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This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.  Please review it carefully.

Understanding Your Protected Health Information (PHI)
The PHI constitutes information created or noted by me, that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. I am required to provide you with this notice about my privacy procedures. This Notice must explain when, why and how I would use and/or disclose your PHI.
Please note that I reserve the right to change the terms of this Notice and my privacy policies at any time as permitted by law.
This Notice (and any changes) will be posted in my office (12820 Hillcrest, Suite 127, Dallas TX 75230) and on my website (
    Your Rights Regarding Your PHI
  • The right to inspect or get a copy of your PHI
  • The right to request , in writing, a restriction on certain uses and disclosures of your PHI
  • The right to request, in writing, that your PHI be amended
  • The right to request that your PHI be sent to you at an alternate address or by an alternate method
  • The right to obtain an accounting of disclosures of your PHI
  • The right to receive a copy of this Notice of Privacy Practices
    My Responsibilities
  • Maintain the privacy of your PHI
  • Provide you with this notice
  • Abide by the terms of the Notice currently in effect
    Uses and Disclosures of PHI Not Requiring Your Consent
  • For treatment
  • For health care operations
  • To obtain payment for treatment
  • Emergency treatment
    Disclosures Required By Law
  • When required by federal, state, or local law; judicial or administrative proceedings; or law enforcement
  • To prevent a serious threat to the health or safety of a person or the public
  • If disclosure is mandated by the Texas Child/Elder Abuse and Neglect Reporting Laws
  • For health oversight activities, such as audits
Other Uses and Disclosures Require Your Prior Written Authorization

Privacy Contact
Address any questions about this notice to: Bill Wilcox, M.Ed., LPC, at the above address

Privacy Complaints
You have the right to file a complaint; if you believe you privacy rights have been violated. Address complaint to the Privacy Contact, or to the Secretary of the Department of Health and Human Services. There will be no retaliation for registering a complaint.

Revised January 2006