REGA MENTAL HEALTH CENTER
FLORIDA NOTICE FORM
Notice of Mental Health Practitioner's Policies & Privacy 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. Uses and Disclosures for Treatment, Payment, and Health Care Operations
II. Uses and Disclosures Requiring Authorization
III. Uses and Disclosures with Neither Consent nor Authorization
IV. Patient's Right and Practitioner's Duties
V. Complaints
VI. Effective Date, Restrictions and Changes to Private Policy
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
Rega Mental Health Center 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 Rega Mental Health Center provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when your therapist consults with another health care provider, such as your family physician or another mental health practitioner.
Payment is when Rega Mental Health Center obtains reimbursement for your healthcare. Examples of payment are when your providers 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 this 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 the Rega Mental Health Center practice group, such as sharing, employing, utilizing, examining, and analyzing information that identifies you.
"Disclosure" applies to activities outside of the Rega Mental Health Center practice group. Such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
Rega Mental Health Center 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. In those instances when your providers are asked for information for purposes outside of treatment, payment and health care operation, they will obtain an authorization from you before releasing your psychotherapy notes and other additional information. "Psychotherapy notes" are notes that your therapist may have made about conversation during a private, group, joint, or family counseling session, which the therapist keeps 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 in writing. You may not revoke an authorization to the extent that (1) Rega Mental Health Center has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer to the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
Rega Mental Health Center may use or disclose PHI without your consent or authorization in the following circumstances.
Child Abuse: If an employee of Rega Mental Health Center knows or has 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 reporting of such knowledge or suspicion to the Florida Department of Child and Family Services
Adult and Domestic Abuse: If an employee of Rega Mental Health Center has reasonable cause to suspect, that a vulnerable adult (disabled or elderly) has been or is being abused, neglected, or exploited, Rega Mental Health Center is required by law to immediately report such suspicion to the Central Abuse Hotline.
Health Oversight: If a complaint is filed against your mental health practitioner with the Florida Department of Health on behalf of the Board of Psychology, the Board of Clinical Social Work, Marriage & Family Therapy & Mental Health Counseling, or Florida Board of Medicine and Nursing, the Department has the authority to subpoena confidential mental health information from Rega Mental Health Center 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 Rega Mental Health Center will not release information without the written\authorization of you or your legal representative, or a 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, Rega Mental Health Center may communicate relevant information concerning this to the potential victim, appropriate family member, or law enforcement or other appropriate authorities.
Worker's Compensation: If you file a worker's compensation claim, Rega Mental Health Center 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. Patient's Right and Practitioner's Duties
Practitioner'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, Rega Mental Health Center is 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 being seen. Upon your request, Rega Mental Health Center will send your bills to another location).
Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI in your 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, an employee of Rega Mental Health Center 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. Rega Mental Health Center may deny your request. On your request, an employee of Rega Mental Health Center 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, an employee of Rega Mental Health Center 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 Rega Mental Health Center upon request, even if you have agreed to receive the notice electronically.
Practitioner's Duties:
Rega Mental Health Center is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.
Rega Mental Health Center reserves the right to change the privacy and practices described in this notice. Unless Rega Mental Health Center notifies you of such changes, however, Rega Mental Health Center is required to abide by the terms currently in effect.
If Rega Mental Health Center revises the policies and procedures, you will be notified in writing with a revised notice via mail.
V. Complaints
If you are concerned that your privacy rights have been violated, or you disagree with a decision made about access to your records, you may contact the Security of Department of Health & Human Services. Rega Mental Health Center will not retaliate against you for exercising your right to file a complaint.
VI. Effective Date, Restrictions and Changes to Private Policy
This notice is currently in effect and has been so since January 1, 2007. Rega Mental Health Center reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHIs that the office maintains. Rega Mental Health will provide you with a revised notice by mail.