Psychiatric Nurse Practitioner - Client Contract

InMindOut Emotional Wellness Center, LLC

Psychiatric Nurse Practitioner - Client Contract

Welcome to our practice. This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between you and me.


This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review carefully.

This Practice uses and discloses health information about for treatment, to obtain payment for treatment, for administrative purposes and to evaluate the quality of care that you receive.

This notice describes our privacy practices. We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post our new notice in the office where it can be seen. You can request a paper copy of this notice, or any revised notice. For more information about this notice, or our privacy practice and policies, please contact the person listed at the end of this document.



We are permitted to use and disclose your medical information to those involved in your treatment. For example, the physician/provider in this practice is a specialist. When we provide treatment we may request that your primary care physician or other referring physician share you medical information with us. Also, we may provide your primary care physician or other designated physician/provider, information about your particular condition so that he or she can appropriately treat you. We may also release information to the On-Call Physician in case of an emergency.


We are permitted to use and disclose your medical information to bill and collect payment for the service we provide to you. For example, if you file a claim with your insurance, the paperwork that we provide to you has a description of the service provided to you and the diagnoses for which you are being treated.


We are permitted to use or disclose your medication information for purposes of health care operations, which are activities that support this practice and ensure quality care is delivered.


There are situations in which we are permitted to disclose or use your medical information without your written consent or an opportunity to object. In other situation, we will ask you for written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and disclosures. However, any revocation will not apply to disclosures or uses already made or that relay on that authorization.


We may disclose your medical information for public health activities. Public health activities are mandated by federal, state or local government for information about disease, vital statistics, or injury by a public health authority. We may disclose medical information, if authorized by law, to a person who may have exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may disclose your medical information to report reactions to medications, problems with products or to notify people of recalls or products they may be using.

Because Texas law requires physicians to report child abuse or neglect, and elder abuse or neglect, we may disclose medical information to the public agency authorized to receive these reports.

We may disclose your medical information to a health oversight agency for those activities authorized by law. Examples of these activities are audits, investigations, licensure applications and inspections, which are all government activities undertaken to monitor the health care delivery systems and compliance with their laws, such as civil rights laws.


We may disclose your medical information in the course of judicial or administrative proceedings in response to an order of the court (or administrative decision-maker) or other appropriate legal process. Certain requirements must be met before the information is disclosed.

If asked by a law enforcement official, we may disclose your medical information under limited circumstances provided:

* The information is released pursuant to legal process, such as warrant or subpoena;

* The information pertains to a victim of a crime and you are incapacitated;

* The information pertains to a person who has died under circumstances that may be related to criminal conduct

* The information is about a victim of crime and we are unable to obtain the person’s agreement;

* The information is released because of a crime that has occurred on these premises or

* The information is released to locate a fugitive, missing person or suspect.

We may also release information if we believe the disclosure is necessary to prevent or lessen an imminent threat to the health or safety of a person.


We may disclose your medical information for specialized governmental functions such as separation from military service, requests as necessary by appropriate military command officers (if you are in the military), authorized national security or intelligence activities, as well as authorized activities for the provision of protective services for the President of the United States, or other authorized government officials or foreign heads of state.


We may release your medical information to a coroner or medical examiner to identify a deceased person or a cause of death.


We may release your medical information when disclosure is required by law.


The U.S. Department of Health and Human Services created regulation intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several privileges that patients may exercise. We will not retaliate against patients who exercise their HIPAA rights.


You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment or health care operation. We DO NOT have to agree to this restriction, but if we do agree, we will comply with your request except under emergency circumstances.

You may also request that we limit disclosure to family member, or other relative, or close personal friends who may or may not be involved in your care.

To request restriction, submit the following in writing: (a) the information to be restricted, (b) what kind of restriction you are requesting (i.e., on the use of information, disclosure of information or both) and (c) to whom the limits apply. Please send the request to the address and person listed at the end of this document.


You may request that we send communication of protected health information by alternative means or to an alternative location. This request must be made in writing to the person listed below. We are required to accommodate only reasonable requests. Please specify in your correspondence exactly how you want us to communicate with you and, if you are directing us to send it to a particular place, the contact/address information. We do have forms for this.


You may inspect and/or copy health information that is within the designated record set, which is information that is used to make decision about your care. Texas law requires that request for copies are made in writing, and we ask that requests for inspection of your health information be made in writing. Please send your request listed at the end of this document.

We may ask that a narrative of that information be provided rather than copies. However, if you do not agree to our request, we will provide copies.

We can refuse to provide some of the information you ask to inspect or ask to be copied for the following reasons:

* The information is psychotherapy notes

* The information reveals the identity of a person who provided information under promise of confidentiality

* The information is subject to the Clinical Laboratory Improvements Amendments of 1988

* The information has been compiled in anticipation of litigation

We can refuse to provide access to, or copies of, some information for other reasons, provided that we arrange for a review of our decision on your request. Any such review will be made by another licensed health care provider who was involved in the prior decision to deny access.

Texas law requires us to be ready to provide copies or narrative within 15 business days of the receipt of your request. We will inform you when the records are ready or if we believe access should be limited. If we deny access, we will inform you in writing. HIPAA permits us to charge a reasonable cost-based fee.


You may request an amendment of your medical information in the designated record set. Any such request must be made in writing to the person listed at the end of this document. Even if we refuse to allow an amendment, you are permitted to include a patient statement about the information at issue in your medical record.

We will respond within 60 days of your request. We may refuse to allow amendment for the following reasons:

* The information wasn’t created by this practice or the physicians in this practice.

* The information is not part of the designated record set (i.e. psychotherapy notes).

* The information is not available for inspection because of an appropriate denial.

* The information is accurate and complete.

If we approve the amendment, we will inform you writing, allow the amendment to be made and tell other that we now have corrected information.


HIPAA privacy regulation permit you to request, and us to provide, an accounting of disclosures that are other for treatment, payment, health care operations or made via an authorization signed by you or your representative. Please submit any request for an accounting to the person at the end of this document. Your first accounting of disclosures (within a 12 month period) will be free. For additional requests within that period we are permitted to charge for the cost of providing the list. IF there is a charge we will notify you, and you may choose to withdraw or modify your request before any costs are incurred.


If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us.


If you have any questions or want to make a request pursuant to the rights described herein, please contact:

Nikki Katibi

645 N. Walnut Ave.

New Braunfels, Texas 78130

(830) 730-6090

This notice is effective 08/02/2018


Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. I understand I am entitled to receive a copy of this document.

If client is a minor, please have the parent or legal guardian sign this form.

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InMindOut Emotional Wellness Center
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Document name: Psychiatric Nurse Practitioner - Client Contract
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