Notice of Privacy Practices




Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information ("PHI"). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act ("HIPAA"), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request, or providing one to you at your next appointment.


As authorized by law, we may use and disclose your PHI for the following purposes:

  • For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.
  • For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection services due to lack of payment for treatment that has been provided, we will only disclose the minimum amount of PHI necessary for purposes of collection.
  • For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., accounting services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
  • Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.


Following is a list of categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.

  • Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.
  • Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.
  • Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.
  • Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.
  • Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
  • Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.
  • Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
  • Specialized Government Functions. We may review requests from U.S military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons, and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws, and the need to prevent serious harm.
  • Public Health. If required, we may use or disclose your PHI for mandatory public health activities  to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.
  • Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.


Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization:

(i) Most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record;

(ii) Most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications;

(iii) HIPAA allows covered entities to sell PHI with the patient's written authorization; however, according to Texas House Bill 300, covered entities in Texas may not receive any payment -direct or indirect- for the disclosure of PHI. This agency will not sell your PHI; and

(iv) Other uses and disclosures not described in this Notice of Privacy Practices.

Research. PHI may only be disclosed for research purposes after a special approval process or with your authorization.

Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.

Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

Notification of Electronic Disclosure of PHI. Texas House Bill 300 states that covered entities must provide notification to individuals if their PHI is subject  to electronic disclosure, and that a separate patient authorization is needed each time an individual's PHI will  be electronically disclosed. Such authorization may be made in written or electronic form, or in oral form if it is documented in writing by the covered entity.


You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request IN WRITING to our Privacy Officer at Imagine Counseling, LLC, 4081 DeZavala Rd. Suite # 1, San Antonio, TX, 78249, phone (210) 884-6629.

  • Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a "designated record set". A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy your PHI will be restricted only in those situations  where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. I will respond to your request within 15 days after the date of receipt of the written request. If your records are maintained electronically, Texas House Bill 300 states that they must be delivered in electronic form, unless the person agrees to accept the record in another form. You may also request a copy of your PHI be provided to another person. We may charge a reasonable, cost-based fee for copies. If you prefer, we could prepare a summary or an explanation of your health information.
  • Right to Amend. If you feel  that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You may be asked to provide a reason to support the requested amendment. We are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal. Please contact the Privacy Officer if you have any questions.
  • Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. If you request this accounting more than once within a 12-month period, we may charge you a reasonable, cost based fee for responding to these additional requests.
  • Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment or health care operations. We are not legally required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In such case, we are required to honor your request for a restriction. In other instances, we are not legally required to accept your request, but if we do, we will put any limits in writing and abide by them, except in an emergency situation.
  • Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location to maintain your confidentiality. We will accommodate reasonable requests and will not require an explanation from you as to the basis for your request, but we may require information regarding how payment will be handled, or specification of an alternative address or other method of contact as a condition for accommodating your request.
  • Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
  • Right to a Copy of This Notice. You have the right to a copy of this notice at any time.


If you have any concerns or questions about this Notice, or if you would like additional information about our privacy practices, or if you want to report a problem regarding the handling of your information, please contact us.

If you are concerned and believe that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information, or in response to a request you made to amend or restrict your protected health information, you have the right to file a complaint in writing with our Privacy Officer at Imagine Counseling, LLC, 4081 DeZavala Rd. Suite # 1, San Antonio, TX 78249, phone (210) 884-6629.

You may also file a complaint with the Secretary of Health and Human Services. Your complaint must be filed in writing, either electronically via the Office of Civil Rights Complaint Portal, or on paper by mail, fax, or e-mail. The address to file a privacy complaint with the Office of Civil Rights for Region VI (TX, AR, LA, NM, OK) is:

Office of Civil Rights, DHHS

1301 Young Street - suite 1169

Dallas, TX 75202

Ph. (214) 767-4056

(214) 767-8940 (TDD)

(214) 767-0432 (Fax)

You can also file a complaint with the DHHS at the following website:

We support your right to the privacy of your protected health information. This agency cannot and will not retaliate against you or refuse you treatment if you choose to file a complaint with this agency or with the U.S. Department of Health and Human Services.

The effective date of this Notice is September 23rd, 2013

Privacy Officer/Contact Person:

Maria del Carmen Mejia-Desatnik, LCSW

Imagine Counseling, LLC

4081 DeZavala Rd. Suite # 1

San Antonio, TX 78249

Ph. (210) 884-6629