HIPPA NOTICE OF PRIVACY PRACTICES
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.THIS NOTICE IS THE RESULT OF THE HEALTH INSURANCE
PORTABILITY AND ACCOUNTABILITY ACT, A 1996 FEDERAL LAW WHCH BECAME EFFECTIVE APRIL 14, 2003.
I. IT IS MY LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI). By law I am required to insure that your PHI is kept private. The PHI constitutes information created or noted by me that can be used to identify you. It
contains information about your past or present condition, the provision of health care services to you, or the payment for such health care. I am required to provide you the with Notice about my privacy procedures. This notice
explains when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share apply, utilize, examine, or analyze information within my practice; PHI is disclosed when I release, transfer, give, or otherwise reveal
it to a third party outside my practice. Whit some exceptions, I any not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally required to
follow the privacy practices described in this Notice. Please note that I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI already on file with me. Before I make
any changes to my policies, I will immediately change this Notice and post a new copy of it in my office. You may also request a copy of this Notice from me, or you can view a copy of it in my office.
II. HOW I WILL USE AND DISCLOSE YOUR PHI. I will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; however some do not require your
pre-authorization. Please review this carefully. A. USES AND DISCLOSURES RELATED TO TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS THAT DO NOT REQUIRE YOUR PRIOR WRITTEN CONSENT. THESE INCLUSE:
1. ABUSE OF A CHILD: If I know or have reasonable cause to suspect that a child is abused, abandoned, or neglected.
2. ABUSE OR EXPLOTATION OF THE ELDERLY OR DISABLED : If I know or have reasonable cause to suspect that an elderly or disabled person is abused or being financially exploited.
3. 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 will not be released without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified and your 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.
4. HEALTH OVERSIGHT: If a complaint is filed against me with the Florida Department of Health on behalf of the Board of Mental Health Counseling or Marriage and Family Therapy, the Department has the authority to subpoena confidential mental health information from me relevant to that complaint.
5. SEROUS THEREAT TO HEALTH AND SAFETY: If you present a clear and immediate probability of physical harm to yourself, to other individuals, or to society, relevant information may be communicated concerning this to the potential victim, appropriate family members, or law enforcement or other appropriate authorities.
6. WORKER’S COMPENSATION: If you file a worker’s compensation claim, we 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.
7. TO OBTAIN PAYMENT FOR TREATMENT: I may use and disclose your PHI to bill and collect payment for the treatment and services I provided you. This includes your insurance company and my billing service.
8. EMERGENCY TREATMENT: If emergency medical treatment is required and you are unable to communicate with me and/or are incoherent.
9. DISASTER RELEIF: PHI may be disclosed in order for disaster relief to be carried out by federal, state or local agencies.
10. NATIONAL SAFETY OR SECURITY: PHI may be disclosed to legal authorities if National safety or security is threatened. B. USES AND DISCLOSURES REQUIRING YOUR PRIOR WRITTEN AUTHORIZATION. In any other situation not described in
Section IIA, I will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any
future uses and disclosures of your PHI.
III. YOUR RIGHTS REGARDING YOUR PHI. A. THE RIGHT TO SEE AND RECEIVE COPIES OF YOU PHI. In general, you have the right to see your PHI and to receive copies of it. You must request it in writing. However, certain types of PHI will
not be made available to you or for copying. This includes but is not limited to records sent from a third party or records for pending litigation. B. RIGHT TO AMEND YOUR PHI. If you believe that your PHI is incorrect or that an
important part of it is missing, you have the right to ask to amend your PHI. Your request must be made in writing and you will receive a response within 30 days. C. RIGHT TO A LIST OF DISCLOSURES. You have the right to request a
list of the disclosures I have made of PHI about you. This list will not include disclosures made for treatment, payment, health care operations, for purposes of national security, made to law enforcement or to corrections personnel
or made pursuant to your authorization or made directly to you. Your request must be in writing and you will receive a response within 30 days. D. RIGHT TO REQUEST RESTRICTIONS. You have the right to request restrictions or
limitations on PHI I use or disclose about you for treatment, payment or health care operations, or that I disclose to someone who may be involved in your care or payment for your care, like a family member or friend. While I will
consider your request, I am not required to agree to it. To request a restrictions you must summit it in writing and you will receive a response within 30 days. I will not agree to restrictions on PHI uses or disclosures that are
legally required or which are necessary to administer business. E. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request that I communicate with you about PHI in a certain way or a certain location if you tell
me that communication in another manner may endanger you. For example, you can ask that I only contact you at work or by mail. I will accommodate all reasonable request. F. RIGHT TO FILE A COMPLAINT: If you feel I have violated your
privacy rights, or if you object to a decision I made about your PHI, please file a complaint with me. Annette R. Maguire, PO Box 15106, Fernandina Beach, FL 32035, (904) 206-0734. You also have the right to file a complaint with
the Secretary of the Department Health and Human Services.
