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11/01/2006
NOTICE OF PRIVACY PRACTICES
Notice of Psychologists’ Policies
and Practices
to Protect the Privacy of Your
Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL
INFORMATION ABOUT YOU OR YOUR CHILD MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
I. Uses and Disclosures for
Treatment, Payment, and Health Care Operations
I may use
or disclose the protected health information (PHI),
of you or your child 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
or your
child.
·
“Treatment, Payment and Health Care Operations”
– Treatment
is when I provide, coordinate or manage the health care of you or
your child and other services related to the health care of you or
your child. 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 the healthcare of you or your
child. Examples of payment are when I disclose the PHI of you or
your child to your health insurer to obtain reimbursement for that
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 office such as sharing,
employing,
applying, utilizing, examining, and analyzing information that identifies you
or
your child.
·
“ Disclosure”
applies to activities outside of my office, such as releasing,
transferring, or providing access to information about you or your child to other
parties.
II. 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 or your
child’s psychotherapy notes. “Psychotherapy notes” are notes
I have made about conversations with you or your child during a
private, group, joint, or family counseling session, which I have
kept separate from the rest of the medical record. These notes are
given a greater degree of protection than PHI.
You may revoke
all such authorizations (of PHI or psychotherapy notes) 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.
III. 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 you or your child’s 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 or
your child present a clear and immediate probability of physical
harm to yourself (or in the case of your child, to himself/herself),
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.
There may be
additional disclosures of PHI that I am required or permitted by law
to make without your consent or authorization, however the
disclosures listed above are the most common.
IV. 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 or your child. 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.
·
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 or your
child 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 or your child. 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 practices such that a change to the notice
is required, I will provide you with a revised notice of my policies
and practices at your next appointment immediately following the
date of such a revision.
V. 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 Alina Font, Ph.D. at (813) 367-6611 for
further information.
If you believe
that your privacy rights have been violated and wish to file a
complaint with me, you may send your written complaint to Alina
Font, Ph.D. at the following address: 405 South Dale Mabry Highway,
Suite 404, Tampa, Florida 33609. All complaints must be submitted in
writing.
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.
VI. Effective Date, Restrictions
and Changes to Privacy Policy
This notice will
go into effect on November 1st 2006.
I reserve the
right to change the terms of this notice and to make the new notice
provisions effective for all PHI that I maintain. I will provide
you with a revised notice by providing you with a copy of the
revised notice at your next appointment immediately following such a
revision.
For an electronic version of this
document please visit:
Notice of Privacy Practices
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