THIS NOTICE DESCRIBES HOW PERSONAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW. PURPOSE OF THIS NOTICE
Deborah Day, M.A., LMHC, NCC is required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information (PHI), and to provide you with a notice of her legal duties and privacy practices with respect to your PHI. This Notice describes your legal rights, advises you of her privacy practices, and lets you know how Deborah Day, M.A., LMHC, NCC is permitted to use and disclose PHI about you.
This notice is covered under HIPAA (Health Insurance Portability & Accountability Act). Any state law that is more stringent than the HIPAA rules and regulations as priority.
Deborah Day, M.A., LMHC, NCC is required to follow the privacy practices described in this Notice, though she reserves the right to change the privacy practices and the terms of the Notice at any time. If this is done, she will post a new Notice in the waiting area. You may request a copy of the new notice from Deborah Day, M.A., LMHC, NCC, Privacy Officer by calling 727-791-7200.
HOW I MAY USE AND DISCLOSE YOUR PROTECTED MENTAL HEALTH INFORMATION
I am authorized to use and disclose PHI for a variety of reasons. For most uses/disclosures, I must obtain our consent. However, the law provides that I am permitted to make some uses/disclosures without your consent. The following offers more descriptions and examples of potential uses/disclosures of PHI.
Uses and Disclosures Requiring Your Consent:
For Treatment: I may disclose your PHI to other mental healthcare practitioners who are involved in providing your mental health care. For example, if a psychiatrist is treating you I may disclose your PHI to him/her to coordinate your care.
For Mental Health Care Operations: I may disclose your PHI to facilitate the efficient and correct operation of my practice. Examples: to evaluate quality of services provided or to my attorney, accountants, consultants, and others to make sure that I am in compliance with applicable laws.
To Obtain Payment for Treatment: I may use and disclose your PHI to bill and collect payment for the treatment and services provided. Examples: I might send your PHI to your insurance company or health plan in order to get payment for health care services. I could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for my office.
Exceptions: Although your consent is usually required for the use/disclosure of your PHI for the activities described above, the law allows me to use/disclose your PHI without your consent in certain situations. For example, I may disclose your PHI if needed for emergency treatment if it is not reasonably possible to obtain your consent prior to the disclosure and I think you would give consent if able. Also, if I am required by law to provide your treatment, I may use/disclose your PHI for treatment operations without obtaining your prior consent.
Uses and Disclosures Requiring Authorization: For uses and disclosures beyond treatment and operational purposes I am required to have your written authorization (signed permission), unless the use of disclosure falls within on the exceptions described below. Like consents, authorizations can be revoked at any time to stop future uses/disclosures except to the extent that I have already undertaken an action in reliance upon your authorization.
Uses and Disclosures NOT REQUIRING CONSENT OR AUTHORIZATION: The law provides that I may use /disclose your PHI without consent or authorization in the following circumstances:
When required by law:
suspected abuse or neglect of a child, elderly person or a physically challenged person
If I believe you are in danger of harming yourself or another person, or unable to take care of yourself
in response to a court order
I must also disclose PHI to authorities who monitor compliance with these privacy requirements.
For Health Oversight Activities: I may disclose PHI for audits or government investigations, disciplinary proceedings, and other administrative or judicial actions undertaken by the government (or their contractors) to oversee the health care system.
To Avert Threat To Health Or Safety: In order to avoid a serious threat to health or safety, I may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm. For example, a plan to commit suicide or a homicidal act.
For Specific Government Functions: I may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government programs relating to eligibility and enrollment, and or national security reasons, such as protection of the President.
Uses and Disclosures Requiring You To Have An Opportunity To Object: In the following situations, I may disclose your PHI if I inform you about the disclosure in advance and you do not object. However, if there is an emergency situation and you cannot be given an opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure if determined to be in your best interest. You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so.
*To families, friends or others involved in our care: I may share with these people information directly related to your family/friends or other person’s involvement in your care. I may also share PHI with these people to notify them about your location or general condition. For example, parents of a minor have certain rights to PHI. Also, I may have to locate family members to inform them of the location of a client who was hospitalized after being diagnosed as severely depressed.
Your Rights Regarding Your Protected Health Information. You have the following rights relating to your protected mental health information:
*To request restrictions on uses/disclosures: You have the right to ask that I limit how I use or disclose your PHI. I will consider your request, but am not legally bound to agree to the restrictions. To the extent that we do agree to any restrictions on the use/disclosures of your PHI, I will put the agreement in writing and abide by it except in emergency situations. I cannot agree to limit uses/disclosures that are required by law.
*To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your protected health information if you put your request in writing. I will respond to your request within 30 days. If I deny you access, I will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, there will be a charge for these copies. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.
*To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in writing, that I correct or add to the record. I will respond within 60 days of receiving your request. I may deny the request if I determine that the PHI is (i) amended and complete; (ii) not created by us and/or part of our records; or (iii) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If I approve the request for amendment, I will amend the PHI and so inform you, and tell others that need to know about the amendment in the PHI.
*To find out what disclosures have been made: you have the right to receive an accounting of the disclosures that I have made. If you would like to receive an accounting, you may send a letter requesting an accounting or contact me directly. The accounting will not include several types of disclosures, including disclosures for treatment or disclosures for which you gave consent. It will also not include disclosures made prior to April 14, 2003. However, from that day forward, disclosures must be documented and retained for a period of six years. I will respond to your request within 60 days of receiving it. There will be no charge for up to one such list each year. There may be a charge for more frequent request.
*To receive this notice: You have a right to receive a paper copy of the Notice and/or an electronic copy by e-mail upon request.
How To Complain About My Privacy Practices
If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a complaint either with me or with the federal government. You may file a written complaint with the Office for Civil Rights (ORC), US Department of Health and Human Services, Atlanta Federal Center, Ste. 3B70, 61 Forsyth Street SW, Atlanta, GA 30303-9808. If you file a complaint about my privacy practices, I will take no retaliatory action against you. If you have questions about this Notice or any complaints about my privacy practices, please contact me at 727-791-7200. My mailing address is 2555 Enterprise Road; Ste 2; Clearwater, FL 33763 and my e-mail is email@example.com.
Licensed Mental Health Counselor MH2820
Certified Practitioner of Psychodrama
& Group Psychotherapy
National Certified Counselor
2555 Enterprise Rd. Suite #2
Clearwater, FL 33763