of My Policies and Practices to Protect the Privacy of Your Health
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
payment, and health care operations purposes
with your consent.
To help clarify these terms, here are some definitions:
refers to information in your health record that could identify you.
Payment and Health Care Operations”
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.
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
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
applies only to activities within my office, such as sharing,
employing, applying, utilizing, examining, and analyzing information
that identifies you.
applies to activities outside of my office, such as releasing,
transferring, or providing access to information about you to other
rely on certain persons or other entities, who or which are not my
employees, to provide services on my behalf. These persons or
entities may include accountants, lawyers and billing services. Where
these persons or entities perform services, which require the
disclosure of PHI, they are considered under the Privacy Rule to be
my Business Associates. I enter into a written agreement with each of
my Business Associates to obtain satisfactory assurance that the
Business Associates will safeguard the privacy of the PHI of my
clients. I rely on my Business Associates to abide by the contract
but will take reasonable steps to remedy any breaches of the
agreement that I become aware of.
Uses and Disclosures Requiring Authorization
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 obtain an authorization from you before using or disclosing PHI
in a way that is not described in this Notice. 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
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.
Uses and Disclosures with
Neither Consent nor Authorization
I may use or disclose PHI without
your consent or authorization in the following circumstances:
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 Children and Families.
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 Florida Abuse Hotline.
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.
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.
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
If you file a worker's compensation claim, I must, upon request of
your employer, the insurance carrier, the attorney for the employer
or insurance carrier, or an authorized rehabilitation provider,
furnish your relevant records to those persons.
When the use and disclosure without your consent or authorization
is allowed under other sections of Section 164.512 of the Privacy
Rule and the state's confidentiality law. This includes certain
narrowly-defined disclosures to law enforcement agencies, to a
health oversight agency (such as HHS or a state department of
health), to a coroner or medical examiner, or for specialized
government functions such as fitness for military duties,
eligibility for VA benefits, and national security and intelligence.
Client's Rights and Psychologist's Duties
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.
to Restrict Disclosures When You Have Paid for Your Care
have the right to restrict certain disclosures of PHI to a health
plan when you pay out-of-pocket in full for my services.
Communications by Alternative Means and at Alternative Locations –
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.)
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.
– 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
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.
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
to Be Notified if There is a Breach of Your Unsecured PHI –
You have a right to be notified if: (a) there is a breach (a use or
disclosure of your PHI in violation of the HIPAA Privacy Rule)
involving your PHI; (B) that PHI has not been encrypted to
government standards; and (c) my risk assessment fails to determine
that there is a low probability that your PHI has been compromised.
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
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.
I revise my policies and procedures, I will provide you with written
Questions and Complaints
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 me with your complaint. 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
Carol Twitchell, 1608 Oak St, Sarasota FL 34236. You may also send a
written complaint to the Secretary of the U.S. Department of Health
and Human Services. I 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
notice will go into effect on April 14, 2003. 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. The
newest version will always be available at www.CarolTwitchell.com.
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