Caitlin Payne LCSW PLLC

407 Heights Blvd.

Houston, TX 77007

832.548.0643

NOTICE OF PRIVACY PRACTICES

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

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 laws and the professional Codes 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.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

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 colleagues, 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 processes due to lack of payment for services, 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., billing or typing 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 make disclosures of 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 the categories of uses and disclosures permitted by HIPAA (Health Insurance Portability & Accountability Act) without an authorization:

Abuse and Neglect

Judicial and Administrative Proceedings

Deceased Persons

Emergencies

Law Enforcement

National Security

Public Health

Public Safety (Duty to Warn)

Without Authorization: Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

1. Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or the health department)

2. Required by court order

3. 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.

With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing.

1. 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 may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. A reasonable charge may be required to cover the cost of copies.

2. 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 although we are not required to agree to the amendment.

3. Right to an Accounting of Disclosures: You have the right to request an accounting of certain disclosures that we make about your PHI.

4. 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 required to agree to your request.

5. Right to Request Confidential Communication: You have the right to request that we communicate with you about treatment matters in a certain way or at a certain location.

6. Right to Copy of this Notice: You have a right to a copy of this notice.

COMPLAINTS

If you have a complaint or concern, speak first to your therapist. If you are not able to resolve the problem, you can file a consumer complaint with the Texas State Board of Social Work Examiners by calling (800) 942-5540 or in writing at Texas State Board of Social Work Examiners

P.O. Box 141369, Austin, Texas 78714-1369.

The effective date of this notice is May 25, 2020.

Consumer Rights & Instructions (HB 4224)

In accordance with Texas law (House Bill 4224 and Section 181.105 of the Texas Health and Safety Code), the following information is provided to help consumers understand their rights and available resources.

Requesting Your Health Care Records

You have the right to request a copy of your mental health records. To request your records, please submit a written request to your treating clinician. Requests may be made via email, secure client portal, or in writing. Records will be provided in accordance with Texas law and applicable privacy regulations. If you have questions about accessing your records, please contact this practice for assistance.

Contacting the Texas Behavioral Health Executive Council (BHEC)

The Texas Behavioral Health Executive Council investigates and prosecutes professional misconduct committed by marriage and family therapists, professional counselors, psychologists, psychological associates, social workers, and licensed specialties in school psychology. Although not every complaint against or dispute with a licensee involves professional misconduct, the Executive Council will provide you with information about how to file a complaint.

If you have questions about licensure or professional standards, you may contact BHEC directly:

Website: https://bhec.texas.gov/contact-us/

Phone: 1-800-821-3205 or 512-305-7700

Address: 1801 Congress Ave., Suite 7.300, Austin, TX 78701

Filing a Consumer Complaint

If you wish to file a consumer complaint regarding mental health services, you may do so with the Texas Office of the Attorney General:

File a complaint online at: https://www.texasattorneygeneral.gov/consumer-protection/file-consumer-complaint

Consumer Protection Hotline: 800-621-0508

Mailing Address: PO Box 12548, Austin, TX 78711-2548

This notice is posted in compliance with Texas House Bill 4224 (Effective September 1, 2025)