Notice of Privacy Practices

Rubina M. Piña, LPC

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

Effective Date: April 22, 2026

How I may use and disclose your health information without your authorization:

I will not use or disclose your health information for any purpose that is not described in this notice without your written authorization. However, I may use and disclose your health information without your written authorization for the following purposes:

  • Treatment: I will use and disclose your health information in the course of providing, coordinating, and/or managing your care and related services. For example, your protected health information may be shared with another health professional for assistance with rendering a diagnosis, developing an appropriate treatment plan, or enhancing the quality of your care. In such cases, your identity and personal details will be protected to the extent possible.

  • Payment: I will use your health information to bill and collect payment from you, an insurance company, or other third-party payers for services you receive from my practice. For example, your health plan may be contacted to get prior approval for coverage of treatment or to determine whether your plan will pay for the services.

  • Healthcare Operations: I will use your health information to manage, operate, and support the business activities of my practice. This includes budgeting, financial reporting, quality assessment, legal services, auditing functions, administrative support (such as coordination by an Operations Manager), and other general activities permitted by HIPAA.

  • Imminent Harm: If there is reason to believe that you may be at risk of imminently harming yourself or someone else, I may need to take steps to ensure safety, including contacting emergency services, family, friends, caregivers, or notifying potential victims.

  • Minors: If you are a minor, I will share your protected health information with your personal representative (e.g., parent or guardian). However, I will not share a minor’s psychotherapy notes with their personal representative unless it is necessary to prevent a serious and imminent threat to the health or safety of the minor, another person, or the public.

  • Required by Law: I will disclose your protected health information when required by federal, state, or local law.

  • Abuse, Neglect, and Domestic Violence: Your protected health information will be disclosed to the appropriate government agency if there is a reasonable belief that you have been or are currently the victim of abuse, neglect, or domestic violence, and such a report is required by law.

  • Judicial and Administrative Proceedings: As sometimes required by law, I may disclose your protected health information in connection with litigation, such as in response to a court order or subpoena. Disclosure will only be made if efforts have been made to inform you of the request or an order protecting the information has been obtained. Your information may also be disclosed if required for our legal defense in the event of a lawsuit.

  • Law Enforcement: I will disclose your protected health information for law enforcement purposes when all applicable legal requirements have been met, such as locating a missing person or complying with a warrant.

  • Coroners and Medical Examiners: I may disclose protected health information to coroners and medical examiners to assist in their investigations.

  • Public Health Risks: Your protected health information may be disclosed and may be required by law to be disclosed for public health risks. For example, I may be required to: report reactions to medications or problems with health products; or report a person who may have been exposed to a disease or may be at risk of contracting and/or spreading a disease or condition as required by state and federal law.

  • Health Oversight Activities: I may disclose your protected health information to a health oversight agency for audits, investigations, inspections, licensures, and other activities as authorized by law.

  • Inmates / Correctional Institutions: If you are an inmate of a correctional institution or under the custody of a law enforcement official, I may disclose your protected health information to the institution or official if the disclosure is necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

  • Military and Veterans: If you are a member of the United States Armed Forces, I may disclose your protected health information as required by military command authorities. If you are a member of a foreign military, I may disclose your information to the appropriate foreign military authority as required by law.

  • Worker’s Compensation: I will disclose the necessary protected health information in compliance with worker’s compensation laws regarding an occupational injury or illness.

  • Practice Ownership Change: If my practice is sold, acquired, or merged with another entity, your protected health information will become the property of the new owner. You will still have the right to request copies of your records.

  • Breach Notification Purposes: If there is an unsecured breach of your protected health information, I will utilize the contact information you have provided to notify you of the breach, as required by law.

  • Business Associates: I may disclose your protected health information to business associates who provide me with services necessary to operate (such as billing, scheduling, or secure communication platforms). They are contractually obligated to comply with the exact same privacy and security rules that I am.

  • Integration with Headway (Therapymatch, Inc.): To facilitate secure scheduling, billing, and administrative operations, this practice partners with Therapymatch, Inc. d/b/a Headway (“Headway”). Headway operates as a Business Associate and/or under an Organized Health Care Arrangement (OHCA) with this practice. By receiving services, you acknowledge that your protected health information will be securely shared with Headway to process insurance claims, manage payments, and provide telehealth infrastructure. In addition to this Notice, your information is also subject to Headway’s separate Notice of Privacy Practices regarding how they securely collect, use, and process data on their specific platform. You can review Headway’s Notice of Privacy Practices directly during your Headway account onboarding.

Uses and disclosures that require your authorization:

I will not disclose or use your protected health information in the situations listed below without first obtaining written authorization from you.

  • Disclosure of Psychotherapy Notes: Unless I obtain your written authorization, in most circumstances I will not disclose your psychotherapy notes, except for continued treatment, legal defense, or to avert a serious threat to health and safety.

  • Marketing & Sale of Information: I will never use or sell your protected health information for marketing purposes.

  • Research: I do not participate in clinical research that involves the use of client records. I will never use or disclose your protected health information for research purposes without obtaining your explicit, written authorization first.

If you provide authorization, you may revoke it at any time by submitting a request in writing to me directly at evolve@rubypina.com. However, once your information has been disclosed to a third party, it may no longer be protected by HIPAA and could be redisclosed.

Uses and disclosures related to reproductive health care:

I am prohibited from sharing your medical information related to reproductive health care for the following activities:

  • To conduct a criminal, civil, or administrative investigation or impose penalties on any person for seeking, obtaining, providing, or facilitating lawful reproductive health care.

  • To identify any person seeking, obtaining, providing, or facilitating reproductive health care.

I will obtain a written attestation that your protected health information related to reproductive care will not be used for prohibited purposes when it is requested from health oversight agencies, courts, law enforcement, or medical examiners.

Your rights with respect to protected health information:

  • Right to inspect and copy: You have the right to request, in writing, to inspect and copy your protected health information in paper or electronic format. (Note: Under federal law, you may not inspect psychotherapy notes).

  • Right to a summary or explanation: You have the right to request a summary or explanation of your health information if you do not desire the entire record.

  • Right to receive a notice of breach: You have the right to be notified in the event of a breach of your unsecured health information.

  • Right to request amendments: If you believe the information I have on file is inaccurate or incomplete, you may request in writing that I amend it.

  • Right to an accounting of disclosures: You have the right to receive a list of the disclosures I have made of your information, excluding those made for treatment, payment, operations, or to family/friends.

  • Right to request restrictions: You have a right to request restrictions on the information I disclose to family members, friends, or for treatment/payment operations. While I am not required to agree to all restriction requests, I will respect restrictions regarding disclosures to your health plan for services you have paid for entirely out-of-pocket.

  • Right to request confidential communications: You have a right to request that I communicate with you by alternative means or at an alternative location (e.g., calling only a specific phone number).

  • Right to a paper copy: You have the right to request a paper copy of this Notice at any time.

My Duties:

I am required by law to maintain the privacy of your protected health information, provide you with this notice of my legal duties, notify you following a breach, and abide by the terms of the notice currently in effect. I reserve the right to revise the terms of this notice and will notify you of any changes.

Questions and Complaints:

I am committed to providing safe, voluntary, and client-centered care. If you have questions about this form, or if you feel your privacy rights have been violated, please bring your concerns directly to me so we can address them promptly. I will never retaliate against you for filing a complaint.

Rubina M. Piña, LPC

Email: evolve@rubypina.com

Phone: 832-304-3366

Address: 2200 N Farm to Market 3083 Rd W, Suite 118, Conroe, TX 77304

You may also file a complaint with the state licensing board:

Texas Behavioral Health Executive Council (BHEC)

1801 Congress Ave., Ste. 7.300, Austin, Texas 78701

(512) 305-7700 | www.bhec.texas.gov

You may also file a formal complaint with the 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; by telephone at (800) 368-1019; or online at https://www.hhs.gov/ocr/privacy/hipaa/complaints.