THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements.

This notice applies to all records of your care generated by this mental health care practice. This notice describes the ways in which I may use and disclose health information about you. It also describes your rights regarding the health information I keep about you and certain obligations I have concerning the use and disclosure of your health information.

I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to your health information.
• Follow the terms of the notice that is currently in effect.

I reserve the right to change the terms of this Notice. Any changes will apply to all health information I maintain. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways I may use and disclose health information. Not every use or disclosure in a category is listed; however, all permitted uses and disclosures will fall within one of these categories.

Treatment, Payment, and Health Care Operations

Federal privacy regulations allow health care providers with a direct treatment relationship with a client to use or disclose the client’s PHI without written authorization to carry out treatment, payment, or health care operations.

I may also disclose your PHI for the treatment activities of another licensed health care provider. For example, if I consult with another licensed clinician regarding your care, your PHI may be shared as necessary to assist in diagnosis or treatment.

Disclosures for treatment purposes are not limited to the minimum necessary standard because health care providers need access to complete information to provide quality care. Treatment includes coordination and management of care, consultations, and referrals between health care providers.

Lawsuits and Disputes

If you are involved in a lawsuit or legal dispute, I may disclose health information in response to a court or administrative order. I may also disclose health information in response to a subpoena, discovery request, or other lawful process, but only if reasonable efforts have been made to notify you or to secure a protective order.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

Psychotherapy Notes

I do maintain “psychotherapy notes” as defined in 45 CFR § 164.501. Any use or disclosure of psychotherapy notes requires your written Authorization unless the use or disclosure is:

a. For my use in treating you

b. For my use in training or supervising mental health practitioners to improve their skills

c. For my use in defending myself in legal proceedings initiated by you

d. For use by the Secretary of Health and Human Services to investigate HIPAA compliance

e. Required by law and limited to the requirements of that law

f. Required for certain health oversight activities

g. Required by a coroner or medical examiner performing duties authorized by law

h. Necessary to avert a serious threat to the health or safety of you or others

Marketing Purposes

I will not use or disclose your PHI for marketing purposes without your written Authorization.

Sale of PHI

I will not sell your PHI.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION

Subject to legal limitations, I may use or disclose your PHI without your Authorization for the following purposes:

• When required by state or federal law
• For public health activities, including reporting suspected child, elder, or dependent adult abuse, 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 my premises
• To coroners or medical examiners, when such individuals are performing duties authorized by law
• For specialized government functions, including ensuring proper execution of military missions, protecting the President of the United States, conducting intelligence or counter-intelligence operations, or ensuring safety within correctional institutions
• For workers’ compensation purposes, as required by law
• For appointment reminders and to inform you about treatment alternatives or other health-related services I offer

V. USES AND DISCLOSURES REQUIRING OPPORTUNITY TO OBJECT

Disclosures to Family or Others Involved in Your Care

I may disclose your PHI to a family member, friend, or other person involved in your care or payment for care unless you object. In emergency situations, consent may be obtained retroactively.

VI. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights:

• The right to request restrictions on certain uses and disclosures of your PHI (I am not required to agree if it would affect your care).
• The right to request restrictions on disclosures to health plans for services paid out-of-pocket in full.
• The right to choose how I communicate PHI to you.
• The right to inspect and obtain copies of your medical record, excluding psychotherapy notes.
• The right to request an accounting of disclosures.
• The right to request corrections or amendments to your PHI.
• The right to receive a paper or electronic copy of this Notice.

EFFECTIVE DATE

This Notice of Privacy Practices is effective August 2024.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have specific rights regarding your protected health information. By agreeing to this form, you acknowledge receipt of this Notice.

Messaging Terms & Conditions

You agree to receive informational messages (such as appointment reminders or account notifications) from Salvaged Soul Counseling, PLLC.

Mobile Messaging Privacy Policy

Information Collected:

We may collect information such as your name, phone number, and email address.

Use of Information:

We may use the information collected to provide services requested, including scheduling, billing, customer service, appointment reminders, and other administrative communications.

Sharing of Information:

We may share information with payment processors or legal authorities as necessary to perform services or comply with the law. Your mobile information will not be shared, sold, rented, or used for marketing or promotional purposes. All policies comply with CTIA Guidelines 5.2.1. You may request removal of your information at any time by contacting us via our email address.

How to Request Your Health Care Records

Clients have the right to request access to their health care records.

To request your records:

Submit a written request by email to the platform you use to access therapy: 

If you use Rula you can request your records at records@rula.com. 

If you use Sondermind, please use the following link: https://help.headspace.com/hc/en-us/articles/42256127648411-How-do-I-request-my-medical-records-from-my-SonderMind-provider#:~:text=You%20can%20choose%20to%20have,representative%20(as%20defined%20by%20HIPAA)

If you use Mindful Therapy Group, you can request your records at https://mindfultherapygroup.com/records-request/

1. Include your full name, date of birth, and the specific records you are requesting.
2. Requests may be subject to identity verification and applicable fees as permitted by law.
3. Records will be provided within the timeframe required by Texas law.

If you use Grow Therapy , you can request your records by emailing: records@growtherapy.com 

Please note: A completed HIPAA Authorization/ROI form is required, and the current form and instructions are in the public records article. Processing can take up to 30 days.

If you have questions about requesting records, please contact the practice directly using the contact information listed on this website.

How to Contact the Texas Behavioral Health Executive Council

If you would like to contact the Texas Behavioral Health Executive Council (BHEC), which oversees behavioral health licensing boards in Texas, you may do so using the information below:

Texas Behavioral Health Executive Council

Website: https://www.bhec.texas.gov

Contact Page: https://www.bhec.texas.gov/contact-us

The Council can provide information about licensure, regulations, and the complaint process.

How to File a Consumer Complaint

If you believe your rights have been violated or you wish to file a consumer complaint, you may contact the Office of the Texas Attorney General’s Consumer Protection Division.

You can file a complaint online at:

https://www.texasattorneygeneral.gov/consumer-protection/file-consumer-complaint

This process is independent of the practice and allows consumers to raise concerns related to services provided in Texas.

These disclosures are provided in accordance with Texas House Bill 4224 and Texas Health & Safety Code §181.105

Use the section for the state where the client is located. I am not an expert witness. I can be called as a fact witness. Records and testimony are not released on an attorney subpoena alone. I need a written waiver from the client or an order signed by a judge.

Texas — Licensed Professional Counselor

Services in Texas are provided under my Texas Licensed Professional Counselor license. If called, I testify as a fact witness (Texas Rule of Evidence 701), not as an expert (Texas Rule of Evidence 702).

I can testify to what is in the treatment record: dates, attendance, the diagnosis and treatment plan in the record, and observations written in the notes.

Custody opinions are legally and ethically barred for a person to whom I provide therapy. That opinion is a forensic role. Texas Family Code §104.008(a) prohibits an expert opinion or recommendation on conservatorship, possession, or access unless the witness has conducted a child custody evaluation under Chapter 107. Board rule 22 TAC §681.53(f) prohibits providing therapy and a child custody evaluation in the same case. Section 681.53(g) prohibits that expert opinion unless the licensee has conducted the evaluation. I do not conduct child custody evaluations. Confidentiality of the record is governed by Texas Health and Safety Code Chapter 611.

Idaho — Interstate Mental and Behavioral Telehealth Registration

Services to a client located in Idaho are provided under my Interstate Mental and Behavioral Telehealth Registration (Idaho Code §54-5714). This is not an Idaho Licensed Professional Counselor or Licensed Clinical Professional Counselor license. The home license is my Texas Licensed Professional Counselor license.

If called, I testify as a fact witness (Idaho Rule of Evidence 701), from personal knowledge of the treatment, not as an expert (Idaho Rule of Evidence 702).

I can testify to what is in the treatment record: dates, attendance, the diagnosis and treatment plan in the record, and observations written in the notes.

A custody or parenting-time recommendation is a forensic evaluation. I do not conduct parenting time evaluations under Idaho Rule of Family Law Procedure 1004, and I do not make that recommendation. The Idaho counseling board adopts the ACA Code of Ethics (IDAPA 24.15.01.002). ACA Code of Ethics E.13.c. states that counselors do not evaluate current or former clients, or a client’s family members, for forensic purposes. Privilege is governed by Idaho Code §54-3410 and Idaho Rule of Evidence 517.

South Carolina — Behavioral Telehealth Registration

Services to a client located in South Carolina are provided under my Behavioral Telehealth Registration (S.C. Code §40-75-800). This is not a South Carolina Licensed Professional Counselor license. That registration does not permit in-person services or a South Carolina office. The home license is my Texas Licensed Professional Counselor license.

If called, I testify as a fact witness (South Carolina Rule of Evidence 701), from what I personally observed in treatment, not as an expert (South Carolina Rule of Evidence 702).

I can testify to what is in the treatment record: dates, attendance, the diagnosis and treatment plan in the record, and observations written in the notes.

I do not give an opinion on custody, visitation, or parental fitness for a person to whom I provide therapy, and I do not act as the custody evaluator in that case. South Carolina has no statute identical to the Texas custody-testimony bar. The board’s ethics rule does bar a dual role that can impair objectivity and professional judgment, and it requires referral when the counselor cannot be of professional assistance (S.C. Code Regs. 36-22). A custody opinion about a therapy client is that dual role. Confidentiality is governed by S.C. Code §40-75-190.

Florida — Out-of-State Telehealth Provider Registration

Services to a patient located in Florida are provided via telehealth under my Out-of-State Telehealth Provider Registration (Fla. Stat. §456.47). This is not a Florida Licensed Mental Health Counselor license. That registration does not permit a Florida office or in-person services. The home license is my Texas Licensed Professional Counselor license. While seeing a Florida patient via telehealth, the Florida scope of practice for mental health counseling applies.

If called, I testify as a fact witness (Fla. Stat. §§90.604 and 90.701), from personal knowledge of the treatment, not as an expert (Fla. Stat. §90.702).

I can testify to what is in the treatment record: dates, attendance, the diagnosis and treatment plan in the record, and observations written in the notes.

A recommendation on parental responsibility, time-sharing, or residence is legally barred for a patient to whom I provide therapy. Fla. Admin. Code R. 64B4-7.006 requires the person who evaluates a minor for that recommendation to be impartial and not to have been the treating psychotherapist, or to have had a prior relationship with any party. I do not conduct those evaluations. Confidentiality and privilege are governed by Fla. Stat. §§491.0147 and 90.503.

Fees

These fees apply in Texas, Idaho, South Carolina, and Florida.

Appearance is $1,200 for each date cleared. The date is reserved as a full day. A reset date is another $1,200.

Preparation is $150 an hour, billed in 15-minute increments, for pulling records, reviewing the file, and speaking with the attorneys.

If travel is required, mileage is the IRS business rate on the travel date, plus parking and tolls. Any required hotel is prepaid by the client.

The client pays these fees even if the other party issued the subpoena, unless that party agrees in writing to pay or the court orders them to. The $1,200 is due five business days before the date. With less than 72 hours’ notice of a cancellation or reset, it is not refunded. If I cancel, or notice is at least 72 hours ahead, the unused appearance fee is refunded. Time already spent preparing is still billed. A judge’s order to testify is followed if the fee has not been paid. The fee is still owed.

Your Rights and Protections Against Surprise Medical Bills

When you receive care as a self-pay (uninsured) client, you have the right to receive a Good Faith Estimate of expected charges under the federal No Surprises Act.

What is a Good Faith Estimate?

You have the right to receive a written estimate of the expected cost of services before you receive care. This estimate includes reasonably expected charges for services provided.

What if my bill is higher than expected?

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.

How to Dispute a Bill

Visit: https://www.cms.gov/nosurprises

Additional Information

Good Faith Estimates are provided to self-pay clients upon scheduling or request. Estimates are based on information known at the time and may change depending on clinical needs. You may request an updated estimate at any time.

If you have questions about your estimate, please contact our office

Florida Telehealth Disclosure

Florida Telehealth Services Disclosure

Jacqueline Maye, MS, LPC-S, LCDC is licensed in the State of Texas and provides telehealth services to clients located in Florida under out-of-state telehealth registration in accordance with Florida law.

• Florida Telehealth Registration Number: TPMC7659
• Texas License: LPC-S #73705 | LCDC #13645

Services provided to Florida residents are delivered via secure telehealth platforms and are subject to the laws and regulations of the State of Florida.

Please note:

• The provider is not licensed in Florida, but is authorized to provide telehealth services under Florida’s out-of-state telehealth registration.
• Telehealth services are limited to non-emergency care.
• If you are experiencing a mental health emergency, please call 911 or go to your nearest emergency room.
• Florida clients may also contact the 988 Suicide & Crisis Lifeline by dialing or texting 988.

By engaging in telehealth services, Florida clients acknowledge and consent to receiving services under these terms.

Telehealth services are provided in accordance with applicable state laws. Clients must be physically located in a state where the provider is authorized to practice at the time of each session.

Idaho Telehealth Disclosure

If you are located in Idaho, services are provided via telehealth in accordance with applicable Idaho laws and regulations for out-of-state providers. While Salvaged Soul Counseling, PLLC is not physically located in Idaho, services are delivered in compliance with telehealth standards and ethical guidelines governing licensed mental health professionals.

Your confidentiality is protected under federal law, including HIPAA, and any applicable state-specific privacy protections. Please note that limits to confidentiality apply, including but not limited to risk of harm to self or others, suspected abuse or neglect, and court orders.

By engaging in telehealth services while located in Idaho, you acknowledge understanding of the nature of telehealth, including potential risks related to technology, and consent to receive services under these conditions.

South Carolina Discolusre

If you are located in South Carolina, services are provided via telehealth in accordance with applicable South Carolina laws and regulations for out-of-state providers. While Salvaged Soul Counseling, PLLC is not physically located in South Carolina, services are delivered in compliance with telehealth standards and ethical guidelines governing licensed mental health professionals.

Your confidentiality is protected under federal law, including HIPAA, and any applicable state-specific privacy protections. Please note that limits to confidentiality apply, including but not limited to risk of harm to self or others, suspected abuse or neglect, and court orders.

By engaging in telehealth services while located in South Carolina, you acknowledge understanding of the nature of telehealth, including potential risks related to technology, and consent to receive services under these conditions.