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THIS
NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment,
payment, and health care operations purposes with your consent. To help
clarify these terms, here are some definitions:
- "PHI" refers to information in your health record that could identify
you.
- Treatment, Payment and Health Care Operations
~Treatment is when I provide, coordinate or manage your health
care and other services related to your health care. An example of treatment
would be when I consult with another health care provider, such as your
family physician or another psychologist.
~ Payment is when I obtain reimbursement for your healthcare.
Examples of payment are when I disclose your PHI to your health insurer
to obtain reimbursement for your health care or to determine eligibility
or coverage.
~Health Care Operations are activities that relate to the performance
and operation of my practice. Examples of health care operations are
quality assessment and improvement activities, business-related matters
such as audits and administrative services, and case management and
care coordination.
- "Use" applies only to activities within my practice, such as sharing,
employing, applying, utilizing, examining, and analyzing information
that identifies you.
- "Disclosure" applies to activities outside of my practice, such as
releasing, transferring, or providing access to information about you
to other parties.
Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment,
and health care operations when your appropriate authorization is obtained.
An "authorization" is written permission above and beyond the general
consent that permits only specific disclosures. In those instances when
I am asked for information for purposes outside of treatment, payment
and health care operations, I will obtain an authorization from you
before releasing this information. I will also need to obtain an authorization
before releasing your psychotherapy notes. "Psychotherapy notes" are
notes I have made about our conversation during a private, group, joint,
or family counseling session, which I have kept separate from the rest
of your medical record. These notes are given a greater degree of protection
than PHI.
You may revoke all such authorizations at any time, provided each revocation
is in writing. You may not revoke an authorization to the extent that
(1) I have relied on that authorization; or (2) if the authorization
was obtained as a condition of obtaining insurance coverage, and the
law provides the insurer the right to contest the claim under the policy.
Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the
following circumstances:
Child Abuse: If I know, or have reasonable cause to suspect,
that a child is abused, abandoned, or neglected by a parent, legal custodian,
caregiver or other person responsible for the child's welfare, the law
requires that I report such knowledge or suspicion to the Florida Department
of Child and Family Services.
Adult and Domestic Abuse: If I know, or have reasonable cause
to suspect, that a vulnerable adult (disabled or elderly) has been or
is being abused, neglected, or exploited, I am required by law to immediately
report such knowledge or suspicion to the Central Abuse Hotline.
Health Oversight: If a complaint is filed against me with the
Florida Department of Health on behalf of the Board of Psychology, the
Department has the authority to subpoena confidential mental health
information from me relevant to that complaint.
Judicial or Administrative Proceedings: If you are involved in a
court proceeding and a request is made for information about your diagnosis
or treatment and the records thereof, such information is privileged
under state law, and I will not release information without the written
authorization of you or your legal representative, or a subpoena of
which you have been properly notified and you have failed to inform
me that you are opposing the subpoena or a court order. The privilege
does not apply when you are being evaluated for a third party or where
the evaluation is court ordered. You will be informed in advance if
this is the case.
Serious Threat to Health or Safety: When you present a clear
and immediate probability of physical harm to yourself, to other individuals,
or to society, I may communicate relevant information concerning this
to the potential victim, appropriate family member, or law enforcement
or other appropriate authorities.
Worker's Compensation: If you file a worker's compensation claim,
I must, upon request of your employer, the insurance carrier, an authorized
qualified rehabilitation provider, or the attorney for the employer
or insurance carrier, furnish your relevant records to those persons.
Patient's Rights and Psychologist's Duties
Patient's Rights:
- Right to Request Restrictions - You have the right to request restrictions
on certain uses and disclosures of protected health information about
you. However, I am not required to agree to a restriction you request.
- Right to Receive Confidential Communications by Alternative Means
and at Alternative Locations - You have the right to request and receive
confidential communications of PHI by alternative means and at alternative
locations. (For example, you may not want a family member to know that
you are seeing me. Upon your request, I will send your bills to another
address.)
- Right to Inspect and Copy - You have the right to inspect or obtain
a copy (or both) of PHI in my mental health and billing records used
to make decisions about you for as long as the PHI is maintained in
the record. On your request, I will discuss with you the details of
the request process.
- Right to Amend - You have the right to request an amendment of PHI
for as long as the PHI is maintained in the record. I may deny your
request. On your request, I will discuss with you the details of the
amendment process.
- Right to an Accounting - You generally have the right to receive
an accounting of disclosures of PHI regarding you. On your request,
I will discuss with you the details of the accounting process.
- Right to a Paper Copy - You have the right to obtain a paper copy
of the notice from me upon request, even if you have agreed to receive
the notice electronically.
Psychologist's Duties:
- I am required by law to maintain the privacy of PHI and to provide
you with a notice of my legal duties and privacy practices with respect
to PHI.
- I reserve the right to change the privacy policies and practices described
in this notice. Unless I notify you of such changes, however, I am required
to abide by the terms currently in effect.
- If I revise my policies and procedures, I will provide you with the
revised policy by mail at the address you provide.
Questions and Complaints
- If you have questions about this notice, disagree with a decision
I make about access to your records, or have other concerns about your
privacy rights, you may contact Melissa Gendleman, Office Manager and
Compliance officer at 561-395-0243. If you believe that your privacy
rights have been violated and wish to file a complaint with my office,
you may send your written complaint to Melissa Gendleman, Office Manager
and Compliance officer at 561-395-0243.
- You may also send a written complaint to the Secretary of the U.S.
Department of Health and Human Services. The person listed above can
provide you with the appropriate address upon request.
- You have specific rights under the Privacy Rule. I will not retaliate
against you for exercising your right to file a complaint.
Effective Date, Restrictions and Changes to Privacy Policy
This notice will go into effect on 4/15/2003. I acknowledge that I have
received the Psychologist's Notice of Privacy Practices with the effective
date of 4/15/2003.
_________________________________ Signature of Patient
_________________ Date
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