FLORIDA NOTICE FORM
Notice of
Psychologists' Policies & Private 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.
David B. Miller, Psy.D., P.A. 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 David B. Miller, Psy.D., P.A. provide, coordinate or manage your
health care and other services related to your health care. An example of
treatment would be when David B. Miller, Psy.D., P.A. consults with
another health care provider, such as your family physician or another
psychologist.
Payment
is when David B. Miller, Psy.D., P.A. obtains 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 practice group, such as sharing, employing,
utilizing, examining, and analyzing information that identifies you.
"Disclosure"
applies to activities outside of my practice group. Such as releasing,
transferring, or providing access to information about you to other parties.
David B. Miller, Psy.D., P.A. 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 David B. Miller, Psy.D., P.A.
is asked for information for purposes outside of treatment, payment and health
care operation, we will obtain an authorization from you before releasing your
psychotherapy notes. "Psychotherapy notes" are notes that I
have made about our conversation during a private, group, joint, or family
counseling session, which David B. Miller, Psy.D., P.A. has 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 in in writing. You may not revoke an authorization to the
extent that (1) David B. Miller, Psy.D., P.A. 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 to the right to
contest the claim under the policy.
I may use or
disclose PHI without your consent or authorization in the following
circumstances.
Child Abuse:
If David B. Miller, Psy.D., P.A. 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 I report such knowledge or suspicion to the Florida Department
of Child and Family Services
Adult and
Domestic Abuse: If David B. Miller, Psy.D., P.A. knows or has
reasonable cause to suspect, that a vulnerable adult (disabled or elderly) has
been or is being abused, neglected, or exploited, David B. Miller, Psy.D., P.A. are required by law to immediately report such suspicion to the
Central Abuse Hotline.
Health
Oversight: If a complaint is filed against David B. Miller, Psy.D., P.A. 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 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.
Serous Threat
to Health or Safety: When you present a clear and immediate probability of
physical harm to yourself, to other individuals, or to society, David B. Miller,
Psy.D., P.A. 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, David B. Miller,
Psy.D., P.A. 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 person.
Right to
Request Restrictions - You have the right to request restrictions on certain
uses and disclosures of protected health information about you. However,
David B. Miller, Psy.D., P.A. 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, David B. Miller, Psy.D., P.A. 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 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. David B. Miller, Psy.D., P.A. may deny
your request. On your request, David B. Miller, Psy.D., P.A. 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, David B. Miller, Psy.D.,
P.A. 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
David B. Miller, Psy.D., P.A. upon request, even if you have agreed to
receive the notice electronically.
David B. Miller, Psy.D., P.A. is 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.
David B. Miller, Psy.D., P.A. reserves the right to change the privacy and practices
described in this notice. Unless David B. Miller, Psy.D., P.A.
notifies you of such changes, however, David B. Miller, Psy.D., P.A. is
required to abide by the terms currently in effect.
If
David B. Miller, Psy.D., P.A. revises the policies and procedures, David B.
Miller, Psy.D., P.A. will notify you in writing with a revised notice via
mail.
If you are
concerned that I have violated your privacy rights, or you disagree with a
decision David B. Miller, Psy.D., P.A. has made about access to your
records, you may contact the Security of Department of Health & Human Services.
This notice will
go into effect on ____________________________________
David B. Miller, Psy.D., P.A. reserves the right to change the terms of this notice
and to make the new notice provisions effective for all PHI that the office
maintains. David B. Miller, Psy.D., P.A. will provide you with a
revised notice by mail.
Sign: _____________________________ Date:
____________________
