Patient Forms – Privacy Policy

Please note: you must read and accept the terms of our privacy policy prior to accessing the client forms on this web site.

FLORIDA NOTICE OF PRIVACY PRACTICES
(HIPPA – FLORIDA FORM)

Notice of Psychotherapist’s Policies and Practices to
Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW HEALTH, PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU 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

We may use or disclose or be required to 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 or you obtain reimbursement from your healthcare provider for my services. 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 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

We may use or disclose PHI for purposes outside of treatment, payment, and health care operations only when your appropriate authorization is obtained. An “authorization” is written permission that permits only specific disclosures above and beyond your general consent. In those instances when we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes for any purpose except as noted otherwise herein. “Psychotherapy notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. If we are counseling with you conjointly with another person or persons, we must have written authorization from every participant in those joint or family sessions, unless federal or state law requires us to do otherwise.

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) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insure the right to contest the claim under the policy.

If we begin seeing you with any other family member or relationship partner, and if we agree that we will have one or more session(s) or have communications with you individually without the other member(s) or partner(s) participating, your signature on the informed consent form provided to you before or at the time of our first session is an acknowledgment and agreement that we will use my own discretion and professional judgment in determining what information may be shared with those other counseling participants and will operate as a release that allows us to disclose this information without further authorization or consent.

III. Uses and Disclosures with Neither Consent nor Authorization

We may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If we 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 we report such knowledge or suspicion to the Florida Department of Child and Family Services.
  
• Adult and Domestic Abuse: If we know, or have reasonable cause to suspect, that a vulnerable adult (disabled or elderly) has been or is being abused, neglected, or exploited, we are required by law to immediately report such knowledge or suspicion to the Central Abuse Hotline.
  
• Health Oversight: If a complaint is filed against us 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 us 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 we 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 us that you are opposing