CHUPIK BEHAVIORAL HEALTH PLLC
Jeffrey Chupik, LPC-S
Licensed Professional Counselor Supervisor
PO Box 35, Temple, TX 76503-0035 • (254) 274-3068 • Jeff@ChupikBH.com
NOTICE OF PRIVACY PRACTICES
Effective Date: 8/1/2026
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.
ABOUT THIS NOTICE
I am Jeffrey Chupik, a Licensed Professional Counselor Supervisor, and I am the sole clinician and owner of Chupik Behavioral Health PLLC. I also serve as the practice’s Privacy Officer. In this Notice, "I," "me," and "my practice" all refer to Chupik Behavioral Health PLLC.
This Notice explains how I may use and share your Protected Health Information ("PHI") and what rights you have regarding it. PHI is information that identifies you and relates to your past, present, or future physical or mental health, the health care you receive, or payment for that care.
Your mental health records are protected by both federal law (HIPAA) and Texas law. In several important respects, Texas law is stricter than federal law. Where the two differ, I follow whichever gives you greater protection. This means this Notice describes fewer permitted disclosures than a general medical privacy notice would — Texas law limits what a mental health professional may share more narrowly than it limits other health care providers.
MY LEGAL DUTIES
I am required by law to:
• Maintain the privacy and security of your protected health information.
• Provide you with this Notice describing my legal duties and privacy practices.
• Notify you promptly if a breach occurs that may have compromised the privacy or security of your information.
• Follow the terms of the Notice that is currently in effect.
I will not use or share your information for any purpose other than those described in this Notice unless you give me written permission.
HOW I MAY USE AND SHARE YOUR INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION
Texas Health and Safety Code § 611.004 states that a mental health professional may disclose confidential information "only" in specific circumstances that the statute lists. The categories below reflect those limits. If a use or disclosure is not described in this Notice and is not required by law, I will not make it without your written authorization.
For Treatment. I may use your information to provide and coordinate your care. For example, if you ask me to coordinate with your physician or psychiatrist, I may share relevant information with that provider so your care is consistent. Texas law generally requires your written consent before I share your mental health information with a provider outside my practice who is not actively participating in your treatment, and I will obtain it before doing so.
For Payment. I may use and share your information to bill and collect payment for the services I provide. For example, I may send an insurance company the information it needs to process a claim, including diagnosis and dates of service. If you pay for a service out of pocket in full, you may ask me not to share information about that service with your health plan — see "Your Rights" below.
For Health Care Operations. I may use your information to run my practice — for example, to review the quality of care I provide, to maintain records, to obtain professional consultation or supervision, or to meet licensing and accreditation requirements.
To Other Professionals Involved in Your Treatment. Texas law permits me to share information, without separate written consent, with other professionals — and people working under their direction — who are actively participating in your diagnosis, evaluation, or treatment. In practice, I will tell you when I am doing this.
To People Who Help Me Run My Practice. I use outside companies to provide services on my behalf — for example, my electronic health record and telehealth platform, and the AI tool I use to help draft session notes. These companies are called "business associates." Each is required by a written agreement, and by law, to protect your information and to use it only to perform the services I have engaged them for. The AI note-taking tool is described in a separate consent form, and I will not use it without your permission.
To Family, Friends, or Others Involved in Your Care. Unlike general medical privacy law, Texas law does not let me share your mental health information with family members or friends simply because they are involved in your care. I will share information with a family member, partner, or friend only if you give me written consent, or in the limited emergency circumstances described below.
For Fee Collection. I may share information with individuals or organizations involved in billing or collecting fees for the services I provide.
For Audits, Program Evaluation, or Research. I may share information with qualified personnel for a management audit, financial audit, program evaluation, or research. Anyone who receives your information for these purposes is prohibited by law from identifying you, directly or indirectly, in any report or in any other manner.
If You Are in a Correctional Facility. If you are detained in a correctional facility, I may share information with designated personnel of that facility for the sole purpose of providing you with treatment and health care.
After Your Death. I may share information with your personal representative if you are deceased, and I may respond to a request for records made under Section 74.051(e) of the Texas Civil Practice and Remedies Code.
DISCLOSURES I AM REQUIRED BY LAW TO MAKE
There are situations in which the law requires me to disclose information, whether or not you agree. These are the limits on confidentiality, and I want you to know about them before you decide what to share with me.
Suspected abuse or neglect of a child
If I have reasonable cause to believe that a child has been or may be abused or neglected, I must report it within 24 hours to the Texas Department of Family and Protective Services or to law enforcement. This duty applies even though our conversations are otherwise confidential, and I cannot agree to keep such information private.
Suspected abuse, neglect, or exploitation of an elderly person or a person with a disability
If I have cause to believe that an elderly person or a person with a disability is being or has been abused, neglected, or exploited, I must report it immediately to the Texas Department of Family and Protective Services or the appropriate state agency.
Sexual exploitation by a mental health provider
If I have reasonable cause to suspect that you have been sexually exploited by any mental health services provider during the course of treatment — including a therapist you saw before me — Texas law requires me to report it within 30 days to the prosecuting attorney in the county where it occurred and to that provider’s licensing board. I must tell you about this duty and ask whether you wish to remain anonymous. If you ask to remain anonymous, your name will not be included in the report. The report itself is required by law and is not something you or I can waive.
Court orders and legal proceedings
If a court orders me to release information, I must comply. I will not release your records in response to a subpoena alone without a court order or your written authorization, and where I am able to, I will notify you so that you have an opportunity to object.
Government agencies and oversight
I must disclose your information to a governmental agency when disclosure is required or authorized by law, and I am required to disclose information to the U.S. Department of Health and Human Services when it needs to determine whether I am complying with federal privacy law.
DISCLOSURES TEXAS LAW PERMITS BUT DOES NOT REQUIRE
Safety concerns. If I determine that there is a probability of imminent physical injury by you to yourself or to another person, or a probability of immediate mental or emotional injury to you, Texas law permits me to disclose information to medical personnel, mental health personnel, or law enforcement.
Texas law permits this disclosure but does not require it. If a situation like this arises, I will use my professional judgment, and wherever it is safe and possible to do so, I will talk with you about it first.
SUBSTANCE USE DISORDER TREATMENT RECORDS
If I hold records about you that came from a federally assisted substance use disorder treatment program, those records receive additional federal protection under 42 CFR Part 2. I will not share those records, or testify about their contents, in any civil, criminal, administrative, or legislative proceeding against you unless you give written consent, or a court issues an order after you (or the holder of the record) have been given notice and an opportunity to be heard. A court order permitting disclosure must also be accompanied by a subpoena or other legal requirement before I will release the records.
USES AND DISCLOSURES THAT REQUIRE YOUR WRITTEN AUTHORIZATION
The following always require your written authorization:
• Psychotherapy notes. These are notes I may keep separately from the rest of your record to document or analyze the contents of a session. I will not share them without your written authorization, except in the narrow circumstances the law allows.
• Marketing. I will not use or share your information for marketing communications without your written authorization.
• Sale of your information. I will never sell your protected health information. Any disclosure that would constitute a sale requires your written authorization.
• Anything else. Any use or disclosure not described in this Notice, and not required by law, will be made only with your written authorization.
You may revoke a written authorization at any time by giving me written notice. Your revocation takes effect when I receive it. It will not undo any disclosure I already made while the authorization was in effect.
ELECTRONIC DISCLOSURE OF YOUR HEALTH INFORMATION
As required by Texas Health and Safety Code § 181.154, I am notifying you that your protected health information may be subject to electronic disclosure. My practice uses an electronic health record system, and information may be transmitted electronically for treatment, payment, and health care operations, and as otherwise authorized or required by law. Except for those purposes, I will not electronically disclose your information to anyone without a separate authorization from you for each disclosure.
YOUR RIGHTS
You have the following rights regarding the information I keep about you. To exercise any of them, contact me using the information at the end of this Notice.
To see and receive a copy of your record
You may inspect and obtain a copy of the information I keep about you. Please make your request in writing. Because my practice uses an electronic health record system, I will provide your records within 15 business days of receiving your written request, and in electronic form if you would like it that way.
I may charge a reasonable, cost-based fee that covers the labor of copying, supplies, and postage if the records are mailed. I will tell you the approximate fee before I fill your request, so you can decide how you would like to proceed. There is no charge simply to inspect your record. I will not withhold your records because of an unpaid balance for services.
If I deny access to part of your record
I may deny access to a portion of your record if I determine that releasing that portion would be harmful to your physical, mental, or emotional health. If I do, I will give you a signed and dated written statement telling you which portion is being withheld, why, and how long the denial will last, and I will keep a copy in your record. I will reconsider the denial each time you ask for that portion again.
If I deny access, you have two ways to seek review:
• You may ask that the denial be reviewed by another licensed health care professional who was not involved in my original decision. I will abide by that professional’s determination.
• You may select another professional to treat you for the same or a related condition, and Texas law requires me to allow that professional to examine and copy your record.
To ask me to correct your record
If you believe information in your record is incorrect or incomplete, you may ask me in writing to amend it. Please tell me what information you want changed, what the correction should be, and why. I will respond in writing within 60 days, with one possible 30-day extension. If I deny your request, I will explain why, and you may submit a written statement of disagreement that will be kept with your record.
To receive a list of disclosures
You may request a list of certain disclosures I have made of your information for purposes other than treatment, payment, or health care operations. Your request must state a time period, which may not be longer than six years before the date of the request. I will respond within 60 days, with one possible 30-day extension. One list per 12-month period is free; I will tell you the cost of any additional list before providing it, and you may withdraw or change your request at that point.
To request restrictions
You may ask me to limit how I use or share your information. I am not required to agree to most such requests, and I cannot agree to restrictions on disclosures that are required by law. However, I must agree to one: if you pay in full, out of pocket, for a specific service, you may direct me not to share information about that service with your health plan, and I will honor that request.
To request confidential communications
You may ask me to contact you in a particular way or at a particular place — for example, only by cell phone, only at a certain address, or with no voicemail. I will accommodate all reasonable requests, and I do not require you to explain why.
To choose someone to act for you
If you have given someone medical power of attorney, or if someone is your legal guardian, that person may exercise your rights and make choices about your information. I will verify that the person has authority before I act.
To receive a paper copy of this Notice
You may ask for a paper copy of this Notice at any time, even if you agreed to receive it electronically. I will provide it promptly and at no charge.
To be notified of a breach
You have the right to be notified if a breach occurs that may have compromised the privacy or security of your information. I will notify you as soon as reasonably possible and no later than 60 days after discovering the breach.
To complain without consequence
You may complain to me or to the government agencies listed at the end of this Notice if you believe your privacy rights have been violated. I will not retaliate against you in any way for filing a complaint, and filing one will not affect your care.
HOW LONG I KEEP YOUR RECORDS
Texas rules require me to keep your record for at least seven years after our work together ends, or, if you were a minor, until five years after you reach age 18 — whichever is longer. Your information stays confidential regardless of how long ago you received services.
I have a written plan for the custody and control of client records in the event of my death, incapacity, or the closing of my practice, so that your records remain protected and accessible to you. You may ask me about this plan at any time.
CHANGES TO THIS NOTICE
I may change this Notice at any time, as permitted by law. Any change will apply to all information I maintain, including information created or received before the change. When I revise this Notice, the new version will be posted in my office and on my website, and I will make a copy available to you on request. The current version is always available from me.
QUESTIONS AND COMPLAINTS
If you have questions about this Notice, or if you believe your privacy rights have been violated, please contact me first. I would rather hear about a problem directly and have the chance to address it.
You may also file a complaint with any of the following, and you may do so without contacting me first:
U.S. Department of Health and Human Services, Office for Civil Rights
Centralized Case Management Operations, 200 Independence Avenue SW,
Room 509F HHH Building, Washington, DC 20201
Toll-free: 1-877-696-6775 • Online: ocrportal.hhs.gov
Texas Behavioral Health Executive Council
1801 Congress Avenue, Suite 7.300, Austin, TX 78701
Complaints: 1-800-821-3205 • Main: (512) 305-7700 • bhec.texas.gov
Office of the Attorney General of Texas, Consumer Protection Division
PO Box 12548, Austin, TX 78711-2548 • texasattorneygeneral.gov
You will not be penalized, and your care will not be affected, for filing a complaint with me or with any of these agencies.
PRIVACY OFFICER
Jeffrey Chupik, LPC-S
Chupik Behavioral Health PLLC
PO Box 35, Temple, TX 76503-0035
Telephone: (254) 274-3068
Email: Jeff@ChupikBH.com