Siegel Counseling Services
5900 SW 73rd Street, Suite 207 South Miami, FL 33143
NOTICE OF PRIVACY PRACTICES
Effective April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFROMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THISINFORMATION.
PLEASE REVIEW IT CAREFULLY
If you have any questions about this privacy Notice, please contact Dr.Sammi L.Siegel,the Privacy Officer at 5900 SW 73rdStreet, Suite 207, South Miami, FL 33143, (305)613-1101.
This Notice of Privacy practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice describes how I may use and give out disclose” your 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 in some cases.
Treatment – I may use and disclose health information about you for the purposes of coordinating your health care. For example, I may need to disclose information to a case managed care organization who is responsible for coordinating your care.
Payment – I may use and disclose health information about you so that the services you receive can be properly billed and paid. For example, I may disclose your health information to permit your health plan to take certain actions before your health plan approves or pays for you services.
Operations – I may use or disclose health information about you, as necessary, so that I can operate the health plan and provide quality care to you. For example, I may use health information about you to review the quality of services you receive.
Other Uses and Disclosures – As part of treatment, payment and health care operations, I may also use or disclose health information about you so that I can send you health care service reminders and/or newsletters.
Federal privacy rules allow me to use or disclose your protected health information without your per
mission or authorization for a number of reasons. These reasons include the following:
When Required by Law – I will disclose health information about you when I am required to do so by law.
When There Are Risks to Public Health – For example, I may disclose your health information to prevent, control, or report a disease.
To Report Abuse, Neglect or Domestic Violence – I may notify government authorities if I believe that a patient is the victim of abuse, neglect, or domestic violence.
To Conduct Health Oversight Activities – I may disclose your health information to a health oversight agency for activities such as audits or inspections.
In Connection With Judicial and Administrative Proceedings – I may disclose your health information in the course of any judicial or administrative proceedings in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a signed authorization.
For Law Enforcement Purposes – I may disclose your health information for law enforcement officials for law enforcement purposes (such as providing information to locate a missing person).
Coroners, Funeral Directors and for Organ Donation – I may disclose your health information to a coroner, funeral director or for organ donation purposes.
For Research Purposes – I may use or disclose your health information for research under limited circumstances.
In The Event of a Serious Threat to Health or Safety – I may use or disclose your health information if I believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health or safety of the public.
For Specified Government Functions – In certain circumstances, the Federal regulations authorize me to use or disclose your health information to facilitate specified government functions such as functions relating to national security.
For Worker’s Compensation – I may release your health information to comply with worker’s compensation laws or similar programs.
Family Members – Unless you object, or I can infer from the circumstances that you do
not object, I may disclose your protected health information to your family member or a
close personal friend if it is directly relevant to the person’s involvement in your care or
payment related to your care. I can also disclose your information in connection with
trying to locate or notify family members or others involved in your care.
Authorization – Other than as stated above, I will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that I have taken action in reliance up the authorization.
Your Right to Inspect and Copy – You may request the right to inspect and get copies of your health information. To inspect and copy your health information, you must submit a written request to the Privacy Officer, whose contact information is listed on the first page of this Notice. I can deny your request for certain limited reasons, but I must give you a written reason for denial. I may charge a fee for copying records.
Your Right to Request a Restriction on Uses and Disclosures of Your Protected Health Information –You may ask me not to use or disclose certain parts of your health information for the purposes of treatment, payment or health care operations. I am not required to agree to a restriction. You may request a restriction by contacting the Privacy Officer.
Your Right to Request Confidential Communications – You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I will accommodate reasonable requests only if you notify me that disclosure of the health information could put you in danger. Requests must be made in writing to our Privacy Officer. This written request must also contain a statement that disclosure of the information could endanger you.
Your Right To Mend – If you feel that the information I have about you is incorrect or incomplete you may request that we amend your information. If I deny your request, I must give you a written reason for my denial. Requests must be made in writing to my Privacy Officer. In this written request, you must also provide a reason to support the requested amendments.
Your Right to a List of Disclosures – You have the right to request a listing of certain disclosures of your health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. I am also not required to account for disclosers that you requested, discloses that you agreed to by signing an authorization form and certain other disclosures that I am permitted to make without your authori
zation. The request for a listing must be made in writing to our Privacy Officer. I am not required to provide a listing of disclosures that took place prior to April 14, 2003. I will provide the first listing
that you request during any 12-month period without charge. Subsequent requests may be subject to a reasonable cost-based fee.
Your Right to a Copy of This Notice – You have the right to receive an additional copy of the Notice at any time. Even if you have already received a copy of the Notice or have agreed to accept this Notice electronically, you are still entitled to a paper copy of this Notice. Please call or write to the privacy Officer, whose contact information is listed on the first page of this Notice, to request a copy.
How To Use Your Rights Under This Notice – For any of the above requests that must be made in writing, I will help you prepare the written request if you need assistance. For assistance with a written and for oral requests, please call the privacy Officer, whose contact in formation is listed on the first page of this Notice. Written requests can be sent to the Privacy Officer at the address listed on the first page of this Notice.
My Duties – I am required by law to maintain the privacy of health information and to provide you with this Notice of my duties and privacy practices. I am required to abide by the terms of this Notice as may be amended from time to time. I reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that I maintain. If I make any major changes to my Notice, you will receive a copy of the new Notice within 60 days of the major changes.
Complaints – If you believe your privacy rights have been violated, you have the right to complain to me. You may complain to me by contacting my Privacy Officer verbally or in writing. I encourage you to express any concerns you may have regarding the privacy of your information to me. You will not to retaliated against in any way for filing a complaint. You also have the right to complain to the Secretary of the Department of Health and Human Services, whose contact information is listed below.
Contact Person – My contact person for all issues regarding the privacy of your health information is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. Complaints against me can be mailed to the Privacy Officer by sending it to the address listed on the first page of this Notice.
Secretary of the U.S. Department of Health and Human Services
200 Independence Avenue S.W.
Washington, DC 20201
Toll-free phone number: 1-877-696-6775