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Notice of Policies and 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
We 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 we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or psychologist.
Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we 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 office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
Disclosure applies to activities outside of the office, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, or 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 information is requested for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information.
You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse We are required to report PHI to the appropriate authorities when there are reasonable grounds to believe that a minor is or has been the victim of neglect or physical and/or sexual abuse.
Adult and Domestic Abuse We are required to disclose PHI when there is a reasonable basis to believe that abuse or neglect of an incapacitated or vulnerable adult has occurred or that exploitation of the adult's property has occurred.
Health Oversight Activities If a state or governmental regulatory body is conducting an investigation, then I am required to disclose PHI upon receipt of a subpoena.
Judicial and Administrative Proceedings If you are involved in a court proceeding and a request is made for information about the professional services I provided you and/or the records thereof, such information is privileged under state law, and will not be released without the written authorization of you or your legally appointed representative 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 If you communicate an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim(s) and it is believed you have the intent and ability to carry out such a threat, we have a duty to take reasonable precautions to prevent the harm from occurring, including disclosing information to the potential victim and the police and in order to initiate hospitalization procedures. If it is believed there is an imminent risk that you will inflict serious harm on yourself, we may disclose information in order to protect you.
Workers Compensation We may disclose PHI as authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
We may disclose your health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials. By law we cannot reveal when we have disclosed such information to the government.
IV. Patients Rights and Analysts Duties
Patients Rights:
Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are 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 seeing a behavior analyst. On your request, we will send correspondence to another address.)
Right to Inspect and Copy You have the right to inspect or obtain a copy (or both) of PHI in my clinical and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process. To inspect your PHI, you will need to make and pay for an appointment during which your behavior analyst is present. If you wish a copy of your PHI, if appropriate, this will be provided for you for the cost of 15 cents per page, paid in advance of receiving the copy.
Right to Amend You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, your behavior analyst 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. On your request, your behavior analyst 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 upon request, even if you have agreed to receive the notice electronically.
Behavior Analysts Duties:
Phoenix Behavior Services, LLC is required by law to maintain the privacy of PHI and to provide you with a notice of their legal duties and privacy practices with respect to PHI.
Phoenix Behavior Services, LLC reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, we are required to abide by the terms currently in effect.
If Phoenix Behavior Services, LLC revises these policies and procedures, you will be notified by mail.
V. Complaints
If you are concerned that Phoenix Behavior Services, LLC has violated your privacy rights, or you disagree with a decision made about access to your records, you may contact Leslie Case, Ph.D. at (727) 736-3496.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services at 200Independence Ave., S.W.; Washington, D.C. 20201.
VI. Effective Date
This notice is in effect as of April 27, 2004.
Updated December 22, 2008, to include provisions related to Patriot Act.
Consumer Grievance Policy
If you have a complaint or grievance about your behavior analyst or their services, you should discuss your concerns with your behavior analyst. If, following this discussion, you continue to feel you have a legitimate concern, you may file a grievance in writing. This written grievance must be filed within ninety (90) days from the date of the occurrence.
You may submit your grievance by mail to the CEO of Phoenix Behavior Services for response, at the following address: Leslie Case, Phoenix Behavior Services, LLC, 1944 Ridgewood Drive, Clearwater, FL 33763. Your behavior analysis services will not be interrupted during the resolution of a grievance.
Upon receipt of the grievance, the CEO will respond both verbally and in writing, within ninety (90) days.
Initial Intake Packet
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