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This notice went into effect on 12/6/2022 and was last updated on 3/12/2024.

Protected health information (PHI) is your information, created or received by a healthcare provider that relates to your past, present or future physical or mental health or condition, to the provision of health care to you, or to payment for your health care. 



Inclusion Therapies LLC, is required by law to:

- Make sure that protected health information (“PHI”) that identifies you is kept private. 

- to provide this Notice of our legal duties and privacy practices, 

- notify affected individuals following a breach of unsecured protected health information; and, 

- to abide by the terms of this Notice [we may change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website]. 

We may use or disclose health information about you for the purpose of your treatment, and also to the extent necessary to obtain payment for treatment and for certain administrative purposes, including evaluation of the quality of care that you receive. We may also use or disclose identifiable health information about you without your authorization in certain other circumstances. For example, subject to certain requirements, for public health purposes, for auditing purposes, for research studies, and for emergencies. We also provide health information when required by law. Uses or disclosures other than those described in this Notice will be made only with your written authorization. If you do authorize a use or disclosure, you have the right to take back or “revoke” your authorization at any time by submitting a revocation in writing. We are unable to take back any use or disclosure that we have taken an action in reliance on the use or disclosure as previously indicated. For additional information, or to make a complaint with respect to your privacy rights, you may contact our administrator or the Department of Health and Human Services Office for Civil Rights, contact information is listed at the end of this Notice.


A. The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

    • For Treatment, Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
    • Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
    • Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
    • Health Care Operations: We may use or disclose your protected health information in order to support our business activities and health care operations. These activities include, but are not limited to, quality assessment audits and improvement activities, communication about products or services, reviewing the competence or qualification of health care professionals, conducting training programs, business planning and development, business management and general administrative activities. 
    • Business Associates. There are some services provided in our organization through business contracts. When these services are contracted, we may disclose your protected health information to our business associate, so that they can perform the job we have asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your protected health information.

B. I, the undersigned below, acknowledge and understand that this office may contact and survey me via e-mail regarding my satisfaction and outcomes. I understand that an independent vendor(s) may assist with this data collection. I understand that in addition to the aforementioned confidential survey, this office or their designated vendor may also send an automated email and/or text to allow me to voluntarily and publicly rate and review my provider online through sites like Google, Yelp, etc. I acknowledge that my responses, like other online responses, may be published on the respective review site(s) and will be publicly disclosed and accessible to anyone who accesses that site. I understand that reviews are optional, and I will not include any sensitive, personal, identifying or medical information that I do not wish to be publicly disclosed in an online review (i.e., name, contact information, social security number, health history, diagnosis, medications, etc.). When submitting a survey or review, I agree to fully release, waive and indemnify this office and/or the associated vendor(s) from any and all claims arising from my voluntary disclosure of protected health information to the sites.


A. Psychotherapy Notes as that term is defined in 45 CFR § 164.501 - Your authorization is required in order for us to disclose psychotherapy notes. Certain situations do not require your authorization for use of psychotherapy notes, these include use by the originator of the psychotherapy notes for treatment; use in training programs in which students, trainees or practitioners in mental health learn to practice and improve their skills; use in order to defend a legal proceeding brought by you; for use by the Secretary of Health and Human Services to investigate our compliance with HIPAA; required by law and the use or disclosure is limited to the requirements of such law; required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes; required by a coroner who is performing duties authorized by law; required to help avert a serious threat to the health and safety of others; and any other use permitted by law.

B. Marketing - Your authorization is required for any use or disclosure of protected health information for marketing except in situations in which the communication is in the form of a face-to face communication or a promotional gift.

C. Sale of PHI - Your authorization is required for any disclosure of protected health information which is a sale, as defined under applicable law. 


Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:

    • When disclosure is required by local, state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
    • For public health activities, including reporting suspected child, elder, or dependent adult abuse, to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or preventing or reducing a serious threat to anyone’s health or safety.
    • For health oversight activities, including audits and investigations.
    • For judicial and administrative proceedings, including responding to a court or administrative order.
    • For law enforcement purposes, including reporting crimes occurring on our premises.
    • To coroners or medical examiners, when such individuals are performing duties authorized by law.
    • For research purposes, including studying and comparing the health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
    • Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
    • Military Activities. We may, if you are a member of the United States or foreign Armed Forces, disclose your protected health information for activities that are deemed necessary by appropriate military command authorities to assure the proper execution of a military mission.
    • Threats to health or safety. Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
    • Highly confidential information. Certain Federal and state laws may require special privacy protections for certain highly confidential information about you. Highly confidential information may include confidential information under Federal laws governing alcohol and drug abuse information and genetic information as well as State laws that often protect the following types of information: (1) mental health and/or developmental disabilities services; (2) HIV/AIDS; (3) genetic tests; (4) communicable disease(s); (5) Alcohol and drug abuse; (6) child abuse and neglect; (7) domestic or elder abuse; and/or (8) sexual assault. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, we will require your written authorization. 
    • Relating to decedents or for organ or tissue donations. We may disclose protected health information relating to an individual's death to coroners, medical examiners or funeral directors for their duties as authorized by law, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.
    • For workers’ compensation purposes o your employer. We may disclose your protected health information to your employer if we are providing health care to you at the request of your employer to conduct an evaluation relating to medical surveillance of your workplace or to evaluate whether you have a work-related illness or injury. We will notify you before making such a disclosure by providing you with written notice at the time we provide health care to you. 
    • Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with me. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer. 



A. Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

B. Disaster relief. We may disclose your protected health information to disaster relief organizations that seek your protected health information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so. 

C.  Right to Request Restrictions for Disclosures Related to Self-Payment. You have the right to request the non-disclosure of health information to a health plan for treatment in situations where you have paid in full out-of-pocket for a health care item or service. 


You have the following rights relating to your protected health information. You will need to give written request in order to exercise these rights. 

A. To request restrictions: You have the right to request that we restrict the uses or disclosures of your information for treatment, payment or healthcare operations. You may also request that we limit the information we share about you with a relative or friends. In most cases we are not required to agree to patient request to restrict except, you have the right to restrict disclosures of information to your commercial health information plan regarding services or products that you have paid for in full, out-of-pocket, we must grant such a request. In all other cases, we are not required to agree to requests. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment and/or safe patient care and we cannot agree to limit uses or disclosures that are required by law. Request for restriction must be made in writing and include: (i) what information you want to limit, (ii) whether you want to limit use or disclosure or both and (iii) to whom you want the limits to apply. We may terminate our agreement to a restriction by notifying you. Termination of the agreed restriction will only apply to protected health information received after notice was given to you. 

B. To choose how we contact you: You have the right to ask that we send your information at an alternative address or by an alternative means. For example, you can ask that we only contact you by mail or at work. Request must be made in writing, you do not need to give us a reason for your request. We must agree to your request as long as it is reasonably easy for us to do so. When appropriate, we may condition the provision of a reasonable accommodation upon receiving information relating to how payment arrangements will be made. 

C. To inspect and obtain a copy your protected health information: With a few exceptions (such as psychotherapy notes and records compiled in anticipation of litigation), you have a right to inspect or receive copies of your protected health information that is kept in a “designated record set.” A “designated record set” is a group of records that includes billing records and records used to make decisions about you. If your protected health information is maintained in an electronic format, you are permitted to receive access to information you requested in electronic format or may have the information transmitted electronically to a designated recipient. We will abide by your request in the format you have requested, if it is feasible to do so, if we cannot, we will attempt to provide your information in an alternative format that you agree to. You may be charged a fee for the cost of copying, mailing or other expenses associated with your request. If we deny your access, you may ask for our decision to be reviewed. We will choose a licensed health care professional to review your request and the denial. The person conducting the review will not be the person who denied the request. We will comply with the outcome of the review. 

D. To request amendment of your protected health information: If you believe that your information is incorrect or incomplete, you may ask that the information is amended. You have the right to request an amendment for as long as the information is maintained by us. A request for amendment must be made in writing. Request for an amendment will be denied if it is not in writing or does not include a reason to support the request. In addition, we may deny the request if the protected health information is: (i) correct and complete; (ii) not created by us and/or not part of our records; (iii) not permitted to be disclosed; or (iv) not part of a designated record set. If we approve the amendment, we will make appropriate changes and inform you and others, as needed or required. If we deny your request, we will explain the denial in writing to you and explain any further steps you may wish to take. 

E. To find out what disclosures have been made: You have the right to request an accounting of disclosures. This is a list of disclosures we have made regarding your protected health information. A request for an accounting must be in writing and must state the time period that may not be longer than six years prior to the date on which you request the list. Certain types of disclosures are not included in such an accounting, these include disclosures made for treatment, payment and healthcare operations; incidental to permitted uses/disclosures; your family, or the company directory, or pursuant to your written authorization; disclosures made for national security purposes, to law enforcement officials or correctional facilities. If specific personal identifying information has been removed before disclosure, we may not be required to include such a disclosure in the list. The first request within a 12-month period will be provided for free, there may be a charge for more frequent requests. If there will be a charge, we will notify you of the cost in advance. 

F. To receive this notice: You have a right to receive a paper copy of this Notice upon request. We reserve the right to change our Notice of Privacy Practices and to make the new provisions effective for all protected health information we maintain, including protected health information received in the past as well as protected health information received after the effective date of the new Notice. A current copy of our Notice will be posted in our office(s) and will also be available on our web site, You may also obtain a copy by writing or calling the office and asking that one be mailed to you or by asking for one the next time you are in our office. 

G. To be notified following a breach of the patient’s unsecured protected health information. In the unlikely event that a patient’s unsecured protected health information has been compromised, Inclusion Therapies LLC will notify the patient of such an incident. 

For questions or complaints, please contact: 

Inclusion Therapies General Counsel (512) 553-5380. 

For More Information or to Make a Complaint -  If you believe your privacy rights have been violated, you can file a complaint with Inclusion Therapies General Counsel at or the Department of Health and Human Services Office for Civil Rights at or or you may email OCR at or call the U.S. Department of Health and Human Services, Office for Civil Rights toll-free at: 1-800-368-1019, TDD: 1-800-537-7697. 

There will be no retaliation for filing a complaint.


Inclusion Therapies LLC complies with applicable federal, state, and local civil rights laws and does not discriminate on the basis of any protected class (including but not limited to, race, color, gender, sexual orientation, national origin, age, disability, pregnancy or veteran’s status). We do not exclude people or treat them differently because of any protected class. 

A. Our Company: 

1. Provides free aids and services to people with disabilities to communicate effectively with us, such as: 

Ø Qualified sign language interpreters 

Ø Written information in other formats (large print, audio, accessible electronic formats, other formats).   

2. Provides free language services to people whose primary language is not English, such as: 

Ø Qualified interpreters 

Ø Information written in other languages.   

If client needs these services, please contact our office at or (512) 553-5380 and let us know ahead of your appointment. 

If client believes that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: 

Inclusion Therapies LLC

Attn: General Counsel 

2110 Ranch Road 620 S, #341225, Lakeway, Texas 78734

or email 

You can file a grievance by mail or by email. If you need help filing a grievance, our Compliance Department is available to help you at (512) 553-5380. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at

or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at


Acknowledgement of Receipt of Privacy & Nondiscrimination Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. 

By signing, I am acknowledging that I have received a copy of this HIPAA Notice of Privacy Practices & Nondiscrimination Notice.