Advantage Mental health center
NOTICE OF PRIVACY PRACTICES
This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you would like a copy, please ask the receptionist.
I. Introduction. Advantage Mental Health Center (“we” or “us”) is required by both federal law (HIPAA) and state law to maintain the privacy of your Protected Health Information. This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information. “Protected Health Information” or “PHI” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
II. Your Health Information Rights.
Under the HIPAA Privacy Rule (45 CFR Part 160 and Part 164) you have the following rights:
- Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Protected Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to the Privacy Officer at the address set forth at the beginning of this Notice. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
- Out-of-Pocket-Payments. If you paid out-of-pocket in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
- Right to Copy of this Notice. You have the right to obtain a paper copy of this Notice of Privacy Practices upon request.
- Right to Inspect and Copy. You have the right to inspect and obtain a copy of your Protected Health Information maintained by us. If we maintain your PHI in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your medical information in the form or format you request, if it is readily producible in such form or format. If your medical information is not readily producible in the form or format you request your medical information will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for copying and transmitting a paper copy of your PHI and for transmitting your PHI in electronic format.
- Right to an Accounting of Disclosures. You have the right to obtain an accounting of certain disclosures of your Protected Health Information (not including routine disclosures for treatment, payment or healthcare operations, unless we maintain your PHI in an electronic health record). If we maintain your PHI in an electronic health record, then we must provide you with routine disclosures of PHI, including disclosures of treatment, payment or healthcare operations, for the 3-year period prior to the date of the request.
- Right to Request an Amendment to Your Medical Record. If you believe medical information that may be used to make decisions about your care is incorrect or incomplete, you may ask us to amend the information. This request must be in writing. Your request must include a reason for the amendment. If we agree to your request, we will amend your medical information as requested. We may also agree to make some changes you ask for but not others. We may deny your request if we believe the records are complete and accurate, if the records were not created by us and the creator of the record is available, or if the records are otherwise not subject to patient access. We will put any denial in writing and explain our reasons for the denial. You have the right to respond in writing to our explanation of denial, and to require that your request, our denial, and your statement of disagreement, if any, be included in future disclosures of the disputed record.
- Right to Request Confidential Communications. You have the right to request that we communicate with you about your PHI in a certain way or at a certain location. For example, you can ask that we only contact you at home, at work, or by mail. To request alternative communications of your PHI, you must submit your request in writing to the Privacy Officer identified in this Notice.
- Right to Receive Notice of a Breach. You have the right to be notified in the event of a breach of any of your unsecured Protected Health Information.
- Right to Revoke Specific Authorizations. You have the right to revoke any authorization that you have provided to us that permits us to use or disclose Protected Health Information except to the extent that action has already been taken in reliance upon that authorization.
III. Our Responsibilities. Advantage Mental Health Center is required to:
- maintain the privacy of your Protected Health Information.
- provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
- abide by the terms of this notice.
- notify you if we are unable to agree to a requested restriction.
- accommodate reasonable requests you may have to communicate PHI by alternative means or at alternative locations.
- notify you in writing if the confidentiality of your PHI has been breached. A breach occurs when there is an unauthorized use or disclosure that compromises the privacy or security of your PHI.
We reserve the right to change our practices and to make the new provisions effective for all Protected Health Information we maintain. Should our information practices change, we will provide you with a revised notice at the time of your next appointment.
We will not use or disclose your PHI without your authorization, except as described in this notice.
V. Examples of How We Will Use or Disclose Your Protected Health Information. Your Protected Health Information may be used and disclosed by members of our staff and others outside of our office that are involved in your care and treatment for the purpose of providing services to you. Your Protected Health Information may also be used and disclosed to enable us to be paid for the services we render to you.
Following are examples of the types of uses and disclosures of your protected health care information that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our Practice.
Treatment: We will use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your Protected Health Information. For example, to ensure continuity of care, we may disclose your Protected Health Information, as necessary, to your primary care physician or other medical providers.
Payment: Your Protected Health Information will be used, as needed, to obtain payment for services that we provide to you. This may include certain activities that your health plan may undertake before it approves or pays for the services we recommend for you. For example, some health plans must make a determination that you are eligible for reimbursement for particular services before we can provide them to you and we must provide them with your Protected Health Information to enable them to make such a determination.
Healthcare Operations: We may use or disclose, as-needed, your Protected Health Information in order to support our own business activities. These activities include, but are not limited to, quality assessment activities, training and supervision of staff members, licensing, certification and conducting or arranging for other business activities. We will share your Protected Health Information with third party “business associates” that perform various activities that are essential to the operations of our practice. Whenever we have an arrangement between our organization and a business associate, we will limit the amount of Protected Health Information that we provide to the minimum necessary to accomplish the particular task and we will have a written contract that contains terms that will protect the privacy of your PHI.
We may use or disclose your Protected Health Information, as necessary, to provide you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
V. Uses and Disclosures That We May Make Unless You Object. In the following situations, we may disclose your Protected Health Information if we inform you about the disclosure in advance and you do not object.
Notification. Upon request, we may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition.
Communication with family or other caregiver: Staff members may disclose to a family member, other relative, close personal friend or any other person you authorize in writing, PHI relevant to that person’s involvement in your care or payment related to your care.
If you are present for, or otherwise available prior to, a notification or communication with family or another caregiver, and you have the capacity to make health care decisions, we may make the disclosure if you agree; or if we provide you with the opportunity to object and you do not object; or we reasonably infer from the circumstances that you do not object. If you are not present for the notification or disclosure, or the opportunity to agree or object cannot be provided because of your incapacity or an emergency circumstance, we may determine whether the disclosure is in your best interest and, if so, we may disclose to the designated person only that information that is directly relevant to the person’s involvement with your health care.
VI. Uses and Disclosures Not Requiring Your Authorization. The federal privacy rules provide that we may use or disclose your Protected Health Information without your authorization in the following circumstances:
Food and Drug Administration (FDA): We may disclose to the FDA Protected Health Information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Worker’s compensation: We may disclose PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
Public health: As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Correctional institution: Should you be an inmate of a correctional institution we may disclose to the institution or agents thereof PHI necessary for your health and the health and safety of other individuals.
Law enforcement: We may disclose PHI for law enforcement purposes as required by law or in response to a valid search warrant or court order.
Criminal Activity: We may disclose your Protected Health Information if we believe that it constitutes evidence of criminal conduct that occurred on our premises. We may also disclose your Protected Health Information if we are required by applicable state law to report suspected child abuse or neglect or abuse of incapacitated adults or an injury that we believe may have been the result of an illegal act. We may also disclose Protected Health Information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Legal Proceedings: We may disclose Protected Health Information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and, in certain situations, in response to a subpoena, discovery request or other lawful process.
Relating to Decedents: We may disclose Protected Health Information regarding an individual’s death to coroners, medical examiners or funeral directors consistent with applicable law.
As Required By Law: We may use or disclose your Protected Health Information to the extent that the use or disclosure is required by state or federal law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. For example, we must make disclosures when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the federal Privacy Rules.
VII. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your Protected Health Information will be made only with your written authorization, unless otherwise permitted or required by law as described in this Notice. You may revoke this authorization, at any time, in writing, except to the extent that we have already relied upon your authorization in making a disclosure.
VIII. For More Information or to Report Complaints
If you wish to exercise any of the rights listed in Section II of this Notice, or if you have questions and would like additional information you may contact our Privacy Officer either in writing or by phone at Advantage Mental Health Center, 28465 US Highway 19 North, Suite 200, Clearwater, FL 33761. 727-600-8093
If you believe that your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the Secretary of the United States Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201. We will not retaliate against you for filing a complaint.
This notice was published and became effective on September 4, 2018 (this document replaces the previous Notice of Privacy Practices provided to all current patients).
Receipt of Notice of Privacy Practices
I have received the Notice of Privacy Practices of Advantage Mental Health Center and acknowledge that I may have a printed version of the Notice if I wish. I understand the Privacy Practices and have been able to ask questions about them.
Signature (client, parent/guardian, responsible party)
Print Name of Signature