| Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health
and Health Education 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
I may use or disclose your protected health information (PHI), for treatment/education,
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 I provide, coordinate or manage your health care and other
services related to your health care. An example of treatment would be when I consult
with another health care provider, such as your family physician or another
- 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 office, such as sharing, employing,
applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of my office, such as releasing,
transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I 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 I am asked for information for purposes outside
of treatment, payment and health care operations, I will obtain an authorization from
you before releasing this information. I will also need to obtain an authorization before
releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made
about our conversation during a private, group, joint, or family counseling session,
which I have 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 is in writing. You may not revoke an authorization to the
extent that (1) I 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 the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following
• Child Abuse: If I know, or have 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 I know, or have reasonable cause to suspect, that a
vulnerable adult (disabled or elderly) has been or is being abused, neglected, or
exploited, I am required by law to immediately report such knowledge or suspicion to
the Central Abuse Hotline.
• Health Oversight: If a complaint is filed against me 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 of which you have been properly notified and you have failed to inform me
that you are opposing the 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, I 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, I 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.
• Other Times Information May Be Disclosed: When the use and disclosure without
your consent or authorization is allowed under other sections of Section 164.512 of
the Privacy Rule and the state’s confidentiality law. This includes certain narrowly-
defined disclosures to law enforcement agencies, to a health oversight agency (such
as HHS or a state department of health), to a coroner or medical examiner, for public
health purposes relating to disease or FDA-regulated products, or for specialized
government functions such as fitness for military duties, eligibility for VA benefits, and
national security and intelligence.
IV. Patient's Rights and Psychologist's Duties
• Right to Request Restrictions – You have the right to request restrictions on
certain uses and disclosures of protected health information about you. However, I am
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 me. Upon
your request, I will send your bills to another address.)
• 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. I may deny your request. On your request, I 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, I 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 me upon request, even if you have agreed to receive the notice electronically.
You have the right to obtain an electronic copy, but in either case, there is a charge for
• Right to Restrict Discloures to Health Plans: You have the right to restrict certain
disclosures of Protected Health Information (PHI) to a health plan if you pay out-of-
pocket in full for the healthcare service. (This right added in 2013 is discussed in the
Footnote section below, in Footnote 1)
• Right to Be Notified if There is a Breach of Your Unsecured PHI - You have a right
to be notified if: (a) there is a breach (a use or disclosure of your PHI (private health
information) in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has
not been encrypted to government standards; and (c) my risk assessment fails to
determine that there is a low probability that your PHI has been compromised.
• Right to Sign Authorization for Release of PHI - You must sign an authorization
before the psychologist can release your PHI for any uses and disclosures not
described in this Privacy Notice.
• I am 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.
• I reserve the right to change the privacy policies and practices described in this
notice. Unless I notify you of such changes, however, I am required to abide by the
terms currently in effect.
• If I revise my policies and procedures, I shall make every attempt to notify you by
mail, e-mail, or fax, and will post the revisions on my website, www.drjanhartz.com.
If you are concerned that I have violated your privacy rights, or you disagree with a
decision I made about access to your records, you may contact me at the above
You may also send a written complaint to the Secretary of the U.S. Department of
Health and Human Services. I can provide you with the appropriate address upon
This notice will go into effect on April 14, 2003. 2013 revisions added August 26, 2013.
I reserve the right to change the terms of this notice and to make the new notice
provisions effective for all PHI that I maintain. I will provide you with a revised notice
by mail, e-mail, fax, or will give you a written copy in person, or will post the changes
to my website.
Footnote 1: The HIPAA Final Rule provides that patients have a right to restrict certain
disclosures of PHI to a health plan (insurance company) when the patient pays out-of-
pocket in full for the healthcare service or item. HHS has not released guidance as to
what exactly paying out-of-pocket in full means, for
example, does this require that the entire course of treatment be paid for out-of-
pocket, or just an individual session? Until HHS issues further guidance on this point,
the APA recommends resolving any ambiguity in favor of recognizing this patient right.
For example, we suggest that psychologists honor the request if a patient pays out-of-
pocket in full for a particular therapy session and requests that you provide no PHI
regarding that session to his or her insurance company, even if other sessions in the
same course of treatment were paid by insurance. However, Medicare eligible
patients, who are paying out of pocket because of the psychologist’s having opted out
of Medicare, will still have to sign forms, acknowledging they are paying directly for
therapy and cannot file with Medicare or supplemental insurance. Medicare does
have the right to view only this acknowledgment form, which includes the patient’s
name and Medicare number.
Printed Name: ________________________________________________
Date received: _______________________________________
New or revised notice provisions shall be posted on my website: www.drjanhartz.com
Form created: 3/03, revised 3/17/14
Your e-mail address: _______________________________________
Your fax number: _________________________________________
Form created: 9/08, revised 3/17/14
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