. If you give me authorization, you may revoke it in writing at any time. Your revocation will not affect any use of disclosures permitted by your authorization while it was in affect. Unless you give me a written authorization, I cannot use or disclose your health information for any reason except those described in the Notice.

To Your Family and Friends: I must disclose your health information to you, as described in the Patient Rights section of this Notice. I may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may.

Persons Involved in Care: I may use or disclose health information to notify, or assist in the notification of a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, I will provide you with an opportunity to object to such use or disclosures. In the event of your incapacity or emergency circumstances, I will disclose health information based on a determination using my professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. I will also use my professional judgment and my experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up health information.

Marketing Health Related Services: I will not use your health information for marketing communication.

Required by Law: I may use or disclose your health information when I am required by law to do so, or if a court of law orders your records.

Abuse, Neglect, or Threats of Harm: I may disclose your health information to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. I may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security:  I may disclose to military authorities the health information of Armed Forces under certain circumstances. I may disclose to authorized federal officials' health information required for lawful intelligence, counterintelligence, and other national security activities. I may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmates or patients certain circumstances.

Appointment Reminders: I may disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

Patient Rights

Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information.  You may obtain a form to request access by using the contact information listed at the end of this Notice.  I will charge you a reasonable fee for expenses, such as those required to make copies and for use of our staff time. You may also request access by sending us a letter to the address at the end of this Notice.

Disclosure Accounting: You have the right to receive a list of instances in which I or my business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, I may charge you a reasonable, cost based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. I am not required to agree to these additional restrictions, but if I do, I will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request in writing that I communicate with you about your health information by alternative means or to alternative locations. You must provide satisfactory explanation of how payments will be handled under the alternative means or locations.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing and must include the reason for the amendment). I may deny your request under certain circumstances.

Electronic Notice: If you received this notice electronically, you have the right to receive it in writing.

Questions and Complaints

If you want more information about my privacy practices or if you have any questions or concerns, please contact me.

If you are concerned that I may have violated your privacy rights or you disagree with a decision I made about your health information, you may complain to me using the contact information at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services.

I support your right to the privacy of your health information. I will not retaliate in any way if you choose to file a complaint with me or with the U.S. Department of Health and Human Services.

Contact the Therapist:                   Kristi Baumbach, LCSW  

Telephone #:                                   512-217-5076

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client or parent's) written permission, except when required by law. I am required to report any known or suspected abuse of child or elder abuse or neglect, and to take action to ensure safety if a client presents danger to self or others. I must also disclose to the proper authorities if there has been sexual abuse perpetrated by a minister or therapist.

For educational and professional purposes, I consult regularly with other professionals regarding clients in order to ensure quality of my service; however, a client's name or other identifying information is never mentioned.

EMERGENCIES: If you are unable to reach me in an emergency, you or someone you trust should call the local emergency room, your medical doctor, or 911. If I assess you may be at risk to harm self or others, I may contact your Primary Care Physician, your emergency contact, or emergency personnel to advocate for your care and safety.

HEALTH INSURANCE - CONFIDENTIALITY OF RECORDS & PAYMENT: Your health insurance may require confidential information in order to process your claims. If I am not in network with your insurance company, I will not bill for your psychotherapy sessions to your insurance, but will provide you the information to do so if requested. If you request a receipt to submit for reimbursement, the full session fee is due on the date of service. It is your responsibility to verify the specifics of your coverage.   If I am in network with your insurance company, your co-pay is due at the time of the session and I will then file with your insurance company as a courtesy to you.  It is your responsibility to make sure your visits are covered and you are responsible for any balance insurance does not pay.

YOUR RIGHT TO REVIEW RECORDS/ HIPAA NOTICE: You have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when releasing information might be harmful in any way. In such case, I will provide the records to a licensed mental health professional of your choice. Considering the above exclusions, I will release information to any entity you specify only upon receiving your written authorization.

LITIGATION LIMITATION: Due to the sensitive nature of therapy and the information shared and addressed, I am not obligated to supply any documentation, correspondence, or presence regarding any legal proceedings. Should you or your attorney desire any documentation or service for court/legal purposes, I must receive such request in writing and by law have 15 days to give a response. I may decline the request if disclosure of the requested information may be harmful in any way to the client; no request will be acknowledged unless it is accompanied by the client or guardian's written permission. Any documentation, consultation, or testimony requests will incur a charge of $100 per half hour. Testimony charges may include time spent traveling, preparing reports, attendance, and other case related costs.

DUAL RELATIONSHIPS: Dual relationships should be avoided whenever possible, especially when ethics or your treatment progress may be in question. Therapy never involves sexual or any other dual relationships that may impair my objectivity, clinical judgment and effectiveness or could be exploitative in nature. Should we encounter each other anywhere outside of my office, I will not approach you or acknowledge you unless you initiate contact.

THE PROCESS OF THERAPY: Participation in therapy can result in benefits to you, including improving relationships and resolution of specific concerns or symptoms that led you to seek therapy. Working toward these requires effort on your part both in and outside of sessions. Although therapy has been shown to improve relationships and symptoms, it may create uncomfortable feelings in the short-term. For example, addressing unpleasant past experiences can result in experiencing discomfort or strong feelings. Please inform me if such issues arise. Therapy is most likely to be successful with your active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. During the course of therapy, I am likely to draw from psychological approaches, such as Cognitive Behavior Therapy, Cognitive Therapy, EMDR, Trauma Focused Yoga, or other modalities according to the problem being treated and my assessment of what will benefit you. 

MINOR CLIENTS: Parents have a right to receive progress reports on their child's counseling. However, personal information shared by a child during an individual session will be kept confidential unless it involves imminent danger to the child or someone else. Young people may not confide in a counselor if they believe that personal information will be revealed to their parents. If applicable, I must receive a copy of the most recent divorce decree or custody order at our first session; this is to ensure proper consent, confidentiality and disclosure of information. All parent/guardian parties must be informed of treatment, and all with custody rights must consent to treatment of minor at or prior to the first session.

DURATION & TERMINATION: The duration of treatment depends entirely on your presenting concerns, treatment goals we develop together, and effort toward those goals in and outside of sessions. We will discuss goals and course of treatment periodically, with initial goals/focused developed by the 3rd or 4th session. I request notice before therapy is terminated in order to process gains made during treatment, and issues to be addressed in the future.

PAYMENTS & FEES: Payment in the amount of your fee is due at each session. I accept cash, check, or debit/credit card.  My fee is $150 per 55 minute session and $175 per 80 minute session unless other arrangements have been made.   I understand that if there is a rate change I will be given 30 days written notice.Telephone conversations, report writing/reading, release of information, longer sessions, etc. will be charged at the same rate, unless indicated and agreed otherwise. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments. A fee of $35 will be assessed for returned checks.

PHONE CALLS & E-MAIL: If you need to contact me between sessions, I allow 10 minutes between sessions without charge. I check my phone and e-mail messages daily except for holidays and vacation days.  I return phone calls within 48 hours. You may e-mail me to make, cancel, or reschedule an appointment, or make brief reports about your progress. Therapy issues or crises will not be addressed by e-mail or text messages.   Email and text messages are not HIPAA compliant and I cannot guarantee the security of using these means of communication.   Please list your preferred email and phone contact information in your intake paperwork.

APPOINTMENT REMINDERS: I typically send appointment reminders via text or email (ie "I'd like to confirm our appt for tomorrow at 3:00").   You may select how to receive reminders through the settings on this system.     

CANCELLATION: Your full fee is charged for "no shows" and appointments cancelled less than 24 hours before the scheduled time. An appointment is considered cancelled when not attended at the agreed time/date. Payment is due for any missed appointment at the beginning of the next session.

CLIENT/GUARDIAN: I have carefully read, understand, and agree to comply with the above policies and information, and consent for treatment and psychotherapy services with Kristi Baumbach, LCSW.

If psychotherapy services are not rendered in a professional and ethical manner, you may file a complaint with the Texas State Board of Social Workers, Complaints Management and Investigative Section P.O. Box 141369, Austin, Texas 78714-1369.  Telephone: 1-800-942-5540