Georgia Minor Intake Form

Below is a series of phrases that describe a child's behavior. Please indicate the frequency describing how often the behavior occurs with your child and then indicate "yes" or "no" if the behavior is a current concern.

If you select “yes,” you are allowing the individual or individuals listed to create, cancel, change, and confirm appointments for you with the Center for Relational Care. If you select “no,” then no other individual will be allowed to create, cancel, change, or confirm appointments for you, including parents, other family members, administrative assistants, spouses, or significant others unless, the individual(s) has the legal authority to do so.

If you select “yes,” you are allowing the individual or individuals listed to receive billing information for your account from the Center for Relational Care. This includes, but is not limited to, TheraNest Statements, TheraNest Superbills, and Quickbooks Statements. These financial forms may contain: your contact information, dates of service, service codes, the length of time of the appointment, the cost of the appointment, diagnostic codes associated with your account, your client ID, and your billing and rendering provider’s information. If you select “no,” then no other individual will be allowed to request your billing information for you, including parents, other family members, administrative assistants, spouses, or significant others unless, the individual(s) has the legal authority to do so.

WELCOME TO THE CENTER FOR RELATIONAL CARE (CRC)

Thank you for choosing to share a part of your life with us. We count it a privilege to work with you and will do our best to merit your trust. The relationship we have with you is an essential part of a successful counseling or consulting process. Therefore, we have prepared this information to inform you of our basic policies and procedures. If you have any questions about this information, please ask the receptionist or your counselor. Within the bounds of our expertise and ethical standards, we will help you to resolve the issues or problems that prompted you to seek our services.

WHO WE ARE

The purpose of the Center for Relational Care is to facilitate healing, growth, and reconciliation for marriages, families, and individuals. We also equip local churches to more effectively give care within their congregations and communities. In pursuit of this mission, our staff provides professional and pastoral counseling services to the general public and training and consulting for other counselors and church leaders. The CRC staff strives to help people develop themselves and their relationships with God and others so that their lives may be satisfying and productive. We work to help people address problems and experience freedom from obstacles to healthy, abundant living. In so doing, our staff facilitates the healing and transforming work of Jesus Christ in a confidential and compassionate manner. CRC counselors are gifted, caring, and committed Christians with advanced education and training. All CRC counselors hold master’s or doctorates in psychology, counseling, social work, theology and/or religious education. Though trained and willing to address spiritual issues, our staff will not impose their own beliefs on clients.

STANDARD SERVICES

Our counseling center provides marital, individual, child and family therapy for personal development and treatment of a variety of issues of an emotional, psychological, and spiritual nature. All CRC staff are trained in counseling approaches designed to bring about positive change in relationships and personal wholeness. Most CRC therapists have specialized training, certification and expertise in clinically respected therapeutic modalities such as play therapy for children and EMDR therapy for symptoms resulting from trauma and post- traumatic stress. We work with couples, children, adolescents, and single adults of all ages. If a need for medical treatment is indicated, CRC staff can help identify and refer you to other medical professionals for evaluation and medical care.

THE PROCESS OF THERAPEUTIC COUNSELING

Participation in therapy can result in a number of benefits to you, including improving interpersonal and spiritual relationships and resolution of specific concerns or symptoms that led you to seek therapy. Although there are no promises or guarantees of what you will experience or benefits you will receive, CRC's counseling has been shown to improve and deepen intimacy in relationships, provide solutions to specific problems and reduce feelings of distress.

A part of this experience can also be an increased awareness of feelings like hurt, sadness, frustration, guilt, and memories of unpleasant events. Your counselor will help you process your important experiences and emotions. Your counseling is most likely to be beneficial through your active involvement, sincere honesty and your commitment to working on the important relationships in your life. Working toward progress, growth and healing requires a collaborative effort on your part both within and outside of sessions.

CONFIDENTIALITY FOR COUNSELING

All counseling relationships and sessions are held in the strictest confidence. The staff of CRC will not knowingly acknowledge a counseling relationship and/or any communication concerning a client without the client's express written permission except in the following circumstances required by law:

1. When there is reasonable suspicion that abuse or neglect of a child, elderly or disabled person has occurred, your Counselor is required to file a report with the proper authorities within 48 hours;
2. When we reasonably believe that a client presents a danger to self or others, we may contact medical or law enforcement authorities. In addition, by your initials and signature, you further authorize your Counselor to disclose information deemed necessary to a spouse, parent or guardian, and/or to the intended victim.
3. If our records are subpoenaed by any person or entity, the Counselor will contact the clients to make them aware of the subpoena and give them the chance to challenge it. By your signature below, you expressly authorize the Counselor to comply with any legally issued subpoena and provide records or testimony without the need for a separate authorization or release. 
4. When the Counselor is court ordered to testify or provide records to any person or entity. 
5. When the records are requested by any state or federal agency.
6. Any other circumstance as outlined in the Notice of Privacy Practices.

If you and your Counselor see each other in a setting other than office, be it public, business or social, your Counselor will not speak to you or otherwise acknowledge that you know each other. If you decide to initiate a greeting, your Counselor will respond. If you do not, your Counselor will not signal verbally or non-verbally that you know each other. By your signature below, you indicate that you have been advised of this policy and you agree to abide by it.

As part of our counseling staff environment, CRC counselors anonymously staff cases in consultations for professional development in accordance with ethical principles of maintaining quality standard of care.

CONFIDENTIALITY ISSUES FOR MINORS

Our family and children’s therapists ask additional considerations on the part of the parents when a minor is the primary client. First, it is your responsibility as a parent to notify your therapist and anyone else so ordered if there is a court order influencing communication about counseling. Open communication among all parties, when possible, is the best philosophy. Secondly, we ask that parents respect their children’s privacy by allowing the therapist to take the lead on communicating relevant details from sessions. As a family-based model, we pursue treatment of familial relationships and will involve parents as soon as the therapist determines it is in your child’s best interest for parent involvement in the counseling work.

EMERGENCIES

Counselors at CRC do not provide 24-hour availability of services. If you have an emergency or crisis and are unable to reach your Counselor during or after regular business hours, you or someone you trust should call your local hospital emergency room, your medical doctor or 911. If during the course of your counseling experience your Counselor assesses that you are at risk for harming yourself or others, they may take steps to contact emergency personnel to advocate for your care and safety or the protection of others. Please do not use email, fax or text to communicate emergencies to your counselor.

LIMITATIONS OF THERAPY

Your Counselor will not offer a diagnosis for medical conditions, although he/she may recommend a medical exam to rule out possible physical issues/problems as a cause of any mental health symptoms. If you have a known medical condition, please let your Counselor know. With your permission, your Counselor will work closely with your physician to ensure the compatibility of your treatment. Your Counselor cannot prescribe medication. If it is determined that a medical evaluation is appropriate, your Counselor may refer you to a medical professional who can fully decide for medical help as a part of treatment. Your Counselor will not make recommendations regarding custody, visitation or parental access to children or any matters pertaining to the “best interest of the child” in Suits Affecting the Parent-Child Relationship (SAPCR), adoption or termination proceedings.

DURATION AND CHARGES FOR SERVICES RENDERED

The length of therapy is dependent on many factors, including the type and severity of the presented issues. At the beginning of therapy, your Counselor will perform an assessment and work with you to develop a plan for your therapeutic treatment.

CRC is a 501(c)(3) non-profit ministry that meets its expenses primarily through fees consistent with area norms for professional counseling. Standard fees, based upon session length and format of the session, follow:

Phone Consultation Fees

Telephone consultations are charged in 15-minute increments at the counselor's normal rate.

Mini Intensives

A Mini Intensive is an appointment scheduled for 4 or more hours of counseling for an individual, couple, or family that is not considered pre-work for an Intensive. All mini intensives require a deposit of 50% of the projected total fee (the number of scheduled hours at your Counselor’s normal hourly rate) with a maximum $500. The deposit is non-refundable. A deposit may be used for a rescheduled Mini Intensive as long as it is rescheduled at least 7 calendar days prior to the date of the original mini intensive. If the rescheduling is done inside of the 7-day window, the deferral of the deposit to a different date is at the discretion of CRC. Mini intensives canceled less than 24 hours in advance are subject to full charge. The deposit must be used within 180 days of the date the deposit is made; otherwise the deposit will be forfeited. The deposit may be transferred to another couple or individual at the discretion of the CRC.

The deposit payment will be applied to the total balance for the scheduled Mini Intensive. The final balance due is the actual number of hours spent in session at your Counselor’s rate, minus the deposit. Payment will be due upon the completion of Mini Intensives unless other arrangements have been made with CRC.

Fees for requests for client records

You have the right to review or receive a summary of your records at any time, except in limited legal circumstances or situations when such release might be harmful to you or others. All requests for records must be submitted in writing to the attention of your counselor by email to info@relationalcare.org or faxed to 512.492.6201. Fees for the copying of records provided will be charged at a minimum of $25.00 for the first 50 pages, and then $0.25 cents per page for each page thereafter. We are required by law to provide records to you within fifteen (15) days of receiving a written request in non-emergency situations.

Fees for depositions and court testimony

CRC counselors prefer to remain uninvolved in clients’ legal matters, including any interaction with a court system or an attorney, as it often compromises the therapeutic relationship. If your counselor is subpoenaed for depositions and court testimony, fees will be billed at the rate of $200 per hour. By your signature below, you agree to pay the rate of $200 per hour for the Counselor’s preparation time, point-to-point travel time, actual time on location by the counselor to attend a hearing, give a deposition or testify in court, and the costs of complying with a subpoena for records or testimony regardless of which party issued the subpoena, and you agree to pay the itemized charges upon receipt of an invoice.

TERMINATION OF THERAPY

You and your Counselor will determine when it is time for your therapy to end. While you are free to end your therapy at any time, it is more beneficial for you if the end of therapy is planned in advance. You will have a role in determining when you have accomplished the stated therapeutic goals. Your Counselor is ethically bound to terminate therapy if he/she determines that you are not benefitting from therapy, if he/she determines that your therapeutic needs are beyond the scope of his/her training, or if there is a conflict that makes further treatment inadvisable. Should any of these situations occur, your Counselor will refer you to other therapists who have specialized training or whose treatment might benefit you.

Additionally, due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to matters of a confidential nature, should there be legal proceedings (including but not limited to divorce and custody disputes, injuries, lawsuits, etc.), therapy may be terminated at the discretion of your Counselor.

By your signature below, you agree that your Counselor’s decision in these matters will be final.

APPOINTMENTS AND CANCELLATIONS

You may schedule your next appointment while you are in the office or by calling 678-653-3272 or toll free 877-567-5656 at your convenience. It is the responsibility of the client/s to remember appointments and allow for traffic delays, work demands and other personal conflicts. Arriving late, missing appointments or late appointment cancellations hinder our ability to provide proper care to you and other clients. We will make every reasonable effort to accommodate changes in your schedule as long as you notify us at least 24 hours in advance. Appointments canceled fewer than 24 hours in advance are subject to full charge. Monday appointments must be canceled by noon on the preceding Friday. Life-threatening emergencies or serious illnesses will be considered grounds for waiving such charges at the discretion of your counselor.

PAYMENT AND INSURANCE

Payment is due upon arrival for your session unless other arrangements have been made in advance.  We accept checks, all major credit cards or cash (please bring correct change or the difference will be credited to your account). The client acknowledges being informed of the option to save a credit card on file and that by consenting to save their credit card on file they are permitting CRC to use the credit card for valid charges owed to CRC on the account under which that the credit card. It is the responsibility of the client to communicate any changes to a credit card that is saved on file prior to the session the new card is intended to be used. In addition to the amount due for a session, in the event a check is returned or a credit card charge is disputed for a valid charge made by CRC, a fee of $25 will be charged to the client.

Sometimes medical insurance may be applied to the cost of professional counseling. CRC is considered out-of- network for all insurance and does not file insurance claims for clients. Since our office doesn’t handle insurance, clients should call their own insurance company to see if they will pay reimbursement for out-of-network psychotherapy and what the procedure is for the client to file. Your health insurance carrier or HMO/PPO/MCO/EAP may require the disclosure of confidential information in order to process your claims. Only information required for billing and authorization will be disclosed by CRC. This does, however, require disclosure of diagnostic codes and CPT procedure codes. Counselors will provide the client with these necessary codes to assist them in filing insurance claims. Clients pay CRC in full and they receive a Statement of Services that includes all necessary information so that they can submit to their insurance company for reimbursement. CRC cannot guarantee insurance reimbursement and it is the responsibility of the client to call their insurance company prior to future counseling appointment.

POLICY ON SOCIAL NETWORKING AND ELECTRONIC COMMUNICATIONS

CRC is committed to following state and federal confidentiality guidelines for protection of the privacy of client sessions and records. To provide for protection of your privacy, a confidential voice mailbox is available for leaving messages for your counselor. Should you choose to send an email to your Counselor, CRC cannot guarantee the protection of the information in an email or text. By signing below, you are acknowledging that you have been informed that if you choose to send an email or text to your Counselor, CRC cannot guarantee the protection of the information in the email.

Your Counselor will not engage in social networking with clients on any social networking site such as Facebook, LinkedIn, Instagram, Twitter or any other social networking site. Please do not send “friend” requests to your Counselor or otherwise communicate with your Counselor through any interactive or social networking websites.

The Counselors at the Center for Relational Care would never post information about a client on a public website. We ask that you respect your Counselor’s privacy and refrain from posting any “reviews” or other information regarding this practice or your Counselor on any website such as Health Grades, Angie’s List, or other forum for posting public reviews of health care providers. By your signature below, you agree that you will not post any “review” or any other information on any such public website. If you refuse to abide by this stated professional boundary, your Counselor may terminate your professional relationship and refer you to other mental health professionals.

CONTACTS FOR COMPLAINTS OR CONCERNS

If you have any complaints or concerns about your Counselor, you may contact Courtney Putnam, Director for the Center for Relational Care Atlanta at 678-653-3237. You may also file a complaint with the Counselor’s licensing board. The Georgia Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists regulates the practice of Licensed Professional Counselors (LPCs) and the practice of Marriage and Family Therapists (MFTs). You may call the complaint hot line (1-487-207-2440) to request a complaint form for both licenses or obtain more information. You can also send a complaint to the Georgia Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists at 237 Coliseum Drive, Macon, GA 31217-3858. If you have a complaint concerning the HIPAA Privacy Regulations, you may contact Jim Walter at 512-492-6200, or the U. S. Department of Health and Human Services, Office for Civil Rights, at OCRMail@hhs.gov.

YOUR AGREEMENT

I have read this entire Agreement carefully. I understand the terms of this Agreement and I agree to comply with them. I agree that this Agreement will stay in effect until I revoke it in writing. I understand that any written revocation must be dated AFTER the date of this Agreement and must be provided to my Counselor at the Center for Relational Care. A copy of this Agreement has the same force and effect as the original.

This notice describes how your Personal Health Information (PHI) may be used and disclosed and how you can get access to this information, please review it carefully.

If you have any questions about this Notice of Privacy Practices, please contact our Privacy Officer at (512-492-6200).

INTRODUCTION

The Center for Relational Care℠ is required by law to maintain the privacy of Protected Health Information (“PHI”), to provide individuals with notice of our legal duties and privacy practices with respect to PHI, and to notify affected individuals following a breach of unsecured PHI. PHI is information that may identify you and that relates to your past, present or future physical or mental health or condition, and relates to the provision of health care or payment for the provision of health care for your past, present or future physical or mental health or condition and related healthcare services. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose PHI to carry out treatment, obtain payment or perform our health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you.

The Center for Relational Care℠ is required to follow the terms of this Notice currently in effect. We reserve the right to change our practices and this Notice and to make the new Notice effective for all PHI we maintain. Upon request, we will provide any revised Notice to you.

OUR PLEDGE

The privacy of your personal health information (PHI) is important to us. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. Our privacy practices must be followed by all of our employees, contractors, and staff.

HOW YOUR PHI MAY BE USED AND DISCLOSED

The following categories describe different ways that we may use and disclose your PHI. For each category of use or disclosure, an explanation of what is meant and some examples are provided. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose PHI will fall within one of the categories.

For Treatment: We may use or disclose your PHI to provide and coordinate the mental health treatment and services you receive. For example, if your mental health care needs to be coordinated with the medical care provided to you by another physician, we may disclose your health information to a physician or other healthcare provider. Also, counselors may disclose your health information to each other to coordinate individual and group therapy sessions for your treatment or information about treatment alternatives or other health---related benefits and services that are necessary or may be of interest to you. CRC will secure your written authorization to disclose this information in these situations.

For Payment: We may use and disclose your PHI for various payment related functions so that we can bill for and obtain payment for the treatment and services we provide for you. For example, your PHI may be provided to an insurance company so that they can reimburse you for claims you submit. Also, your PHI may be provided to other third-party payers.

For Healthcare Operations: We may use and disclose your PHI for certain operational, administrative and quality assurance activities, in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, and conducting training programs, accreditation, certification, licensing or credentialing activities.

For Special Purposes: We are permitted under federal and applicable state law to use or disclose your PHI without your permission only when certain circumstances may arise, such as the following:

• Individuals Involved in Your Care or Payment for Your Care. With your authorization, we may disclose to a member of your family, a relative, a close friend or any other person you identify your PHI that directly relates to that person’s involvement in your health care. If you do not authorize such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

• Disclosures to Parents or Legal Guardians. We may release PHI to parents or legal guardians when we are permitted or required under federal and applicable state law. CRC abides by its Minor Consent Policy where applicable.

• Worker’s Compensation. We may disclose your PHI to the extent authorized by and necessary to comply with laws relating to worker’s compensation or other similar programs established by law. 

• Public Health. We may disclose your PHI to federal, state, or local authorities, or other entities charged with preventing or controlling disease, injury, or disability for public health activities.

• Health oversight activities. We may disclose your PHI to an oversight agency for activities authorized bylaw. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for government monitoring of the health care system, government programs, and compliance with federal and applicable state law.

• Law Enforcement. We may disclose your PHI for law enforcement purposes as required by law or in response to a court order, subpoena, warrant, summons, or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about a death resulting from criminal conduct; about crimes on the premises or against a member of our workforce; and in emergency circumstances, to report a crime, the location, victims, or the identity, description, or location of the perpetrator of a crime. 

• Judicial and administrative proceedings. If you are involved in a lawsuit or a legal dispute, we may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process.

• United States Department of Health and Human Services. Under federal law, we are required to disclose your PHI to the U.S. Department of Health and Human Services to determine if we are following federal laws and regulations regarding the privacy of PHI.

• Coroners, medical examiners, and funeral directors. We may release your PHI to assist in identifying a deceased person or determine a cause of death.

• Organ or tissue procurement organizations. Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

• Notification. We may use or disclose your PHI to assist in a disaster relief effort so that your family, personal representative, or friends may be notified about your condition, status, and location. 
• Correctional institution. If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents PHI necessary for your health and the health and safety of others.

• To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI to appropriate authorities when necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public. We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. 

• Military and Veterans. If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.

• National Security, Intelligence Activities and Protective Services for the President and Others. We may disclose your PHI to authorized federal officials for intelligence, counterintelligence, provision of protection to the President, other authorized persons or foreign heads of state, and other national security activities authorized bylaw.

• Appointment Reminders. We may use or disclose PHI to provide you with appointment reminders (such as voicemail messages, text messages, postcards, or letters). You have a right, as explained below, to request restrictions or limitations on the PHI we disclose. You also have a right, as explained below, to request that information be communicated with you in a certain way or at a certain location.

• As required by law. We must disclose your PHI when required to do so by applicable federal or state law.

Uses and Disclosures of Your PHI Requiring Your Authorization

We will obtain your written authorization before using or disclosing your PHI for the following purposes which are other than those described above (or as otherwise permitted or required by law):

• Psychotherapy Notes. We will not use or disclose psychotherapy notes without your written authorization, and only as permitted by law.

• Marketing Health---Related Services. We will not use or disclose your PHI for marketing communications without your written authorization, and only as permitted by law.

• Research. We may use or disclose your PHI for research purposes. However, before disclosing your PHI, the research project must be approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI. Before using your PHI for research purposes, CRC will secure your written authorization.

 
If you give us an authorization for use of your PHI for any purpose, you may revoke it by submitting a written notice to our Privacy Official at the address listed below. Your revocation will become effective upon our receipt of your written notice. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by the written authorization. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

Sale of your PHI

CRC will not sell your PHI under any circumstances.

CHANGES TO THIS NOTICE

CRC reserves the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changed Notice effective for all health information that we maintain, including health information we created or received before we made the changes. When we make a change in our privacy practices, we will change this Notice and make the new Notice available to you.

YOUR HEALTH INFORMATION PRIVACY RIGHTS

You have privacy rights under federal and state laws that protect your health information. These rights are important for you to know. You can exercise these rights, ask questions about them, and file a complaint if you think that your rights are being denied or your health information isn’t being protected. CRC must comply with your rights as follows:

To Request Restrictions on Certain Uses and Disclosures of PHI. You have the right to request restrictions on our use or disclosure of your PHI by sending a written request to the Privacy Office. We are not required to agree to those restrictions. We cannot agree to restrictions on uses or disclosures that are legally required, or which are necessary to administer our business. We must agree to the request to restrict disclosure of PHI to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the PHI pertains solely to a health care item or service for which you, or another individual other than a health plan on behalf of you, has paid us in full.

To Request Confidential Communications. You have the right to request that PHI be communicated to you by alternative means or at alternative locations. For example, you can ask that you only be contacted at work or by mail. We will accommodate all reasonable requests.

To Access PHI. You have the right of access to inspect and obtain a copy of your PHI. You may not be able to obtain all of your information in a few special cases such as, if your treatment provider determines that the information may endanger you or someone else. In most cases, your copies must be given to you within fifteen (15) days.

We may charge you a fee for the costs of copying, mailing and supplies that are necessary to fulfill your request.

In accordance with Texas law, you have the right to obtain a copy of your PHI in electronic form for records that we maintain using an Electronic Health Records (EHR) system capable of fulfilling the request. Where applicable, we must provide those records to you or your legally authorized representative in electronic form within fifteen (15) days of receipt of your written request and a valid authorization for electronic disclosure of PHI. You may request a copy of an authorization from the Privacy Office at the address below.

To Obtain a Paper Copy of This Notice Upon Request. You may request a copy of our current Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. You may obtain a paper copy from the Privacy Office at the address below. A reasonable fee may be charged for the costs of copying, mailing or other supplies associated with your request.

To Request an Amendment of PHI. If you feel that PHI we have about you is incorrect or incomplete, you may request an amendment to the information. Requests must identify: (i) which information you seek to amend, (ii) what corrections you would like to make, and (iii) why the information needs to be amended. We will respond to your request in writing within 60 days (with a possible 30-day extension). In our response, we will either: (i) agree to make the amendment, or (ii) inform you of our denial, explain our reason, and outline appeal procedures. If denied, you have the right to file a statement of disagreement with the decision. We will provide a rebuttal to your statement and maintain appropriate records of your disagreement and our rebuttal.

To Receive an Accounting of Disclosures. You have the right to request an accounting of your PHI disclosures for purposes other than treatment, payment or healthcare operations. Your request must state a time period. The time period for the accounting of disclosures must be limited to less than 6 years from the date of the request. We will respond in writing within 60 days of receipt of your request (with a possible 30-day extension). We will provide an accounting per 12-month period free of charge, but you may be charged for the cost of any subsequent accountings. We will notify you in advance of the cost involved, and you may choose to withdraw or modify your request at that time.

To Notification in the Event of a Breach. You have a right to be notified of an impermissible use or disclosure that compromises the security or privacy of your PHI. We will provide notice to you as soon as is reasonably possible and no later than sixty (60) calendar days after discovery of the breach and in accordance with federal and state law.

To File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our privacy official, listed below. You may also file a complaint directly with any or all of the following federal and state agencies: The Secretary of the Department of Health and Human Services, the Office of the Attorney General of Georgia, or the applicable Board of the Georgia Department of Health and Human Services: the Georgia Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists. We will provide you with the addresses to file your complaint with the Secretary, the Office of the Attorney General of Georgia and/or the applicable Board of the Georgia Department of Health and Human Services: the Georgia Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists, upon request. You will not be penalized in any way for filing a complaint.

If you want more information about our privacy practices or have questions or concerns, please contact us. Privacy Official:

Jim Walter, Executive Director, Pastoral Counselor
The Center for Relational Care
11615 Angus Road, Suite 218
Austin, Texas 78759

I have been given a copy of The Center for Relational Care’s Notice of Privacy Practices (“Notice”), which describes how my health information may be used and shared. I understand that The Center for Relational Care has a right to change this Notice at any time and that I may obtain a current copy by contacting the practice’s Privacy Official. 

My signature below acknowledges that I have been given a copy of the Notice of Privacy Practices.