Notice of Privacy Practices (HIPAA)
(HIPAA—Health Insurance Portability and Accountability Act)
(Florida Residential Clients Only)

Notice of Privacy Practices (HIPAA):

How I use and disclose your protected health information (PHI) with your consent: I will use the information I collect about you mainly to provide you with treatment, to arrange payment for services, and for some other business activities that are called, under the law, health care operations. If I want to use or send, share, or release your information for other purposes, I will discuss this with you and ask you to sign an authorization form to allow this.

Confidentiality:

In all but a few rare situations, your confidentiality (that is, your privacy) is protected by federal and state laws and by the rules of my profession. Here are the exceptions under Florida law where confidentiality is not protected:

http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&UR L=0400-0499/0491/Sections/0491.0147.html

Please note that I am also mandated to report abuse. I do not have to prove the abuse occurred, I only have to file a complaint. The complaint will be investigated by the appropriate authorities, who will ultimately decide if abuse occurred or not. As part of cost control efforts, an insurance company will sometimes ask for more information on symptoms, diagnoses, and my treatment methods. It will become part of your permanent medical record. I will let you know if this should occur and what the company has asked for. Please understand that I have no control over how these records are handled at the insurance company itself. My policy is to provide only as much information as the insurance company will need to pay your benefits.

It is my office policy to destroy clients' records 7 years after the end of our work, which is the required minimum length of time that Florida requires records to be kept. Until then, your records are stored in a HIPAA-secure software system online.

For full information regarding your HIPAA rights, please visit http://www.hhs.gov/hipaa/. Please note that failure to sign this form does not prevent me from using your information as outlined above. The law does not require healthcare providers to obtain your consent; it only requires that healthcare providers make you aware of your HIPAA rights.

I acknowledge that I have been made aware of my rights under HIPAA. I understand my printed/typed signature will act in lieu of my signature.