Carrollwood Village Counseling Associates
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Carrollwood Village Counseling Associates
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Carrollwood Village Counseling Associates NOTICE OF PRIVACY PRACTICES Effective April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control of your PHI in some cases. Your Protected Health Information (PHI) means any of your written and oral health information, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
Your Authorization Except as outlined below, we will not use or disclose your PHI unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing except to the extent that we have taken action in reliance upon the authorization.
Treatment -- We may use and disclose your PHI to provide treatment or services. For example, we may use or disclose your Protected Health Information to doctors, nurses, technicians or other individuals involved in your care. We may also disclose your Protected Health Information to another care provider upon referral.
Uses and Disclosures for Payment We may make requests, uses, and disclosures of your PHI as necessary for payment purposes. For example, we may use information regarding your mental health condition to process claims.
Uses and Disclosures for Health Care Operations We may use and disclose your PHI as necessary for our health care operations. Examples of health care operations include continuing quality improvement activities, review and auditing supervision and evaluation of staff.
Family and Friends If you are available and do not object, we may disclose your PHI to your family, friends, and others who are involved in your care or payment of a claim. For example, when you request a family member be present during your session(s), the therapist can than infer that you are giving your approval for the therapist to share PHI with that family member. We may also release PHI to someone who helps pay for your care or to an entity assisting in disaster relief efforts so that your family is notified of your condition, status and location.
Business Associates Certain aspects and components of our services are performed through contracts with outside persons or organizations. Examples of these outside persons and organizations include our legal counsel, outside computer consultants and auditors.
Appointment Reminders We may contact you to remind you of any appointment.
Other Products and Services We may contact you to provide information about other health-related products and services that may be of interest to you.
Other Uses and Disclosures We may make other uses and disclosures of your PHI without your authorization, specifically: · We may use or disclose your PHI for any purpose required by law. For example, Child and Family Service of Saginaw County may be required by law to use or disclose your PHI to respond to a court order. · We may disclose your PHI to the proper authorities if we suspect child abuse or neglect. · We may disclose your PHI if authorized by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings. · We may disclose your PHI in the course of a judicial or administrative proceeding (e.g. to respond to a subpoena or discovery request). · We may disclose your PHI to the proper authorities for law enforcement purposes, including reporting of certain types of wounds or other physical injuries; to identify or locate a suspect, fugitive, material witness, or missing person; to provide information about a death we believe may be the result of criminal conduct; and to provide information about criminal conduct. · We may disclose your PHI to avert a serious threat to health or safety. · We may disclose your PHI to workers compensation agencies for your workers compensation benefit determination. · We will, if required by law, release your PHI to the Secretary of the Department of Health and Human Services for enforcement of HIPAA. Specialized Government Functions -- We may disclose the PHI of Armed Forces personnel, veterans and foreign military personnel for authorized activities under the appropriate circumstances. Further, your PHI may be disclosed to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities and special investigations, including the provision of protective services to the President, other authorized persons or foreign heads of state, as authorized by law.
RIGHTS THAT YOU HAVE
Access to Your PHI You have the right to copy and/or inspect certain parts of your PHI that we maintain. Certain requests for access to your PHI must be in writing, must state that you want access to your PHI and must be signed by you or your personal representative (e.g. requests for clinical records). We may charge you a fee for copying and postage.
Amendments to Your PHI You have the right to request that PHI that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. To be considered, your amendment request must be in writing, must be signed by you or your representative, and must state the reasons for the amendment/correction request. Amendment request forms are available from Child and Family Service of Saginaw County at the address below.
Accounting for Disclosures of Your PHI You have the right to receive an accounting of certain disclosures made by us of your PHI after April 14, 2003. To be considered, your accounting requests must be in writing and signed by you or your representative. Accounting request forms are available from Child and Family Service of Saginaw County at the address below. The first accounting in any 12-month period is free; however, we may charge you a fee for each subsequent accounting you request within the same 12-month period.
Restrictions on Use and Disclosure of Your PHI You have the right to request restrictions on certain uses and disclosures of your PHI for insurance payment or health care operations and disclosures made to persons involved in your care. Your request must describe in detail the restriction you are requesting. HIPAA does not require us to agree to your request but we will accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction. Requests for a restriction (or termination of an existing restriction) may be made by contacting Child and Family Service of Saginaw County at the telephone number or address below.
Request for Confidential Communications You have the right to request that communications regarding your PHI be made by alternative means or at alternative locations. For example, you may request that statements not be sent to your home address. We are required to accommodate reasonable requests when appropriate. Requests for confidential communications must be in writing, signed by you or your representative, and sent to Child and Family Service of Saginaw County at the address below.
Right to a Copy of the Notice You have the right to a paper copy of this Notice upon request by contacting Child and Family Service of Saginaw County at the telephone number or address below.
Complaints If you believe your privacy rights have been violated, you can file a complaint with Carrollwood Village Counseling Associates in writing at the address below. You may also file a complaint in writing with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C., within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.
THIS NOTICE MAY BE AMENDED AT ANY TIME We may change the terms of this Notice at any time. Any revised Notice will be effective for all health information that we maintain. The effective date of a revised Notice will be noted. A copy of the current Notice in effect will be posted. You may request a copy of the current Notice at any time.
FOR FURTHER INFORMATION If you have any questions or need further assistance regarding this Notice, you may contact Carrollwood Village Counseling Associates Privacy Officer by writing to: Carrollwood Village Counseling Associates 14502 North Dale Mabry Highway, Suite 326 Tampa, Florida 33628
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