Professional Disclosures
You have the right to understand who you are seeing for services, their qualifications, and the following requirements and ethics that protect the public.
PROFESSIONAL DISCLOSURE
Jenna Mountain, PhD, LPC, CST
Owner of Jenna Mountain, PLLC
PhD in Counselor Education and Supervision with cognate in Marriage and Family Therapy
Licensed Professional Counselor (TX)
Approved Telehealth Provider (FL)
Certified Sex Therapist (American Board of Christian Sex Therapists)
EMDR Certified (EMDR International Association)
*For more information about other trainings and specialties, please see Jenna Mountain’s Bio.
HIPAA NOTICE OF PRIVACY POLICIES
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. The notice contains the client’s rights under the law. The full Notice of Privacy Practices is included in the intake paperwork for clients, and can be requested at any time..
Jenna Mountain, PLLC may use or disclose your health information for the following purposes: treatment, payment, scheduling, operations, safety, law, marketing, public, health, check-in, health oversight, legal proceedings, breach notification, psychotherapy notes, and/or research.
Except as described in the Notice of Privacy Practices, this practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
You have the right to your health information. This includes the right to: request special privacy protections, request confidential communications, inspect and copy, amend or supplement, accounting of disclosures, paper or electronic copy of notice.
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. A copy will be provided within the informed consent and we will keep a current copy posted to our website.
Complaints about this Notice of Privacy Practices or how this practice handles your PHI should be directed to our Privacy Officer listed at the top of the Notice of Privacy Practices.
If you are not satisfied with the manner in which we have handled a complaint, you may submit a formal complaint to:
DSHS Consumer Services and Rights Protection/Ombudsman Office by mail at Mail Code 2019, P.O. Box 149347 Austin, TX 78714-9347; or by telephone at (512) 206-5760 or (800) 252-8154 (toll free); and Office for Civil Rights, Region VI, U.S. Department of Health and Human Services, by mail at 1301 Young St., Suite 1169, Dallas, Texas 75202; or by telephone at (800) 368-1019, (214) 767-0432 (fax), or (800) 537-7697 (TDD).
The complaint form may be found at www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf. You will not be penalized in any way for filing a complaint.
GOOD FAITH ESTIMATE
You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost
Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.
You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services.
If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate and the bill.
For questions or more information about your right to a Good Faith Estimate, visit
www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.
PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.
RECORDS REQUESTS
Notice to Consumers – Texas Mental Health
In accordance with Texas law (House Bill 4224 and Section 181.105 of the Texas Health and Safety Code), the following information is provided to help consumers understand their rights and available resources.
You have the right to request a copy of your mental health records.
To request your records, please submit a written request to your treating clinician or to the practice directly. Requests may be made via email, secure client portal, or in writing. Records will be provided in accordance with Texas law and applicable privacy regulations.
Administrative fees may be charged for the preparation and release of records or for affidavit requests, as permitted by law and per the Informed Consent.
If you have questions about accessing your records, please contact our office for assistance.
HOW TO REQUEST RECORDS AS A CLIENT:
Texas law requires that requests for mental health records be in writing. In order to obtain your records, or your minor’s records from your provider, you must contact your provider directly. I am the guardian for client records. You can contact me directly via email to request records.
The following may be a part of the process:
Complete a written request of the records. Please be sure to include the records you want, and the name, address, and/or e-mail address of the intended recipient. I may request a phone call in order to ensure clarity about what is being requested and format.
If the records are to be used in litigation, please include case information, such as the cause number, case title, and court where the case is pending.
If you need a Business Records Affidavit, please let us know in your request for records. There is a $15 charge for providing a Business Records Affidavit. No Affidavit will be provided unless the fee is paid in advance.
I have the right to charge for providing records and I accept credit cards.
If you are requesting a copy of couples counseling records, family counseling records, or records for a person who is not yourself or your child, state and federal law require that you provide either a Court Order or an Authorization signed by the person (or parent of the person) whose records you are requesting. 45 C.F.R. §164.512(e); Texas Health & Safety Code §611.004, §611.0045, §611.008.
HOW TO REQUEST RECORDS: INSTRUCTIONS FOR ATTORNEYS AND DOCUMENT COMPANIES:
A subpoena alone is not sufficient to compel the disclosure of confidential counseling and billing records or “Protected Health Information” (PHI) under the Health Insurance Privacy and Portability Act Privacy Rule (HIPAA), 45 C.F.R. Chapter 164.
For medical/hospital/mental health records or information that are requested or subpoenaed in litigation (including court testimony), HIPAA allows a covered entity (such as INSERT YOUR NAME OR NAME OF YOUR PRACTICE) to disclose PHI in the course of any judicial or administrative proceeding as follows:
(1) In response to an order of a court or administrative tribunal; or
(2) Where the individual (or parent) is a party to the proceeding, he/she knows that the request for his/her PHI has been made, and does not object.
45 C.F.R. §164.512(e). An Authorization from the individual or parent is the kind of document that will satisfy the second option.
NOTE: If the client or parent has indicated that they do not want their records released, a “Statement of Assurance” will not be accepted, and an Authorization or Court Order will be required.
COMPLAINTS PROCESS
While I would like the opportunity to resolve concerns if you have any, you have a right to have your complaints heard and resolved in a timely manner. If I cannot work things out to your satisfaction, you may file a complaint with my licensing board:
Texas Behavioral Health Executive Council
1801 Congress Avenue, Suite 7.300
Austin, TX 78701
Telephone: 1-800-821-3205
Link to Complaint Form: http://www.bhec.texas.gov/wp-content/uploads/2020/07/BHEC-Complaint-Form.pdf.
If you have a complaint concerning the HIPAA Privacy Regulations, you may contact the U. S. Department of Health and Human Services, Office for Civil Rights, at: OCRMail@hhs.gov.
If you believe that you have a Consumer Complaint regarding the privacy and security of your health information, you may contact the Texas Office of the Attorney General and file a consumer complaint by clicking this link:
https://www.texasattorneygeneral.gov/consumer-protection/health-care/patient-privacycription
To file a complaint for telehealth services for Florida clients:
https://complaint-portal.mqa.flhealthsource.gov/person