Consumer Rights

Notice Regarding Access to Protected Health Information and Filing Complaints:

Patients of our practice and patients’ authorized representatives have a right to their

treatment record and information. To request a copy of your record with our office,

please send a written request to our office at 1117 Rising Ridge Dr./Desoto, TX 75115 or

at

Lili-Erika@Fiatcounselingservices.com. Further, if you believe your rights have been

violated or your care has been compromised, you may file a complaint with the Texas

Behavioral Health Executive Council (TBHEC) which licenses mental health

professionals in Texas. For information on how to file a complaint and to access

complaint forms, visit the BHPEC website at: https://www.bhec.texas.gov. Complaints

may also be submitted in writing to the BHPEC at 1801 Congress Avenue, Suite 7.300,

Austin, Texas 78701.

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form

and any supporting documentation under section 2799B-7 of the Public Health Service

Act, as added by section 112 of the No Surprises Act, title I of Division BB of the

Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on

the form to process your request to initiate a payment dispute, verify the eligibility of

your dispute for the PPDR process, and to determine whether any conflict of interest

exists with the independent dispute resolution entity selected to decide your dispute.

The information may also be used to: (1) support a decision on your dispute; (2) support

the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR

entity’s compliance with program rules. Providing the requested information is voluntary.

But failing to provide it may delay or prevent processing of your dispute, or it could

cause your dispute to be decided in favor of the provider or facility.