NOTICE OF PRIVACY PRACTICES
As required by the Health Insurance Portability and Accountability Act (HIPAA)
Effective date: March 25, 2007
This Notice describes how medical and other information about you may be used and disclosed and how you can get access to this information. Please read it carefully.
The privacy and confidentiality of your health information is very important, and I am committed to protecting it to the extent that I can, consistent with federal and state laws and ethics of the counseling profession. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow me, Angel L. DeVoe, LMHC to use and disclose your health information for these purposes.
TREATMENT The counseling office of Angel L. DeVoe, LMHC may need to use or disclose health information about you to provide, manage or coordinate your care or related services, which could include consultants and potential referral sources.
PAYMENT As applicable, information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. Angel L. DeVoe, LMHC may bill the person in your family who pays for your insurance.
HEALTHCARE OPERATIONS Information about you may be used to review Angel L. DeVoe’s treatment procedures and business activity. Information may be used for certification, compliance and licensing activities.
OTHER USES OR DISCLOSURES OF YOUR INFORMATION THAT DOES NOT REQUIRE YOUR CONSENT: The Department of Health and Human Services requires me, as a licensed mental health counselor in Florida, to list specific situations in which one’s personal information might be released. Thus, your verbal communication and clinical records are strictly confidential except for:
a) Abuse or Neglect - to report suspected abuse, neglect, or exploitation of any child or vulnerable adult; in these cases, I am required by Florida State Law to report this to the Florida Abuse Registry, 1-800-96-ABUSE
b) Communication with Insurance Companies – if I work with your insurance company and you decide to use your insurance, then I will need to communicate with your insurance provider
c) Harm to Self or Others - if you provide information that informs me that you are in danger of harming yourself or others
d) Supervision and Consultation - information necessary for case supervision or consultation
e) Appointments – for appointment reminders or notification when an appointment
must be cancelled or rescheduled
f) Emergency Treatment – when you need medical care in a crisis
g) Health and Safety – to prevent or reduce a serious threat to someone’s health or safety
h) Oversight – when my office is reviewed by licensing and accreditation agencies or auditors
i) Legal Proceedings – in response to court orders and other legal actions
j) Government – when it is necessary to release information to government regulatory agencies, including national security and intelligence agencies
k) Law Enforcement – if you are missing or in danger. Law enforcement may have access to your information for legal or civil proceedings and if a crime is committed at the counseling office.
l) Required by law – at other times when the law requires releasing information
m) Public Health – to report diseases, drug reactions or other public health concerns
n) Workers’ Compensation – to process a Workers’ Compensation claim
NOTE: If I need to share personal information about you for other reasons, I will ask you to sign an Authorization Form to give your approval. This will tell you what information needs to be shared, who will receive the information, and why. Your approval stands until the date stated on the form. If you change
your mind about sharing the information, tell me in writing and I will no longer share the information.
Right to request how I contact you
I’ll normally communicate with you at your preferred number or the number you gave when you scheduled your appointment. Sometimes I may leave voicemail messages. You have the right to request that I communicate with you differently. May I contact you at home yes no? May I contact you at work yes no?. May I contact you by cell phone yes no? Specify the preferred number to contact you___________ May I leave a voicemail on this number yes no? Are there any numbers in which I may not leave a voicemail yes no; if yes, which number may I not leave a voicemail message:_____________
Right to release your counseling record
You may consent in writing to release your records to others. You have the right to revoke this authorization, in writing, at any time. However, a revocation is not valid to the extent that I acted in reliance on such authorization.
Right to inspect and copy your counseling and billing records
You have the right to inspect and obtain a copy of your information contained in the counseling record. You also may request access to your billing or health information. I may charge a reasonable fee for the costs of copying, mailing and supplies.
Right to add information or amend your counseling record
If you feel information contained in your record is incorrect or incomplete, you may ask to add information to amend the record. Your counselor will make a decision on your request w/in 60 days, or some cases w/in 90 days. Under certain circumstances, your request may be denied. If your request is denied, you have a right to file a statement that you disagree. Your statement and your counselor’s response will be added to your record. To request an amendment, you must contact your counselor. You must submit your request in writing & provide an explanation concerning the reason for your request.
Right to an accounting of disclosures
You may request an accounting of any disclosures, if any, that have been made related to your medical information, except for information used for treatment, payment, or health care operational purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information your counselor was required to release.
Right to request restrictions on uses and disclosures of your health information
You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to your counselor. However, your counselor is not required to agree to such a request.
Right to complain
If you believe your privacy rights have been violated, please contact your counselor personally, and discuss your concerns. If you are not satisfied, you may file a written complaint with the U.S. Department of Health and Human Services. An individual will not be retaliated against for filing such a complaint.
Right to receive changes in policy
You have the right to receive any future policy changes secondary to changes in state and federal laws. This can be obtained from your counselor.