HIPAA Privacy Statement



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.

This notice gives you information required by law about the duties and privacy practices of Acacia, and how we may use and disclose your protected health information.

“Protected Health Information” is health information created or received by your health care provider that contains information that may be used to identify you, such as demographic data, and that may relate to your past, present or future physical or mental health condition. This notice goes into effect immediately, and shall remain in effect until modified or amended.

Uses and Disclosures of Protected Health Information

Acacia Counseling will take all necessary steps to protect your health information and limit its disclosure as described in this notice. Acacia may use and disclose protected health information as permitted by the rules and regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and also with your consent or specific authorization.

Following are categories that describe the different ways that Acacia Counseling may use and disclose your protected health information. Acacia will not participate in research activities requiring release of consumer confidential information without obtaining For Payment Purposes:prior written informed consent for release of information from the consumer.

For Treatment Purposes:

Treatment purposes are defined as the provision, coordination or management of your care. An example of this would be consultations between agency staff.

For Payment Purposes

Payment purposes means activities that Acacia undertakes to obtain reimbursement for the mental health treatment provided to you, such as determination of insurance eligibility and coverage, obtaining authorization for services, filing of claims and other utilization review activities.

Health Care Operations:

Health care operations are defined as functions which facilitate the operation of this agency. For example, we may use your protected health information to review and improve the quality of care we provide, or for program compliance audits.

With Your Authorization:

Acacia may disclose your private health information for purposes not described in this Notice or otherwise permitted by law only with your written authorization. You may revoke an authorization at any time, but only as to future uses or disclosures, and only where we have not already acted in reliance on your authorization.

Appointment Reminders:

We may use and disclose your protected health information to remind you about appointments. We may phone your home. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.

Business Associates:

Acacia may use and disclose protected health information to third party “business associates” that perform various activities on behalf of Acacia. These business associates may include the insurers, state auditors or other persons associated with providing services to the agency or you.

Acacia will have in place a written document, signed by a representative of the business associate, that contains terms and conditions that will protect the privacy of your protected health information.

As Required by Law:

Acacia may use and disclose protected health information for purposes required by law, but only to the extent and under the circumstances provided in that law.

Special Circumstances for Use and Disclosure

Abuse or Neglect:

Acacia may use or disclose protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect.

Court Order:

Acacia may disclose protected health information to a court of law upon the receipt of duly executed court order signed by a judge.

Reporting of a Crime or Threats Against Agency Personnel:

Acacia may disclose protected health information to a law enforcement official in the reporting of a crime on the premises or against the agency or the reporting of threats against agency personnel.

Your Protected Health Information Rights

You have the right:

To request restrictions on certain uses and disclosures of your protected health information. This request must be made to us in writing and specify what information you want to limit and what limitations on our disclosure of the information you wish to impose. We reserve the right to accept or reject your request and will notify you of our decision.

To request that you receive protected health information in a specific way or at a specific location. For example, you may request that Acacia send all correspondence to you at your work address rather than your home address.

To review and obtain a copy of your protected health information that is contained in a designated record as long as Acacia maintains the protected health information, with limited exceptions defined by law. A reasonable fee may be charged for making copies. The request to review and/or obtain a copy of your protected health information must be made in writing to the agency Privacy Officer.

To request that we amend your protected health information that you believe is incorrect or incomplete. The request to amend protected health information must be made in writing to the agency. We are not required to change your protected health information and will provide you with an explanation if we deny your request for amendment or change.

To receive an accounting of disclosures made of your protected health information by Acacia, unless the disclosures were pursuant to your written authorization or for the purposes of treatment, payment, or healthcare operations as described in this Notice of Privacy Practices . 


If you believe your privacy rights have been violated, you may file a complaint with Acacia, or with the State Board of Behavioral Health, or with the Secretary of the Department of Health and Human Services. You can not be penalized for filing a complaint.

Acacia Counseling reserves the right to change or amend this Notice of Privacy Practices at any time in the future. After an amendment is made, the revised Notice of Privacy Practices will apply to all protected health information created after the amendment or change. A copy of any revised Notice of Privacy Practices will be made available to you at your next appointment following the revision.

For examples of codes of ethics, see "Mental Health Professionals" and scroll about a quarter of the way down.

You also have the following rights:

As a consumer of mental health and substance abuse services in Oklahoma you have rights! There are many oversight agencies that govern the delivery of therapeutic services. Your basic rights are listed here.

1. Each consumer shall retain all rights, benefits, and privileges guaranteed by law except those lost through due process of law.

2. Each consumer has the right to receive services suited to his or her condition in a safe, sanitary and humane treatment environment regardless or race, religion, gender, ethnicity, age, degree of disability, handicapping condition or sexual orientation.

3. No consumer shall be neglected or sexually, physically, verbally, or otherwise abused.

4. Each consumer shall be provided with prompt, competent and appropriate treatment; and an individualized treatment plan. A consumer shall participate in his or her treatment programs and may consent to or refuse to consent to the proposed treatment. The right to consent or refuse to consent may be abridged for those consumers adjudged incompetent by a court of competent jurisdiction and in emergency situations as defined by law. Additionally, each consumer shall have the right to the following:

(A) Allow other individuals of the consumer’s choice to participate in the consumer’s treatment and with the consumer’s consent;

(B) To be free from unnecessary, inappropriate, or excessive treatment;

(C) To participate in consumer’s own treatment planning;

(D) To receive treatment for co-occurring disorders if present;

(E) To not be subject to unnecessary, inappropriate, or unsafe termination from treatment; and

(F) To not be discharged for displaying symptoms of the consumer’s disorder.

5. Every consumer’s record shall be treated in a confidential manner.

6. No consumer shall be required to participate in any research project or medical experiment without his or her 

informed consent as defined by law. Refusal to participate shall not affect the services available to the consumer.

7. A consumer shall have the right to assert grievances with respect to an alleged infringement on his or her rights.

8. Each consumer has the right to request the opinion of an outside medical or psychiatric consultant at his or her 

own expense or a right to an internal consultation upon request at no expense.

9. No consumer shall be retaliated against or subjected to any adverse change of conditions or treatment because the consumer asserted his or her rights.

Our Responsibilities

Acacia Counseling is required to:

  • Maintain the privacy of your health information.
  • Abide by the terms of this notice.
  • Accommodate reasonable requests you may have to communicate health information by alternative means or locations.
  • Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
  • Notify you if we are unable to agree to a requested restriction.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will post a revised notice in the office.

We will not use or disclose your health information without your authorization, except in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.

To Report a Problem

If you believe your privacy rights have been violated, you can file a complaint with our practice’s Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will no retaliation for filing a complaint with either the Privacy Officer or the Office of Civil Rights.

Examples of Disclosure for Treatment, Payment, and Health Options

We will use your health information for treatment:

For example: Information obtained by other members of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your provider will document his or her expectation of your treatment. This way, the provider will know how you are responding to treatment. We will also provide your physician or subsequent health care provider with copies of various reports that should assist him or her in treating you one you’re discharged.

We will use your health information for payment:

For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedure and tests used.

We will use your health information for regular health operations:

Business associates: There are some services provided in our organization through contacts with business associates. Examples include the giving and scoring of certain tests.

Workers Compensation and No Fault: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation, no fault insurance or other similar programs established by law.

We can only release your psychotherapy notes, reports, and tests with your release or by Court Order.