Your Information. Your Rights. Our Responsibilities.
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 it comes to your health information, you have certain rights. This section explains your rights and some of our
responsibilities to help you.
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 15 days of your request. We may
charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are
not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for
the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to
share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the
date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and
certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but
will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We
will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can
exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting the Privacy and Security Officer: Connie
M. Siciliano Avila, Ph.D., LP, LPC-S and sending a letter to PO Box 5407, Frisco, TX 75035 or calling 214-830-9879.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by
sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
• We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for
how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will
follow your instructions. In most cases and when possible, we will acquire your written permission to release your
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your
information if we believe it is in your best interest. We may also share your information when needed to lessen a
serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes: Although, at MindSprouts Personal Growth Therapy, PLLC. (MindSprouts PGT, PLLC.), we
never release your information for marketing purposes.
• Sale of your information: However, at MindSprouts PGT, PLLC., we never sell your information.
• Most sharing of psychotherapy notes: In most cases, we seek your written permission before releasing
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again. However, at this time,
MindSprouts PGT, PLLC. does not practice fundraising exercises, so we would never ask you to participate in a
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you. However, under
most circumstances, we would seek your written permission before releasing any information.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities. At this time,
MindSprouts does not bill health plans, so we would not release information without your written consent.
Example: We can give information about you to your health insurance plan so it will pay for your services, which does
not apply at this time.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good,
such as public health and research. We have to meet many conditions in the law before we can share your information
for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
• Reporting treatment of sex offenders
We can use or share your information for health research. However, MindSprouts PGT, PLLC. does not participate in
research at this time. In the future, if we participate in research, then we will seek your written consent before
releasing your information.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and
Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations. At this time, we believe this
action to be highly unlikely to occur.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If
you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice
will be available upon request, in our office, and on our web site.
Other Instructions for Notice
• Effective Date of this Notice: June 22, 2014
• Privacy and Security officer: Connie M. Siciliano Avila Ph.D., LP, LPC-S. See contact information below.
• Special notes: We never market or sell personal information. Additionally, we do not fund raise, and you should
not be asked to participate. At this time, we neither conduct nor participate in research. In most cases, we will
never share any substance abuse treatment records without your written permission.
Connie M. Siciliano Avila, Ph.D
Licensed Professional Counselor Supervisor
Mail: PO Box 863842, Plano, TX 75086
Office: 16135 Preston Rd, Ste. 116, Dallas, TX 75248
Form updated 1/2021