Notice of Privacy Practices

Effective Date: [Effective Date]

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Mindbloom Medical Group of TX PLLC
Mindbloom House Austin, 3906 Menchaca Rd, Austin, Texas 78704

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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.

Who Follows This Notice

This notice applies to Mindbloom Medical Group of TX PLLC (the “Practice”), which operates Mindbloom House Austin. It also applies to all of the Practice’s physicians, nurse practitioners, physician assistants, technicians and staff. The Practice uses business associates, including Mindbloom, Inc., which provides technology and administrative support services to the Practice. Business associates may handle your information only on the Practice’s behalf, under written contracts that require them to protect it.

Our Duties

We are required by law to:

• keep your protected health information (“health information”) private
• give you this notice of our legal duties and privacy practices
• notify you if a breach affects your unsecured health information
• follow the terms of the notice currently in effect

Texas Law Gives Your Mental Health Information Extra Protection

We provide psychiatric care. Texas law treats your communications with us, and records of your diagnosis, evaluation and treatment, as confidential mental health records. These rules are stricter than federal law in several areas. When federal and Texas law differ, we follow the law that better protects your privacy. The descriptions below reflect those stricter rules.

How We Use and Share Your Information Without Your Written Authorization

• Treatment. We use your information to provide care, and we share it with other professionals who take part in your diagnosis, evaluation or treatment, and staff working under their direction. Example: we share your treatment notes with your primary care physician or a consulting psychiatrist involved in your care.
• Payment. We use and share information to bill and collect payment from your health plan or others responsible for payment. Example: we send your insurer the treatment dates, procedure codes and clinical information it requires to authorize and pay for Spravato® or TMS treatment.
• Health care operations. Our employees and agents use information to provide care and to meet legal, licensing and accreditation requirements, under safeguards that limit any other use. Qualified personnel may also review information for audits and program evaluations, but they may not identify you in any report. Example: we review records to monitor treatment quality and safety.
• Spravato® safety program. Federal law requires a safety program (called a REMS) for Spravato®. If you receive Spravato®, we will enroll you in the program and report required treatment and monitoring information after each dose. You will sign the program’s enrollment form, which explains this sharing.
• As required by law and to government agencies. We share information with government agencies when a law requires or authorizes it. This includes required public health reporting, reports of abuse or neglect, oversight by agencies such as the Texas Medical Board and the U.S. Department of Health and Human Services, and FDA reporting of problems with medications or devices.
• Serious and imminent threats. We may share information with medical, mental health or law enforcement personnel if we determine there is a probability of:
  • imminent physical injury by you to yourself or others, or
  • immediate mental or emotional injury to you.
• Legal proceedings. We may share information in a court or administrative proceeding only where Texas and federal law allow. This includes when you waive confidentiality in writing, when you bring a claim against us, and in response to a court order or subpoena that meets federal requirements.
• Law enforcement. We share information with law enforcement only when the law requires it or when the serious-threat standard above is met.
• Research. We may use or share information for research only under federal research safeguards. Researchers may not identify you directly or indirectly in any report. Otherwise, we will ask for your written authorization.
• Deceased patients. We may share information with the personal representative of a deceased patient. We may also share it with medical examiners as required by law.
• Workers’ compensation and specialized government functions. We may share information to the extent federal or Texas law requires.

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Family and Friends. Because of Texas mental health law, we will not share your information with family members, friends or others involved in your care without your written consent. The only exception is a serious and imminent threat as described above.

Uses That Require Your Written Authorization

• We will not use or share psychotherapy notes without your authorization, except as federal law permits.
• We will not use your information for marketing without your written permission.
• We will never sell your information.
• Any other use or disclosure not described in this notice needs your written authorization.

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You may revoke an authorization at any time with a written, dated and signed revocation sent to the Privacy Official. A revocation does not affect information already shared in reliance on your authorization. It also does not apply to a disclosure required to obtain payment for services we have provided to you.

Substance Use Disorder Records

We may receive substance use disorder treatment records from programs subject to 42 C.F.R. Part 2. Those records, or testimony relaying their content, will not be used or disclosed in civil, criminal, administrative or legislative proceedings against you, except:

• with your written consent, or
• under a court order issued after you or the record holder receive notice and an opportunity to be heard, together with a subpoena or other legal requirement compelling disclosure.

Information Shared With Others

When we share information as this notice permits, a recipient that is not subject to federal privacy rules may share it further, and federal law may no longer protect it. Texas law still limits recipients of mental health information to the purposes for which they received it.

Electronic Disclosure (Texas Notice)

Your health information is subject to electronic disclosure. We will not disclose it electronically without your separate authorization for each disclosure, except:

• to another covered entity for treatment, payment, health care operations or insurance functions, or
• as otherwise authorized or required by state or federal law.

Communications From Us

We may contact you by phone, text or email about appointments, treatment, billing and our own health care services. Texts and regular email may not be encrypted. You may ask us to contact you a different way or at a different place, and we will agree to reasonable requests. We will not send you marketing communications without your written permission.

Your Rights

• Get a copy of your records. You may inspect or get a copy of your records, including an electronic copy, by written request to the Privacy Official. We will respond within 15 days. We may charge a reasonable fee permitted by law.
  • We may withhold a portion of your record if we determine it would harm your physical, mental or emotional health. If we do, we will give you a signed, dated written statement explaining which portion is withheld, why, and for how long.
  • You may have another professional treating you for the same or a related condition examine and copy the withheld portion.
  • You may ask for a summary instead of a copy.
• Ask us to correct your records. You may request an amendment in writing. If we deny it, we will tell you why in writing.
• Request confidential communications. You may ask us to contact you in a specific way or at a specific place.
• Request restrictions. You may ask us to limit how we use or share your information.
  • We are not required to agree, except in one case. If you pay for a service in full out of pocket, we must agree not to share information about that service with your health plan for payment or operations, unless the law requires it.
• Get an accounting of disclosures. You may request a list of certain disclosures we made in the six years before your request. The first list in any 12-month period is free.
• Get a paper copy of this notice at any time, even if you agreed to receive it electronically.
• Choose someone to act for you. A legal guardian or other personal representative may exercise your rights. For patients under 18, a parent, managing conservator or guardian may access the minor’s records as Texas law provides, unless state or federal law or a court order restricts access.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with:

• Our Privacy Official (contact information below).
• U.S. Department of Health and Human Services, Office for Civil Rights: 200 Independence Avenue, S.W., Washington, D.C. 20201; 1-877-696-6775; www.hhs.gov/hipaa/filing-a-complaint.
• Texas Medical Board (physicians and physician assistants): www.tmb.texas.gov; (512) 305-7030.
• Texas Board of Nursing (nurse practitioners): www.bon.texas.gov.
• Texas Attorney General (list of health care regulators and complaint processes): www.texasattorneygeneral.gov/consumer-protection/health-care/health-care-list-agencies.

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We will not retaliate against you for filing a complaint.

Changes to This Notice

We may change this notice. Any change will apply to all information we hold. The new notice will be posted at Mindbloom House Austin and on our website at [Website URL], with its effective date. A copy will be available on request.

Contact

[Privacy Official Name and Title]
Mindbloom Medical Group of TX PLLC, 3906 Menchaca Rd, Austin, Texas 78704
Phone: [Phone] | Email: [Email]

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Contact the Privacy Official to request your records, make any rights request, or file a complaint.