This Notice describes how your personal health information (PHI) is protected, and how Madison may use and disclose this information. PHI includes personally identifiable information that relates to your past, present, or future health, treatment, or payment for health care services. Madison’s employees and professional staff are required to comply with this privacy policy, and have access to this information only when there is an appropriate reason to do so, such as to confer with other health care providers or to submit claims for these services.

Under the Health Insurance Portability and Accountability Act (HIPAA), you are afforded privacy rights regarding the use and disclosure of your health information. These include:

• A right to be informed of the potential uses and disclosures of your protected health information, and to limit those uses and disclosures of this protected health information;

• A right to receive this written notice that explains how we may use and disclose your protected health information, your rights under HIPAA’s privacy rule, and Madison’s responsibilities as a covered entity under HIPAA;

• A right to a paper copy of this notice, or to have your legally designated representative receive a copy of this notice; you are asked to acknowledge receipt of this notice;

• A right to amend your record, to restrict what information from your record is disclosed to others, and to receive an accounting of disclosures of this information that were made without your authorization, other than for treatment, payment or health care operations;

• A right to have your complaints about my policies and procedures recorded in these records.

As a health care provider, Madison is making a good faith effort to see that you or your representative have received and acknowledged this notice of privacy practices. If you are seen for emergency treatment, you will receive this notice as soon as practically possible afterward.

Madison may use or disclose your protected health information (PHI), for certain treatment, payment, and health care operations purposes without your authorization. To help clarify these terms, here are some definitions:

• PHI refers to information in your health record that could identify you.

• Treatment is when Madison or another healthcare provider diagnoses or treats you. An example of treatment would be when Madison consults with another health care provider, such as your family physician or another psychologist, regarding your treatment.

• Payment is when Madison obtains reimbursement for your healthcare. Examples of payment are when Madison discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

• Health Care Operations is when Madison discloses your PHI to your health care service plan (for example your health insurer), or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination.

• Use applies only to activities within Madison’s office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• Disclosure applies to activities outside of Madison’s office, such as releasing, transferring, or providing access to information about you to other parties.

• Authorization means written permission for specific uses or disclosures. All authorizations to disclose must be on a specific, legally required form.

Madison may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances when Madison is asked for information for purposes outside of treatment and payment operations, Madison will obtain an authorization from you before releasing this information.

You may revoke or modify all such authorizations of PHI at any time, provided each revocation is in writing; however, the revocation or modification is not effective until Madison receives it. You may not revoke an authorization to the extent that (1) Madison has relied on that information; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

Madison may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: Whenever Madison, in her professional capacity, has knowledge of or observes a child Madison knows or reasonably suspects, has been the victim of child abuse or neglect, Madison must immediately report such to a police department or sheriff’s department, county probation department, or county or state welfare department.

• Adult and Domestic Abuse: If Madison, in her professional capacity, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if Madison is told by an elder or dependent adult that he or she has experienced these, or if Madison reasonably suspects such, she must report the known or suspected abuse immediately to the local ombudsman or the local law enforcement agency.

• Health Oversight: If a complaint is filed against Madison with the State Board that licenses her profession, the Board has the authority to subpoena confidential mental health information from Madison relevant to that complaint.

• Serious Threat to Health or Safety: If you communicate to Madison a serious threat of physical violence against an identifiable victim, Madison must make reasonable efforts to prevent harm, which may include communicating that information to the potential victim, and the police. If Madison has reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, Madison may release relevant information as necessary to prevent the threatened danger.

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that Madison has provided you, Madison must not release your information without:

1. your written authorization or the authorization of your attorney or personal representative; or

2. a court order

The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. Madison will inform you in advance if this is the case.

Patient’s Rights:

• Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, Madison is not required to agree to a restriction you request.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing Madison and may request that she not telephone your residence).

• Right to Inspect and Copy You have the right to inspect or obtain a copy (or both) of PHI in Madison’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Madison may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, Madison will discuss with you the details of the request and denial process.

• Right to Amend You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Madison may deny your request. On your request, Madison will discuss with you the details of the amendment process.

• Right to an Accounting You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, Madison will discuss with you the details of the accounting process.

• Right to a Paper Copy You have the right to obtain a paper copy of the notice from Madison upon request, even if you have agreed to receive the notice electronically.

Duties of Provider:

• Madison is required by law to maintain the privacy of PHI and to provide you with a notice of her legal duties and privacy practices with respect to PHI.

• Madison reserves the right to change the privacy policies and practices described in this notice. Unless Madison notifies you of such changes, however, she is required to abide by the terms currently in effect.

• If Madison revises her policies and procedures, Madison will provide you with a written copy of the revised policies and procedures at the earliest possible opportunity following this revision, in person or by mail.

For direct or informal complaints, or concerns about your privacy or rights, you can contact Madison at (737) 218-9943, or:

Madison Clausen, MA, LPA
11200 Menchaca
Austin, TX 78748

Madison’s supervisor, Dr. Krista Jordan, can be contacted at (512) 202-7279, or:

Krista Jordan, Ph.D.
2222 Western Trails
Suite 103
Austin, TX 78745

Madison is a Licensed Psychological Associate (TX License #40371) regulated by the Texas Behavioral Health Executive Council (BHEC). Texas BHEC can be contacted at (512) 305-7700. You can visit their website here. If you are concerned that Madison has violated your privacy rights, or you disagree with a decision Madison made about access to your records, you may contact the Compliance Officer for further information or to file a complaint. More information regarding filing a formal complaint with the board can be found here.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Madison will provide the appropriate address upon request.

You have a right to request your medical records at any time. Records requests can be sent directly to Madison at madisonclausenma@gmail, or by mail to 11200 Menchaca Rd, Austin, TX, 78748.

This notice went into effect September 13, 2024. Madison reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that Madison maintains. Madison will provide you with a revised notice by mail, at the earliest opportunity following the revision.