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THIS LEGAL NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices (this “Notice”) of LIFE TREE Counseling Center (“LIFE TREE”) is being provided to you in accordance with the requirements of the Standards for Privacy of Individually Identifiable Health Information of the Health Insurance Portability and Accountability Act (the “HIPAA Privacy Rules”). The HIPAA Privacy Rules are federal laws that seek to ensure the privacy and confidentiality of your health information. This notice has been prepared to advise you of the uses and disclosures of your Protected Health Information that may be made by LIFE TREE and to advise you of your rights and LIFE TREE’S legal duties relating to the privacy of your Protected Health Information (henceforth referred to as “PHI”). In referring to “Health Care” in this document it is understood we are also referring to “Mental Health Care”.

The law permits LIFE TREE to use or disclose PHI to carry out “treatment”, “payment” and other “daily office operations”. LIFE TREE is not required to obtain an authorization from you or notify you each time it uses or discloses your PHI for treatment, payment or health care operations purposes.

Treatment: “Treatment” means the provision, coordination, or management of health care and related services by health care providers, including the coordination or management of health care by a health care provider with a third party (such as an insurer of LIFE TREE), consultation between providers with respect to a patient, and the referral of a patient for health care from one provider to another. LIFE TREE may disclose PHI to your Primary Care Physician, or to another physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your PHI will be used, as needed, to obtain “payment” for your health care services provided by LIFE TREE. This may include certain activities that your health insurance plan may undertake before it approves or pays for the services LIFE TREE recommends for you such as making a determination of eligibility or coverage for insurance benefits, and undertaking utilization review activities necessary to obtain precertification for services (“Sessions”). PHI may be disclosed to your health care plan to obtain approval for hospitalization as well.

Daily Office Operations: These are those other functions and activities that LIFE TREE performs in connection with providing health care. These activities include, but are not limited to quality assessment activities, training of psychology students, credentialing, underwriting, auditing functions, budgeting and financial reporting, and conducting or arranging for other business and administrative activities. In addition, LIFE TREE may use a sign-in sheet at the registration desk where you will be asked to put your first name and indicate your Therapist. LIFE TREE may also call you by name in the waiting room when your Therapist is ready to see you. LIFE TREE may share your PHI with third party “business associates” that perform various functions (e.g. billing services) for LIFE TREE Therapists. LIFE TREE will have a written contract with each business associate that contains terms that will protect the privacy of your PHI.

Additional Uses of Information:

LIFE TREE may use or disclose your PHI to provide you with appointment reminders or information about your treatment alternatives or other health-related benefits and services that may be of interest to you.

Other Uses and Disclosures:

For uses and disclosures of PHI that are not for treatment, payment, or daily office operations purposes and for which no exception applies, the law requires LIFE TREE to obtain your written approval in order to disclose your PHI to a particular person or entity for a particular purpose (“Authorization”). You may revoke Authorization at any time, but a revocation is not effective if LIFE TREE has already reasonably relied on your Authorization to make a particular use or disclosure.

The types of uses and disclosures of PHI that may be made without your Authorization and without giving you the opportunity to object include these (among others): for public health activities; for FDA-related purposes; to address work-related illness/injuries and for worker’s compensation purposes (such as when the Government requests certain information from LIFE TREE to determine its compliance with applicable laws): when a judge or administrative tribunal orders the release of PHI; to properly assist law enforcement agencies to carry out their duties; pursuant to a request from a law enforcement official if the individual is a victim of a crime; for purposes of identifying or locating a suspect, fugitive, material witness, or missing person; for reporting to correctional institutions/law enforcement officials acting in a custodial capacity; and for certain military/security purposes.

There are several types of uses or disclosures of PHI that LIFE TREE may make without your Authorization as long as, whenever possible you are given the opportunity to agree or object before LIFE TREE makes the disclosure. These exceptions are very limited and generally involve the release of a limited amount of PHI, and include, but are not limited to the following purposes: to aid family members, close personal friends or persons identified by you to assist in your care, payment of care; or to aid them in locating you and notifying them of your condition. In these circumstances, LIFE TREE will make a concerted effort to obtain your Authorization prior to making these disclosures.

Your Rights under the Privacy Standards:

You have the right to request additional restrictions relating to LIFE TREE’S use or disclosure of your PHI beyond those otherwise required under the HIPAA Privacy Rules. Although LIFE TREE is not legally required to grant these requests, it is your right to make such a request. To obtain the proper form for making such a request, please ask your Therapist.

LIFE TREE may communicate your PHI to you in a variety of ways, including by mail or telephone. If you believe that LIFE TREE’S communications to you by the usual means will endanger you or your care and you would like LIFE TREE to make it’s communications by an alternate method or at an alternate location, you may advise your Therapist, in writing, of your concerns.

Subject to certain limitations, you have the right to request and obtain access to inspect and to copy your PHI maintained by your LIFE TREE Therapist unless the information is not required to be accessible under the HIPAA Privacy Rules or other applicable law. LIFE TREE does not have to disclose (to you) the release of your PHI to law enforcement officials, correctional institutions, and other federal agencies.

LIFE TREE may charge you a reasonable, cost-based fee for copying (including the cost of supplies and labor) any PHI required to be copied to adequately respond to your access request, as well as any postage costs and costs associated with preparing an explanation or summary of the PHI necessary to meet your request (unless otherwise precluded by applicable State or other law). Please notify your Therapist to obtain the appropriate forms. You have the right to request that LIFE TREE amend your PHI. LIFE TREE reserves the right to deny or partially deny requests for amendments that are not required to be granted under the HIPAA Privacy Rule. If you would like to request an amendment of you PHI, please notify your Therapist so that you can complete the appropriate form.

You have the right to request and obtain an accounting of disclosures that LIFE TREE has made of your PHI in the six years prior to the date on which the accounting is requested. LIFE TREE is not required to provide an accounting of disclosures made for treatment, payment, or daily office operations or for disclosures made without your Authorization. Also, LIFE TREE reserves the right to limit its accountings to disclosures made after the compliance date of the HIPAA Privacy Rules.

LIFE TREE may change the terms of this Notice at any time. The new notice will be effective for all PHI that LIFE TREE maintains at that time. Upon your request LIFE TREE will provide you with any revised Notice of Privacy Practices. You may request this Notice from your LIFE TREE Therapist.

If you have any questions or concerns or feel that LIFE TREE has violated your privacy rights or has acted inconsistently under the HIPAA Privacy Rules, you may file a complaint with your Therapist on the appropriate form. You may also file a complaint with the Office of Civil Rights (“OCR”) at the United States Department of Health and Human Services.

It is against the policies and procedures of LIFE TREE to retaliate against any person who has filed a Privacy complaint, either with LIFE TREE or with HHS OCR.

This Notice is effective as of April 14, 2003.
© 2003-2012 Life Tree Counseling Center, Inc.


Our counselors are trained and experienced in a wide variety of counseling disciplines including marital problems, children’s play therapy, drug-abuse counseling, faith-based counseling, ADHD treatments and more. Call us right now at 972-234-6634 and let’s see how we can help you, or visit our online appointment scheduling system and select your own day and time. We’d love to meet you and see how we can help.