Notice of Privacy Practices
This notice describes how your medical information may be used and/or disclosed and how you can get access to this information. Please review this notice carefully before signing.
As outlined in the Advisement Form related to your court-ordered custody/adoption evaluation or parenting facilitation, the process of such an evaluation or service is not confidential. The information acquired during the evaluation or facilitation can include your Protected Health Information, which may be summarized in the evaluation, produced to the court and the attorneys of record, or to clients who represent themselves upon completion of that evaluation. Health records contain personal information that may identify you and your past, present, or future physical or mental health and related health care services. This is referred to as Protected Health Information (hereinafter “PHI”). This Notice of Privacy Practices describes how Dr. Tammi Axelson and her employees or staff may use and disclose your PHI in accordance with applicable law. This includes the Health Insurance Portability and Accountability Act (“HIPPA”) regulations and Dr. Axelson’s professional code of ethics and licensure. Information about Dr. Axelson’s licensure (license #37655) and code of ethics can be found on the Texas Behavioral Health Executive Council website (www.bhec.texas.gov). This Notice of Privacy Practices also describes your rights regarding how you may gain access to and control your PHI.
Dr. Axelson and her staff are required to maintain the privacy of PHI and to provide you with notice of the legal duties and privacy practices related to PHI. Dr. Axelson and her staff are required to abide by the terms of this Notice of Privacy Practices at all times. Dr. Axelson has the right to change the terms of her Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that is maintained at the time of the change. If Dr. Axelson changes her policy during your evaluation, you will be provided with a copy of the revised Notice of Privacy Practices and asked to sign that new document. Should your evaluation be completed before such a revision occurs, you will not be provided a copy since services are no longer in process. However, you can access Dr. Axelson’s current Notice of Privacy Practices at any time on her website (www.tammiaxelsonlmsw.com).
THE USE AND DISCLOSE OF HEALTH INFORMATION FOR COURT-RELATED EVALUATIONS
During a child custody evaluation, adoption evaluation, or other court-ordered evaluations, your PHI and your child/children’s PHI may be acquired as part of the evaluation process as required by the standards of practice and the Texas Family Code. This information will be used to ensure a thorough evaluation of you and your family to provide an accurate assessment to the court related to the best interest of your child or children. This information, once acquired, may be disclosed in the evaluation, reproduced to the court, the attorneys of record, and/or to the clients who represent themselves, potentially via E-file or provided in testimony. This is clearly outlined in the Releases of Information that you must sign during the evaluation. This information may also be utilized anonymously in consultation with other clinical professionals to assist the evaluator in completing your case with appropriate peer review. In addition, your PHI and your child/children’s PHI may be disclosed or provided to another mental health professional or consultant with your authorization only.
For most forensic services (court-ordered evaluations and services), there is an exception in federal law regarding access to PHI that supersedes the procedures below. See 45 CFR 164.524(a)(1)(ii) regarding exemption for “information compiled in reasonable anticipation of, or for use in, civil, criminal, or administrative action or proceeding.” Additionally, CFR 164.512(e) covers additional provisions for disclosure for judicial and administrative proceedings. Litigants who participate in court-ordered evaluations or parenting facilitation generally have the right, unless restricted by the court, to be provided copies of all information in Dr. Axelson’s possession regarding their case. As these services do not generate PHI but collect it, Dr. Axelson is prohibited from altering the information contained in these records received. Litigants must contact the original creator of these records to make corrections. Information obtained in court-related services is not confidential.
Required by Law: Under the law, Dr. Axelson must disclose your PHI to you upon your request, though this information will not be produced until the evaluation process has been completed to ensure the evaluator’s neutrality. In addition, Dr. Axelson must make disclosures to the Secretary of the Department of Health and Human Services to investigate or determine compliance with the requirements of the Privacy Rule. This form details other circumstances where disclosures are required or permitted by law such that Dr. Axelson will comply with any lawful request or requirement to provide information.
Without Authorization: The following is a list of the categories of uses and disclosures permitted by HIPAA without authorization. Applicable law and ethical standards permit Dr. Axelson to disclose information about you or your children without your authorization in a limited number of situations.
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Abuse or Neglect: Dr. Axelson may disclose your or your child/children’s PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect of vulnerable populations such as children, the elderly, or the disabled.
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Judicial and Administrative Proceedings: Dr. Axelson may disclose your or your child/children’s PHI pursuant to a subpoena, court order, administrative order, or similar process.
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Law Enforcement: Dr. Axelson may disclose your or your child/children’s PHI to a law enforcement official as required by law, in compliance with a subpoena, a court order, an administrative order, or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, and in connection with a crime on the premises.
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Public Safety: Dr. Axelson may disclose your or your child/children’s PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If the information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
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Public Health: If required, Dr. Axelson may use or disclose your or your child/children’s PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health agency.
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Medical Emergencies: Dr. Axelson may use or disclose your or your child/children’s PHI in a medical emergency to medical personnel only to prevent serious harm. Dr. Axelson’s staff will provide you with notice as soon as possible after the resolution of the emergency.
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Deceased Clients: Dr. Axelson may disclose PHI regarding a deceased client as mandated by state law or to a family member or friend based on prior consent. A release of information regarding deceased clients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. In situations where disclosure is unclear, Dr. Axelson may require a court order to release records. Dr. Axelson retains records for seven years according to her licensure.
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For Business Operations: Dr. Axelson may use or disclose, as needed, your or your child/children’s PHI to support normal business activities, including, but not limited to, quality assessment, employee reviews, licensing, and conducting or arranging other business activities. For example, Dr. Axelson may share PHI with third parties that perform other business activities, such as copying and transcription services, with a written contract with the business regarding safeguarding the privacy of your PHI.
With Authorization: Uses and disclosures of PHI not specifically permitted by applicable law will be made only with your written authorization, which may be revoked in writing at any time, except to the extent that Dr. Axelson has already made a use or disclosure based upon your authorization or an applicable court order related to your family law matter. The following uses and disclosures of PHI will be made only with your written authorization. Dr. Axelson will discuss with litigants the authorization to release information and provide ample opportunity to consider this release before it is signed. Litigants with questions related to the implications of authorizing Dr. Axelson to obtain PHI or declining to authorize will be referred to their attorney.
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Research: PHI will only be disclosed after special approval and with your authorization for research.
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Fundraising: Dr. Axelson will never use your or your child/children’s PHI for fundraising.
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Verbal Permission: Dr. Axelson may use or disclose your and your child/children’s PHI or information to a family member directly involved in your case with your verbal permission. The evaluator will not speak to your family members during a court-ordered evaluation unless they reside with you on a full-time or part-time basis, or they have completed a personal reference questionnaire form or a personal witness statement for you and if a telephone call is warranted after the written information is received. If a family member who does not reside with you or has submitted one of these forms listed above on your behalf contacts the evaluator, they will be asked to submit any information they want to provide in writing. After receiving the information in writing, the evaluator may contact them with questions, but no PHI will be discussed or disclosed.
DISCLOSURE OF PHI THAT IS NOT APPLICABLE TO COURT-ORDERED EVALUATIONS
NOTE: The laws related to the maintenance policies of your PHI changed in 2013, and these laws require that this information be disclosed to you, even though this does not apply to the evaluator’s process. The reasons that each item does not apply will be outlined in bold below each item identified:
For Treatment: Your PHI may be used and disclosed by those involved in your care to provide, coordinate, or manage your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization. (The process of a court-ordered custody case evaluation is not treatment, and the evaluator does not provide treatment services in her practice.)
For Payment: Your PHI may be used and disclosed to receive payment for the treatment services provided. This will only be done with your authorization. Payment-related activities include determining eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for collection purposes. (Payment for a court-ordered evaluation or other court-ordered services is payable directly to the evaluator by check or money order. The evaluator does not bill insurance, and insurance does not cover Dr. Axelson’s services. The only payment that may be necessary and related to your PHI information is any costs that your current or previous providers may require you to pay to produce your records to the evaluator for the court-ordered evaluation process as required by the Texas Family Code and the standards of practice. As noted in the release forms that you will sign, you are responsible for all costs related to the records acquired for your evaluation.)
For Health Care Operations: We may use or disclose, as needed, your PHI in order to support our business activities, including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. PHI will be disclosed only with your authorization for training or teaching purposes. (The evaluator’s court-ordered evaluation services do not entail health care operations, and this aspect of the required privacy policy does not apply outside of what has been outlined within this policy. The evaluator does have a signed document with all students in training, graduate-level interns, and contractors hired to perform administrative tasks and editing services.)
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI that is maintained about you. To exercise any of these rights, please submit your request to Dr. Axelson in writing after completing your evaluation using the contact information at the top of this form.
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Right of Access to Inspect and Copy: Once your court-ordered evaluation is complete, you have the right, which may be restricted only in exceptional circumstances or via court order, to inspect and copy any PHI information related to you or your child/children that has not already been attached to your evaluation and produced to the court and/or your attorney or clients who represent themselves. The evaluator may charge a reasonable, cost-based fee for the copies, and if the records are maintained electronically, you may also request an electronic copy of your PHI. You may not request that this information be provided to another person aside from your attorney of record.
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Right to Amend: Once your court-ordered evaluation is completed and filed with the court, you have the right to ask that the PHI be amended if you feel that the PHI Dr. Axelson has about you is incorrect or incomplete. Dr. Axelson is not required to agree with your amendment. If your amendment is directly related to information produced to Dr. Axelson, it would be most appropriate for you to seek an amendment from the provider who produced the PHI to the evaluator. If Dr. Axelson denies your request for an amendment, you have the right to file a statement of disagreement with the evaluator that will be forwarded to the court and the attorneys of record or to clients who represent themselves.
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Right to an Accounting of Disclosures: You have the right to request an accounting of certain of the disclosures Dr. Axelson makes of your PHI or your child/children’s PHI. The evaluator may charge a reasonable fee for this request. Within a court-ordered adoption/custody evaluation, your PHI or your child/children’s PHI will only be disclosed as outlined in your Advisement Form to the court, the attorneys, clients who represent themselves, and individuals for whom releases were signed and have not been revoked.
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Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI. Dr. Axelson is not required to agree to your request. However, the court will be notified if an attempt is made to restrict the evaluator’s access to necessary PHI required as part of the standards of practice and the Texas Family Code.
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Breach of Notification: If there is a breach of unsecured PHI concerning you, Dr. Axelson may be required to notify you of this breach, including what happened and what you can do to protect yourself. Dr. Axelson has a separate policy in her HIPP policy manual regarding the investigation of a breach of PHI, which will be followed. Once your evaluation is completed, Dr. Axelson will maintain your records under lock and key for seven years until those records are destroyed in the evaluator’s presence.
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Right to a Copy of this Notice: You have a right to a copy of this notice, which can be found online via the evaluator’s website and will be provided to you in writing before your evaluation begins.
NOTE: The current law requires Dr. Axelson to notify you of your Right to Request Confidential Communication. This notice states that you have the right to request that she communicate with you about health matters in a certain way or at a certain location. Dr. Axelson will accommodate reasonable requests. Dr. Axelson may require information regarding how payment will be handled or the specification of an alternative address or other contact methods as a condition for accommodating your request. Dr. Axelson will not ask you for an explanation of why you are making the request. (During an evaluation, you are asked to provide the evaluator with a preferred telephone number and email address for communication purposes. The evaluator will contact you as needed via one of these means primarily for administrative purposes, and as noted, your information acquired during an evaluation is not confidential).
ADDITIONAL NOTIFICATIONS
The following additional notifications are required to ensure that you have a thorough understanding of how your information may or may not be used or transmitted during a court-ordered child custody evaluation:
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As outlined in the evaluator’s Advisement Form, should the evaluator die, become incapacitated, or terminate her practice, the custody and control of the records maintained by Dr. Axelson, LMSW-IPR, will be turned over to Andrea Musick, LMSW. In the event of Mrs. Musick’s death, incapacitation, or termination of her practice, other successors will be appointed as selected by her or Dr. Axelson’s office manager.
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The majority of your record will be maintained by the court and your attorneys of record once your evaluation is complete and filed with the court. After that time, the evaluator will maintain your record under lock and key until seven years have passed, at which time, those records will be destroyed in the evaluator’s presence.
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The evaluator utilizes virus protection software and firewall protection on all computers (laptop, desktop, and iPad) utilized during her evaluation.
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The evaluator does not release your PHI or your child/children’s PHI without your signed consent unless of specific circumstances detailed in this policy under the section pertaining to the release without authorization. Otherwise, this information is only released within the guidelines established within the evaluator’s court order and Advisement Form to the court, the attorneys of record, or clients who represent themselves.
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Information related to your case may be kept during your evaluation in several different places, including but not limited to the evaluator’s locked office, the evaluator’s locked storage locations, the evaluator’s car when in transport to the courthouse or clients’ homes, the evaluator’s P.O. Box, the evaluator’s facsimile machine, the evaluator’s desktop and/or laptop computers or iPad, the evaluator’s cellular phone, the evaluator’s email account, and the evaluator’s paper files and/or electronic files.
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If you choose to communicate with the evaluator by mail, email, text, or facsimile, you understand the limitations of confidentiality that may exist specifically with each of these forms of communication despite all efforts that have been made to protect your confidentiality in this regard (i.e., the evaluator’s computers, email accounts, etc., are all password and/or firewall-protected). Most reports and PHI are stored within a cloud-based management system that is password protected.
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The process of an evaluation does not entail the creation or generation of PHI. The process of an evaluation only entails the acquirement of such information. Due to the court-ordered nature of that process, the acquired information is not confidential and can and/or will be produced for the court, the attorneys of record, and the parties who represent themselves once the evaluation is completed and filed with the court.
Complaints
If you believe that the evaluator has violated your privacy rights, you have the right to file a complaint in writing with the evaluator/privacy officer via the address outlined above or with the Secretary of Health and Human Services at 200 Independence Avenue, SW Washington DC 20201 or by calling (202) 619-0257. The Texas Behavioral Health Executive Council investigates and prosecutes professional misconduct committed by marriage and family therapists, professional counselors, psychologists, psychological associates, social workers, and licensed specialists in school psychology. Although not every complaint against or dispute with a licensee involves professional misconduct, the Executive Council will provide information about filing a complaint. An individual who wishes to file a complaint against a Licensed Social Worker may do so to the Texas Behavioral Health Executive Council. Complaints can be submitted by mail to 1801 Congress Avenue, Ste. 7.300, Austin, Texas 78701, or by phone at 1-800-821-3205. In addition, you can find more information about complaints, submit one in writing, or verify Dr. Axelson’s license (#37655) at their website: https://www.bhec.texas.gov/discipline-and-complaints/index.html.
The effective date of this Notice is September 2013, and last revised in September 2022
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