Form 3/3 Texas Health Information Act

IN ORDER TO COMPLY WITH THE HEALTH INFORMATION PORTABILITY AND ACCESSIBILITY ACT (effective April 14, 2003), YOUR SUBMISSION IS REQUIRED ON THIS FORM WHICH WILL BE KEPT IN YOUR CLINICAL RECORD TO INDICATE THAT YOU HAVE RECEIVED A COPY OF THE NOTICE OF YOUR COUNSELOR’S POLICY AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION.

When you click the submit button the one page PDF detailing Policy and Practices will be automatically downloaded to your device. You may keep the PDF for your records.