Notice of Psychologists’ 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.
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:
– 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 with your knowledge and consent unless it would be detrimental to your mental, physical, or psychological health or to the health of others concerned.
- 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.
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 as regards your personal, mental, psychological or physical health status. 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 medical 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:
Health Oversight: If there is an inquiry or complaint about my professional conduct
to the Florida State Board for Psychology, I must furnish to the Florida Department of Medical Quality Assurance, your confidential mental health records relevant to this inquiry according to State and Federal Statutes.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is privileged under state law, and I must not release this information without your written authorization, or a court order. This privilege does not apply when you are being evaluated by a third party or where the evaluation is court ordered. I must inform you in advance if this is the case.
Worker’s Compensation: If you file a worker’s compensation claim, and I am treating you for the issues involved with that complaint, then I must furnish to the chairman of the Worker’s Compensation Board records which contain information regarding your psychological condition and treatment according to Florida State and Federal Statutes.
Patient's Rights and Psychologist's Duties
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 Leslie Sadoff (or other official assigned to this office), the Assistant Director, or Robert H. Reiner, the Executive Director, at (212) 860-8500.
If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to the address above.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint. If I am found innocent of the allegations against me made by you or your dually authorized representatives, you will be held responsible for any and all charges, fees, attorney’s fees, court costs, and my professional time while participating in these proceedings.
This notice will go into effect on ______________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 by either distributing it to you in the office or mailing it to your home address.
Name & Signature of Guardian or patient advocate (if applicable)