Disclaimer

HIPPA Acknowledgment

​

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was created to protect and regulate the use of your private health information (PHI).  This policy describes how medical information obtained from you may be used and disclosed, how you can get access to your individually identifiable health information, and your rights and my obligations regarding your PHI. My practice will have a copy of my current Notice on hand in my office, and you may request a copy of my most current Notice at any time.  I ask that you please review this Notice, and let me know about any questions you may have.

​

PLEASE TAKE NOTICE. I AM NOT A LICENSED HEALTH CARE PROVIDER AND AM NOT LICENSED BY THE STATE.  I WILL NOT SHARE YOUR INFORMATION UNLESS COMPELLED BY LAW OR BY YOUR WRITTEN REQUEST, AND WILL MAKE EVERY EFFORT TO PROVIDE NOTICE TO YOU IF/WHEN I MAKE DISCLOSURES.

 

I.  Your Private Information -

I am committed to protecting your private information, including individually identifiable health information (i.e. protected health information, or PHI).  On intake, I create a client file for you, using both personal and medical information, to assist us in providing services to you.  I will add to your file as you provide more information during the course of your sessions, whether written or oral, in order to track and plan your progress.   This file is kept completely confidential and remains at my place of practice for your protection.  The terms of this notice apply to all records created or retained by my practice that include private information.

Regarding your protected health information, I am required by federal and state law to maintain the confidentiality of your health information and provide you notice of our legal duties and privacy practices affecting the handling of that information.  In compliance with the law, I will follow the terms of the Notice of Privacy Practices and HIPAA Policy in effect at the time of service, but reserve the right to revise or amend this policy at any time.  Any revision or amendment to this notice will be effective for all of your records that my practice has created or maintained in the past, and for any of your records that I may create or maintain in the future.

 II. Permitted Disclosures -

1. Treatment. I may use your PHI to treat you. For example, I might disclose your PHI in order to treat you or to assist others in your treatment. Additionally, I may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, I may also disclose your PHI to other health care providers for purposes related to your treatment.

2. Payment. My practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, I may use your PHI to bill you directly for services and items. I may also contact third parties that may be responsible for such costs, such as family members. Last, I may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

3. Business operations. My practice may use your PHI to operate my business. As examples of the ways in which I may use and disclose your information for my operations, my practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for my practice.

4. Optional Appointment reminders. My practice may use and disclose your PHI to contact you and remind you of an appointment.

5. Optional Treatment options. My practice may use and disclose your PHI to inform you of potential treatment options or alternatives.

6. Optional Health-related benefits and services. My practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.

7. Optional Release of information to family/friends. My practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you.

8. Disclosures required by law. My practice will use and disclose your PHI when I are required to do so by federal, state or local law.
 

III. Disclosure in Special Circumstances -

1. Public health risks. My practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

• Maintaining vital records, such as births and deaths,

• Reporting child abuse or neglect,

• Preventing or controlling disease, injury or disability,

• Notifying a person regarding potential exposure to a communicable disease,

• Notifying a person regarding a potential risk for spreading or contracting a disease or condition,

• Reporting reactions to drugs or problems with products or devices,

• Notifying individuals if a product or device they may be using has been recalled,

• Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult client (including domestic violence); however, I will only disclose this information if the client agrees or I am required or authorized by law to disclose this information,

• Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

 

2. Health oversight activities. My practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and similar proceedings. My practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. I also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if I have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. 

 

4. Law enforcement. I may release PHI if asked to do so by a law enforcement official:

• Regarding a crime victim in certain situations, if I am unable to obtain the person’s agreement,

• Concerning a death I believe has resulted from criminal conduct,

• Regarding criminal conduct at my offices,

• In response to a warrant, summons, court order, subpoena or similar legal process,

• To identify/locate a suspect, material witness, fugitive or missing person,

•  In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

 

5. Optional Deceased clients. My practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, I also may release information in order for funeral directors to perform their jobs.

6. Optional Research. My practice may use and disclose your PHI for research purposes in certain limited circumstances. I will obtain your written authorization to use your PHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies all of the following conditions:

(A) The use or disclosure involves no more than a minimal risk to your privacy based on the following: (i) an adequate plan to protect the identifiers from improper use and disclosure; (ii) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (iii) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted;

(B) The research could not practicably be conducted without the waiver,

(C) The research could not practicably be conducted without access to and use of the PHI.

7. Serious threats to health or safety. My practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, I will only make disclosures to a person or organization able to help prevent the threat.

8. Military. My practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

 9. National security. My practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. I also may disclose your PHI to federal and national security activities authorized by law. I also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations.

10. Inmates. My practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.  

11. Workers’ compensation. My practice may release your PHI for workers’ compensation and similar programs.

 

IV. Your Legal Rights -

1. Confidential communications. You have the right to request that my practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that I contact you at home, rather than work. My practice will accommodate reasonable requests, and no reason for the request needs to be given.  In order to request a type of confidential communication, you must make a written request, specifying the requested method of contact, or the location where you wish to be contacted.

2. Requesting restrictions. You have the right to request a restriction in my use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that I restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. I am not required to agree to your request; however, if I do agree, I are bound by my agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in my use or disclosure of your PHI, you must make your request in writing, describing in a clear and concise fashion: 

• The information you wish restricted,

• Whether you are requesting to limit my  practice’s use, disclosure or both,

• To whom you want the limits to apply.

 

3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including client medical records and billing records, but not including psychotherapy notes.  In order to inspect and/or obtain a copy of your PHI you must submit your request in writing.  My practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request, and may deny your request in certain limited circumstances.  Should I deny your request, you may request a review of my denial by a licensed healthcare professional.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for my practice. To request an amendment, your request must be made in writing, providing us with a reason that supports your request for amendment. My practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, I may deny your request if you ask us to amend information that is in my opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by my practice, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of disclosures. All of my clients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures my practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine client care in my practice is not required to be documented.  In order to obtain an accounting of disclosures, you must submit your request in writing stating a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but my practice may charge you for additional lists within the same 12-month period. My practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Right to a paper copy of this notice. You are entitled to receive a paper copy of my notice of privacy practices. You may ask us to give you a copy of this notice at any time, either from my physical office, during session, or by contacting us directly. 

7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with my practice or with the Secretary of the Department of Health and Human Services. To file a complaint with my practice, contact the Florida HIPAA Privacy and Security Compliance Office, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #5, Tallahassee, FL 32308-5403, Phone: (850) 488-3849 All complaints must be submitted in writing. You will not be penalized for filing a complaint.

 

8. Right to provide an authorization for other uses and disclosures. My practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, I will no longer use or disclose your PHI for the reasons described in the authorization. Please note: I am NOT required to retain records of your care.