FLORIDA NOTICE OF PRIVACY POLICY FORM 

Notice of Psychotherapists’ Policies and Practices to 

Protect the Privacy of Your Health Information 

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. 

Effective April 14, 2003, Florida law and the Health Insurance Portability Act of 1996 (HIPAA)  requires me to maintain the privacy of protected health information and to provide you with this  Notice of my legal duties and privacy practices with respect to protected health information,  whether electronically, on paper, or orally. I am dedicated to protecting your clinical/medical  information and required by law to abide by the terms of this Notice. 

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 such as sharing, employing, applying, utilizing,  examining, and analyzing information that identifies you. 

· “Disclosure” applies to activities outside of my office 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  only 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 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 clinical record. These notes are given a  greater degree of protection than PHI. 

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) 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: Updated 3/2022

· 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. Also, I may use or disclose information for public  health activities, including the reporting of disease, injury, vital events and the conduct of public  health surveillance, investigation and /or intervention, and for intelligence, counter intelligence  or other national security purposes. 

· Worker’s Compensation/Disability: 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. 

IV. Client's Rights and Psychologist's Duties 

Client’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. 

Updated 3/2022

Psychotherapist’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. · If I revise my policies and procedures, I will provide you with a written notification, by mail, of  those revisions on or before the effective date. 

V. Complaints 

If you are concerned that I have violated your privacy rights, or you disagree with a decision I  made about access to your records, please discuss this with me. You have also the right to call  (877-696-6775) and/or send a formal written complaint within 180 days to the Secretary of the  U.S. Department of Health and Human Services at the following address: 

Secretary of Health and Human Services 

200 Independence Avenue, SW 

Washington, D.C. 20201 

There will be no retaliation for filing a complaint. VI. Effective Date, Restrictions and Changes to  Privacy Policy This notice is effective as of 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. I will  provide you with a revised Notice of Privacy Practices upon request.