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.
When we refer to “you” or “your” in this Notice we refer to the person or persons receiving the services provided by Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT. When we refer to disclosures of information to “you,” we mean disclosures to children, the parents of children, legal guardians or other persons legally authorized to receive information about the person or persons receiving services from Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT.
Each time you receive services from Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT, we create a record of the services provided. Typically, this record contains information about the type of services you have received, the dates of service and the results of the services provided. At times this record will include the reason you have come to Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT and the agreed upon goals of the services provided.
This Notice applies to all health information created and maintained by Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT in connection with services provided at any clinic of Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT If you have any questions after reading this Notice, please contact Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT.
For Treatment: Your health information 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, but is not limited to, consultation with clinical supervisors or other treatment team members. For example, a therapist may use health information about you from a clinic record to determine which treatment option, such as family or individual therapy, best addresses your needs. Your therapist may discuss information found in your record with our consultants, a colleague or his or her supervisor to assist in treatment planning for you.
For Payment: We may use and disclose health information to send bills and collect payment from you, your insurance company, or other payors, such as governmental agencies, for the treatment or other related services you receive from Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT, so we can receive payment for the treatment services provided. For example, we may use your health information to determine eligibility or coverage for insurance benefits, to process and send claims to your insurance company, to review services provided to you to determine medical necessity, or to undertake utilization review activities.
For Health Care Operations: We may disclose health information about you for the business operations of Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT. These uses and disclosures are necessary for Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT to provide quality care and cost-effective services. The operations where we may need to disclose health information include, but are not limited to, quality assessment activities, employee review activities, and licensing activities. Quality assessment activities may include evaluating the performance of your therapist or examining the effectiveness of treatment provided to you when compared to patients in similar situations. For example, we may share your health information with third parties that perform various business activities (such as billing or typing services). We will only share your information if these third parties have a contract with us requiring them to safeguard the privacy of your health information.
Appointments: We may use your health information for the purpose of sending appointment reminders to you through the mail or by telephone; or for the purpose of appointment waitlist cancellation notifications via text message. Messages left for you will not contain specific health information.
Health Information: We may use or disclose your health information to provide information to you about treatment alternatives or other health-related benefits and services that may be of interest to you.
Required or Permitted by Law: We may use or disclose your health information when we are required or permitted by law to do so, including without limitation to disclose your health information for the following purposes:
∙ For public health and public health oversight activities
To report suspected abuse, neglect, or violence to responsible law enforcement agencies so they may investigate or prosecute.
In response to a valid court order
To a law enforcement official for purposes of identifying or locating a suspect, fugitive, or missing person.
To coroners and medical examiners
To help conduct medical research (under certain circumstances)
For limited and specialized government functions, such as military and/or national security reasons, or to prison officials if you are in custody.
To Worker’s Compensation officials if your condition is work-related
If necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public
If you are under the age of 18, to your parent, legal guardian, or someone to whom parental power has been legally delegated (under most circumstances), and if you are over 18 years of age, to your court-appointed guardian or to an agent appointed by you under a health care power of attorney.
When sharing health information with others outside of Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT, we share only what is reasonably necessary unless we are sharing health information to help treat you, in response to your written authorization, or as the law requires.
With Your Authorization: Other uses and disclosures of your health information not described above will be made only with your written authorization. Such uses and disclosures requiring your written authorization include, but are not limited to:
Most uses and disclosures of psychotherapy notes
Most uses and disclosures for marketing purposes
Disclosures that constitute a sale of protected health information
You have the following rights regarding your health information we maintain. To exercise any of the rights discussed in the remainder of this section, please contact the Privacy Officer using the information provided below.
Right to Request Restrictions: You have the right to request certain restrictions of use and disclosure of your health information by Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT for treatment, payment or health care operations. You also have the right to request a restriction on our disclosure of your health information to someone who is involved in your care or the payment for your care. We are not required to agree to restrict the use and disclosure of your health information, unless (1) the request is to restrict disclosure of your protected health information to a health plan, (2) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and (3) the protected health information in question pertains solely to a health care item or service for which you or someone other than the health plan has paid Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT in full. A request for restriction must be made in writing using the form available from the Privacy Officer.
Right to Obtain a Copy of this Notice: You have the right to receive a paper copy of this Notice from us upon request.
Right to Inspect and Copy: With a few exceptions you have the right to inspect and receive a copy of your health information. Should you wish to review a copy of your health information you should make a request using the form available from the Privacy Officer. We will arrange for your therapist or another health professional in our clinic to review the health information with you in our office or to copy the information requested. We may charge you a reasonable fee if you want a copy of your health information.
Right to Amend or Correct Your Record: If you feel the health information we have about you is incorrect or incomplete, you may ask us to amend the information for as long as the information is maintained by Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT, Requests for amendment or correction should be made by submitting a form requesting amendment or correction available from the Privacy Officer. We will respond to your request within 60 days after you submit the form. We are not required to agree to the amendment.
Right to an Accounting of Disclosures: You have a right to request an accounting for disclosures. This accounting is a list of those people with whom Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT may have shared your health information, with certain exceptions. We may charge you a reasonable fee if you request more than one accounting for disclosures in any 12-month period. Requests for an accounting of disclosures should be made by submitting a form requesting an accounting of disclosures to the Privacy Officer. This form is available from the Privacy Officer. We will respond to your request within 60 days after you submit the request.
Right to Request Confidential Communications: You have the right to ask that we communicate your health information to you in a certain way or at a certain location. For example, you can request that we contact you only at work or by mail. We will accommodate reasonable requests.
Right to Revoke Authorization: If you authorize Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT to use or disclose your health information, you may revoke that authorization in writing at any time, unless certain exceptions apply. We are unable to reverse any disclosures we have made previously with your authorization. To revoke an authorization please contact the Privacy Officer in writing using the contact information provided below.
Right to Complain: If you believe your privacy rights have been violated, you may file a complaint with Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT or with the U.S. Secretary of the Department of Health and Human Services. To file a complaint with Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT, contact the Privacy Officer using the contact information provided below. All complaints to us must be made in writing. You will not be retaliated against for filing a complaint.
Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT is required by law:
To maintain the privacy of protected health information
To provide you with a notice of our legal duties and privacy practices with respect to protected health information
To notify you following a breach of your unsecured protected health information
To abide by the terms of the Notice of Privacy Practices then in effect.
Midlothian Family Therapy/ Adrienne Armstrong, LPC, LMFT reserves the right to change its information practices, and to make the new provisions effective for all health information we maintain. If we change our privacy practices, you will receive a revised copy at your next visit.
Effective Date: January 1, 2025
Contact Information
Midlothian Family Therapy Privacy Officer:
Telephone number: (713)865-6339
Mailing address:
Attn: Privacy Officer
Midlothian Family Therapy
15473 Foxvale Way Midlothian, VA 23112
U.S. Secretary of the Department of Health and Human Services: (877) 696-6775