Privacy Practice
Kristina L. Vellucci-Cook, Psy.D.
phone: (714) 457-6007
e-mail: kristina@drkvcook.com
Notice of Privacy Practices
This notice describes how your Protected Health Information may be used and/or disclosed and how you can get access to this information. Please review this notice carefully before signing.
As outlined in the Evaluation Agreement Form related to your court-ordered psychological or
child custody evaluation, the process of such an evaluation is not confidential, and the
information acquired during the course of that evaluation, which can include your Protected
Health Information (PHI), can be produced to the Court and to the attorneys of record or to
clients who represent themselves upon completion of that evaluation.
As a mental health professional, Kristina Vellucci-Cook, Psy.D. [evaluator] is required to
maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy
practices related to your PHI. I am required to always abide by the terms of this Notice of
Privacy Practices, and while I reserve the right to change the terms of my Notice of Privacy
Practices at any time, any new Notice of Privacy Practices will be effective for all PHI that I
maintain at that time. Should I change this policy at any time during the course of your
evaluation, you will be provided with a copy of the revised Notice of Privacy Practices and asked
to sign that new document. Should your evaluation be completed before such a revision occurs,
you will not be provided such a copy since my services with your family at that time will no
longer be in process.
Your health record contains personal information about you and your health, and while the
process of a psychological and/or child custody evaluation does not involve the creation of a
health record, the process does entail the necessity of the evaluator acquiring PHI related to you
and/or your children. This information about you may identify you and relate to past, present,
and future physical or mental health or condition and related health care services and is thus
referred to as your PHI. This Notice of Privacy Practices describes how I may use or disclose
your PHI in accordance with applicable law, including the Health Insurance Portability and
Accountability Act (HIPAA), regulations promulgated under HIPAA including the HIPAA
Privacy and Security Rules, and the evaluator’s code of ethics, which are located on the
evaluator’s website via a link to the Texas State Board of Examiners for Professional
Counselors. It also describes your rights regarding how you may gain access to and control your
PHI.
How the Evaluator May Use and Disclose Health Information about you.
For the evaluation: During the course of a psychological/child custody evaluation, your PHI
and/or your child(ren)’s PHI may be acquired as a part of the evaluation process as required by
the standards of practice and the Texas Family Code. This information will be used for the
purpose of ensuring a thorough evaluation of your family in order to provide an accurate
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assessment to the Court related to your child(ren) and his/her best interest. This information,
once acquired, may be reproduced to the Court, the attorneys of record, and/or to the clients who
represent themselves, potentially efile or email, and this is clearly outlined in the Releases of
Information that you will be required to sign during the course of the evaluation. This
information may also be utilized anonymously in consultation with other clinical professionals to
assist the evaluator in completing your case with appropriate peer review, and I may disclose
your actual PHI or your child(ren)’s PHI to another mental health professional or consultant with
your appropriate authorization only.
After the evaluation: Upon completion of a court ordered evaluation, it is possible that I may be
deposed or testify at any final trials in your case. If that occurs, it is possible that information
related to your case may be ordered to be disclosed in any future cases where I am designated as an expert, e.g., the cause number of your case, the styling of your case, the court and county
where your case is heard, and the attorneys in your case.
Required by law: Under the law, I must disclose your PHI to you upon your request, though this
information will not be produced until the evaluation process has been completed in order to
ensure the evaluator’s neutrality. In addition, I must make disclosures to the Secretary of the
Department of Health and Human Services for the purpose of investigating or determining my
compliance with the requirements of the Privacy Rule.
Without authorization: Following is a list of the categories of uses and disclosures permitted by
HIPAA without authorization. Applicable law and ethical standards permit me to disclose
information about you without your authorizations in a limited number of situations, which
include the following:
- Child abuse or neglect: I may disclose your PHI or your child(ren)’s PHI to a state or
local agency that is authorized by law to receive reports of child abuse or neglect. - Judicial and administrative proceedings: I may disclose your or your child(ren)’s PHI
pursuant to a subpoena, court order, administrative order, or similar process. This is the
crux of a court-ordered evaluation. - Law enforcement: I may disclose your PHI or your child(ren)’s PHI to a law enforcement
official as required by law, in compliance with a subpoena (with your written consent), a
court order, an administrative order, or similar document, for the purpose of identifying a
suspect, material witness or missing person, in connection with the victim of a crime, in
connection with a deceased person, in connection with the reporting of a crime in an
emergency, and in connection with a crime on the premises. - Public safety: I may disclose your PHI or your child(ren)’s PHI if necessary to prevent or
lessen a serious and imminent threat to the health or safety of a person or the public. If
the information is disclosed to prevent or lessen a serious threat, it will be disclosed to a
person or persons reasonably able to prevent or lesson the threat, including the target of
the threat.
With authorization: Uses and disclosures not specifically permitted by applicable law will be
made only with your written authorization, which may be revoked in writing at any time, except
to the extent that I have already made a use or disclosure based upon your authorization or an
applicable court order related to your family law matter.
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How your PHI may be used and disclosed, which do not apply to the evaluator’s courtordered psychological/child custody evaluations.
NOTE: The laws related to the maintenance policies of your PHI changed in Texas in 2013, and
these laws require that I disclose this information to you, though this information does not apply
to the evaluator’s process. The reasons that each item do not apply will be outlined in bold below each item identified.
For treatment: Your PHI may be used and disclosed by those who are involved in your care for
the purpose of providing, coordinating, or managing your health care treatment and related
services. This includes consultation with clinical supervisors or other treatment team members.
We may disclose PHI to any other consultant only with your authorization. (The process of a
court-ordered psychological/child custody evaluation is not treatment, and the evaluator
does not provide treatment services in her practice.)
For payment: I may use and disclose PHI so that I can receive payment for the treatment
services provided to you. This will only be done with your authorization. Examples of paymentrelated activities are: making a determination of eligibility or coverage for insurance benefits,
processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary
to use collection processes due to lack of payment for services, I will only disclose the minimum
amount of PHI necessary for purposes of collection. (Payment for a court-ordered evaluation
is payable directly to the evaluator by check or money order. The evaluator does not bill
insurance, and her services are not covered by insurance. The only payment that may be
necessary and related to your PHI information is related to any costs that your current or
previous providers may require you to pay to produce your records to the evaluator for the
court-ordered evaluative process as required by the Texas Family Code and the standards
of practice. As noted in the release forms that you will sign, you are responsible for all
costs, if any, related to the records acquired for your evaluative process.)
For Health Care Operations: I may use or disclose, as needed, your PHI in order to support
business activities including, but not limited to, quality assessment activities, employee review
activities, licensing, and conducting or arranging for other business activities. For example, I
may share your PHI with third parties that perform various business activities (e.g., billing or
typing services) provided I have a written contract with the business that requires it to safeguard
the privacy of your PHI. For training or teaching purposes, PHI will be disclosed only with your
authorization. (The evaluator’s court-ordered evaluation services do not entail health care
operations, and this aspect of the required privacy policy does not apply outside of what
has been outlined within this policy.)
Research: Your PHI may only be disclosed after a special approval process or with your
authorization. (The evaluator does not conduct research within her practice.)
Fundraising: We may send you fundraising communications at one time or another. You have
the right to opt out of such fundraising communications with each solicitation you receive. (You
will never receive fundraising communications from the evaluator.)
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Verbal permission: I may also use or disclose your information to family members that are
directly involved in your treatment with your verbal permission. (The evaluator will not speak
to your family members during a court-ordered evaluative process unless they reside with
you on a full or part-time basis, or they have completed a personal reference form or a
written witness statement for you and a telephone call to them is warranted. Should a
family member contact the evaluator, she will ask that they place all information to the
evaluator in writing, and any questions answered will be process driven only, with your
PHI not being discussed or disclosed.)
Without authorization: Applicable law and ethical standards permit me to disclose information
about you without your authorizations in a limited number of situations. The following is a list of
the categories of uses and disclosures permitted by HIPAA without authorization:
- Deceased patients: I may disclose PHI regarding deceased patients as mandated by state
law, or to a family member or friend that was involved in your care or payment for care
prior to death, based on your prior consent. A release of information regarding deceased
patients may be limited to an executor or administrator of a deceased person’s estate or
the person identified as next of kin. PHI of persons that have been deceased for more than
fifty years is not protected under HIPAA. (Any and all records related to a deceased
client may be acquired via the attorney of record or by court order. All of the
evaluator’s records are retained for seven years upon the completion of the
evaluation or litigation and are then destroyed as allowed per her licensure
requirements.) - Medical emergencies: I may use or disclose your PHI in a medical emergency situation to
medical personnel only in order to prevent serious harm. Staff will try to provide you a
copy of this notice as soon as reasonably practicable after the resolution of the
emergency. (The evaluator’s court-ordered process does not generate PHI; this
factor does not apply to her process.) - Family involvement in care: I may disclose information to close family members or
friends directly involved in your treatment based on your consent or as necessary to
prevent serious harm. (During an evaluation, your information will only be available
to the Court, the attorneys, and/or to clients who present themselves aside from
what has already been outlined previously in this policy.) - Health oversight: If required, I may disclose PHI to a health oversight agency for
activities authorized by law, such as audits, investigations and inspections. Oversight
agencies seeking this information include government agencies and organizations that
provide financial assistance to the program (such as third-party payors based on your
prior consent) and peer review organizations performing utilization and quality control.
(This situation only applies as outlined previously in this policy. Your PHI may only
be disclosed otherwise if a board compliant is made against the evaluator; at which
time, you will be notified that your information will be published to the board to
address the complaint.)
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5. Specialized government functions: I may review requests from US military command
authorities if you have served as a member of the armed forces, authorized officials for
national security and intelligence reasons and to the Department of State for medical
suitability determinations, and disclose your PHI based on your written consent,
mandatory disclosure laws and the need to prevent serious harm. (Any contact that the
evaluator has with the military will have been previously authorized by you via an
informed consent.)
6. Public health: If required, I may use or disclose your PHI for mandatory public health
activities to a public health authority authorized by law to collect or receive such
information for the purpose of preventing or controlling disease, injury, or disability, or if
directed by a public health authority, to a government agency that is collaborating with
that public health authority. (The evaluator does not generate PHI related to you; this
aspect does not apply.)
Your Rights Regarding Your PHI.
You have the following rights regarding PHI that is maintained about you. To exercise any of
these rights, after your evaluation has been completed, please submit your request in writing via
your attorney to the evaluator at the evaluator’s address.
- Right of access to inspect and copy: Once your court-ordered evaluation is complete, you
have the right, which may be restricted only in exceptional circumstances or via court
order, to inspect and copy any PHI information related to you or your child(ren) that has
not already been attached to your psychological/child custody evaluation and produced to
your attorney or clients who represent themselves. The evaluator may charge a
reasonable, cost-based fee for the copies, and if the records are maintained electronically,
you may also request an electronic copy of your PHI. You may not request that this
information be provided to another person aside from your attorney of record. - Right to amend: Once your court-ordered evaluation is completed and published to the
attorneys of record, you have the right to ask that the PHI be amended if you feel that the
PHI that I have about you is incorrect or incomplete. I am not required to agree with your
amendment, and if your amendment is directly related to information that was produced
to me, it would be most appropriate for you to seek amendment of this information from
the provider who produced the PHI to the evaluator. If I deny your request for an
amendment, you have the right to file a statement of disagreement with the evaluator that
will be forwarded to the attorneys of record or to clients who represent themselves. - Right to an accounting of disclosures: You have the right to request an accounting of
certain of the disclosures that I make of your PHI or your child(ren)’s PHI. The evaluator
may charge a reasonable fee for this request, and within a court-ordered
psychological/child custody evaluation, your PHI or your child(ren)’s PHI will only be
disclosed as outlined in your Evaluation Agreement to the attorneys, to clients who
represent themselves, and to the individuals for whom releases were signed and have not
been revoked. - Right to request restrictions: You have the right to request a restriction or limitation on
the use or disclosure of your PHI. I am not required to agree to your request, though the
Court will be notified if an attempt is made to restrict the evaluator’s access to necessary
PHI required as part of the standards of practice and the Texas Family Code in relation to
the court-ordered evaluation.
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5. Breach of notification: If there is a breach of unsecured PHI concerning you, I may be
required to notify you of this breach, including what happened and what you can do to
protect yourself. Once your evaluation is completed, I maintain your records under lock
and key for seven years until those records are destroyed in the evaluator’s presence.
6. Right to a copy of this notice: You have a right to a copy of this notice, which will be
provided to you upon request.
NOTE: The current law requires that I also notify you as to your Right to Request Confidential
Communication. This notice states that you have the right to request that we communicate with
you about health matters in a certain way or at a certain location. I will accommodate reasonable
requests. I may require information regarding how payment will be handled or specification of
an alternative address or other method of contact as a condition for accommodating your request.
I will not ask you for an explanation as to why you are making the request. (During an
evaluation, you are asked to provide a preferred telephone number and email address to
the evaluator for communication purposes. The evaluator will contact you as needed via
one of these means primarily for administrative purposes, and as noted, your information
acquired during an evaluation is not confidential.)
ADDITIONAL NOTIFICATIONS.
The following additional notifications are required in order to ensure that you have a thorough
understanding of how your information may or may not be used or transmitted during the course
of a court-ordered evaluation:
- Most of your record will be maintained by the Court or your attorneys of record once
your evaluation is complete and published to the attorneys of record. After that time, the
evaluator will maintain your record under lock and key until seven years have passed; at
which time, those records will be destroyed in the evaluator’s presence. - The evaluator utilizes virus protection software and firewall protection on all computers
that are utilized during the course of her evaluation with your family. - The evaluator does not release your PHI or your child(ren)’s PHI without a signed
consent from you, and otherwise, this information is only released within the guidelines
established within the evaluator’s court order and Evaluation Agreement to the attorneys
of record, to clients who represent themselves, and possibly the Court. - Information related to your case may be kept during the course of your evaluation in a
number of different places including but not limited: the evaluator’s locked office, the
evaluator’s car when in transport to the courthouse or to clients’ homes, the evaluator’s
P.O. Box, the evaluator’s facsimile machine, the evaluator’s computers, the evaluator’s
cellular phone, the evaluator’s email account, and the evaluator’s paper files and/or
electronic files.
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5. If you choose to communicate with the evaluator by email, by text, by facsimile, or via
her P.O. Box, you understand the limitations of confidentiality that may exist specifically
in relation to each of these forms of communication despite all efforts that have been
made to protect your confidentiality in this regard, i.e., the evaluator’s computers, email
accounts, etc., are all password and/or firewall protected. Most reports and drafts of those
reports are stored within a cloud-based management system; however, these reports and
related drafts do not specifically contain your PHI. In addition, the evaluator for the most
part works diligently to not transmit any PHI via an electronic means or text messages
and asks that you do the same, though your providers for whom you have signed a
written authorization may choose to transmit such information electronically upon
request from the evaluator during your evaluation.
6. The evaluator has attended and will continue to attend the required HIPAA trainings.
7. As stated previously, the process of an evaluation does not entail the creation or
generation of PHI. The process of an evaluation only entails the acquirement of such
information, and due to the court-ordered nature of that process, the information that is
acquired is not confidential and can and/or will be produced to the Court, the attorneys of
record, and to parties who represent themselves, potentially via efile, once the evaluation
is completed and published to the attorneys of record.
8. Should the evaluator die, become incapacitated, or terminate her practice, the custody and
control of the records maintained by Kristina Vellucci-Cook, Psy.D., will be turned over
to Christy Bradshaw Schmidt, MA, LPC.
Complaints.
If you believe that the evaluator has violated your privacy rights, you have the right to file a
complaint in writing with the evaluator/privacy officer via the address outlined above or with the
Secretary of Health and Human Services at 200 Independence Avenue, SW Washington DC
20201 or by calling 202-619-0257.
The effective date of this Notice is September 2013, and this notice was last updated in May
2023.
Signed on this______day of ________________, 2023.
___________________________________ ___________________________________
Printed Name Signature
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