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I.
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 [office, clinic, practice group,
etc.] such as sharing, employing, applying, utilizing, examining,
and analyzing information that identifies you.
·
“Disclosure” applies
to activities outside of my [office, clinic, practice group,
etc.], such as releasing, transferring, or providing access
to information about you 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.
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.
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 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.
·
Social Security Administration:
If you are referred to me for a disability determination
evaluation, all personal information SSA collects is protected
by the Privacy Act of 1974. Once medical information is
disclosed to SSA, it is no longer protected by the health
information privacy provisions of 45 CFR, part 164, mandated
by the Health Insurance Portability and Accountability Act
(HIPAA).
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. 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. Changes
will be posted on my office website at www.WEBenet.com/hipaa.htm,
and a paper copy will be available from my office upon request.
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 the office manager at (352) 375-2545.
If you believe that your
privacy rights have been violated and wish to file a complaint
with my office, you may send a written complaint to:
Dr. William
E. Benet
9141 SW 49th Place, Gainesville, FL 32608
You may also send a written
complaint to the Secretary of the U.S. Department of Health
and Human Services. The Office Manager will provide
you with the address upon request.
You have specific rights
under the Privacy Rule, which are protected and will not
affect the services that you receive, if you exercise your
right to file a complaint.
VI.
Effective Date
These privacy practices
are effective April 14, 2003
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