Effective Date: September 6, 2026

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

The Safe State Counseling, PLLC is committed to protecting the privacy and security of your health information. This Notice describes your rights regarding your protected health information (“PHI”), how The Safe State Counseling may use and disclose your PHI, and the practice's legal responsibilities.

This Notice applies to health information maintained by The Safe State Counseling, PLLC.

YOUR RIGHTS

When it comes to your health information, you have certain rights.

Get an electronic or paper copy of your health information.

You may ask to inspect or obtain an electronic or paper copy of health information about you maintained in a designated record set. Certain information, including psychotherapy notes as defined by HIPAA and other information excluded or restricted by law, may not be subject to the same access rights.

We will respond to requests for access within the time required by applicable law. When permitted, we may charge a reasonable, cost-based fee. If access is denied in whole or in part, you will be informed as required by law and, when applicable, told whether the decision may be reviewed.

Ask us to correct your health information.

You may ask us to amend health information about you that you believe is incorrect or incomplete. We may deny the request in circumstances permitted by law, but if we do, we will explain the denial in writing within the time required by law.

Request confidential communications.

You may ask us to contact you in a particular way or at a different address. We will accommodate reasonable requests as required by law.

Ask us to limit what we use or disclose.

You may ask us not to use or disclose certain health information for treatment, payment, or health care operations. We generally are not required to agree to such a request.

If you pay for a health care item or service completely out of pocket and ask us not to disclose information about that item or service to a health plan for payment or health care operations, we will comply when required by law unless disclosure is otherwise required by law.

Get a list of certain disclosures.

You may request an accounting of certain disclosures of your health information made during the period provided by law. The accounting will not include every type of disclosure.

We will provide one accounting without charge during the period required by law. A reasonable, cost-based fee may apply to additional requests when permitted by law, after giving you notice and an opportunity to withdraw or modify the request.

Get a copy of this Notice.

You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.

Choose someone to act for you.

If a person has legal authority to act as your personal representative, that person may exercise applicable rights concerning your health information. We may verify that person's authority before taking action.

File a complaint.

You may contact The Safe State Counseling if you believe your privacy rights have been violated. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.

The Safe State Counseling will not retaliate against you for filing a privacy complaint.

YOUR CHOICES

For certain health information, you may tell us your preferences about what we disclose.

For example, when permitted by law, you may tell us whether you want us to share relevant information with a family member, close friend, or another person involved in your care or payment for your care.

If you are unable to communicate your preference, there may be circumstances in which information may be disclosed when permitted by law and reasonably necessary in connection with your care, safety, or another legally permitted purpose.

Identifying someone as an emergency contact does not, by itself, provide that person with general authorization to receive information about your treatment.

We will obtain your written authorization for uses and disclosures when authorization is required by law. You may revoke an authorization in writing as permitted by law, although revocation generally will not affect actions already taken in reliance on the authorization.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

We may use or disclose health information without your written authorization when HIPAA and other applicable law permit or require us to do so. Because mental health information may also be protected by Texas or other laws that are more protective than HIPAA, a disclosure permitted by HIPAA will not necessarily be made if another applicable law imposes greater restrictions.

Treatment.

We may use and disclose health information to provide, coordinate, or manage your treatment. This may include consultation and coordination with other health care professionals when permitted by applicable law.

As an LPC Associate, Jasmine Rivera receives clinical supervision from Casey Davids, M.Ed., LPC-S. Treatment information may be used or disclosed as reasonably appropriate for lawful professional supervision consistent with applicable law and the disclosures provided in your Informed Consent & Client Services Agreement.

Payment.

We may use and disclose health information for payment-related activities permitted by law, including collecting payment for services and, when applicable, preparing documentation you request for out-of-network reimbursement.

Health Care Operations.

We may use and disclose health information as permitted by law to operate the practice, such as quality assessment, compliance activities, business management, professional review, and other health care operations.

We may use service providers that perform functions on behalf of the practice. When a service provider is a business associate under HIPAA, appropriate safeguards and agreements are required.

Appointment Reminders and Communication About Care.

We may use your information to contact you regarding appointments, treatment, or other health-related services as permitted by law.

Required by Law.

We may use or disclose information when required by federal, state, or local law, subject to applicable conditions and limitations.

Public Health and Safety.

We may use or disclose information for certain legally authorized public-health or safety purposes. This can include circumstances involving reports of abuse, neglect, or exploitation and certain circumstances involving serious safety concerns, when disclosure is permitted or required by applicable law.

Health Oversight.

We may disclose information for legally authorized oversight activities such as audits, investigations, inspections, licensing, or disciplinary proceedings.

Judicial and Administrative Proceedings.

We may disclose health information in response to certain court or administrative orders or other legal processes when the requirements of applicable law are satisfied. Receipt of a subpoena or other request does not necessarily mean that records will automatically be disclosed.

Law Enforcement and Other Government Purposes

. We may disclose health information for certain law-enforcement or specialized government purposes when permitted or required by law.

Coroners and Medical Examiners.

We may disclose information to coroners or medical examiners when authorized by law.

Workers' Compensation.

We may disclose health information as authorized or required by workers' compensation or similar laws.

Research.

Health information may be used or disclosed for research only when the requirements of applicable law are satisfied.

PSYCHOTHERAPY NOTES

Psychotherapy notes, as specifically defined by HIPAA, receive additional protection and are different from the clinical record generally used to document and provide treatment.

When The Safe State Counseling creates or maintains psychotherapy notes as defined by HIPAA, most uses or disclosures of those notes require your written authorization unless an exception under applicable law permits or requires the use or disclosure.

An authorization for psychotherapy notes will be obtained separately when required.

SUBSTANCE USE DISORDER RECORDS

Federal law provides additional protections for certain substance use disorder (“SUD”) patient records subject to 42 CFR Part 2.

To the extent The Safe State Counseling receives or maintains records that are protected by Part 2, those records will be handled in accordance with applicable federal requirements.

Part 2 records may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against a patient based on the content of those records without the patient's specific written consent or a court order accompanied by a subpoena or other legal mandate meeting applicable Part 2 requirements.

Other uses and disclosures of Part 2 records will be made only as permitted by applicable law.

USES AND DISCLOSURES GENERALLY REQUIRING AUTHORIZATION

We will obtain your written authorization when HIPAA or another applicable law requires it.

This generally includes most uses and disclosures of psychotherapy notes as defined by HIPAA, most uses of PHI for marketing when authorization is required, and the sale of PHI.

The Safe State Counseling does not sell your PHI in the ordinary course of business.

Other uses or disclosures not described by this Notice will be made only with authorization when required by law.

OUR RESPONSIBILITIES

The Safe State Counseling is required by law to:

• Maintain the privacy and security of your protected health information.

• Provide you with this Notice describing our legal duties and privacy practices.

• Follow the duties and privacy practices described in the Notice currently in effect.

• Notify affected individuals following a breach of unsecured PHI when notification is required by law.

• Respect applicable federal and Texas protections governing confidential mental health information.

• Use or disclose health information only as permitted or required by applicable law.

We may change the terms of this Notice, and changes may apply to health information we already maintain as well as information we receive in the future. When required, the revised Notice will be made available upon request, at the practice, and on our website.

CONTACT & COMPLAINTS

For questions about this Notice, requests concerning your privacy rights, or complaints concerning The Safe State Counseling's privacy practices, contact:

The Safe State Counseling, PLLC
Privacy Contact: Jasmine Rivera, MS, LPC Associate
6850 Manhattan Blvd, Suite 510-6

Fort Worth, TX 76120
Phone: 817-529-0599
Email: contact@thesafestate.com

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.

Information about filing a health-information privacy complaint is available through the U.S. Department of Health and Human Services Office for Civil Rights.

The Safe State Counseling will not retaliate against you for filing a complaint.