I 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:
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.
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 operation, I will obtain an authorization from you before releasing your psychotherapy notes. “Psychotherapy notes” are notes that 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 in 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 to the right to contest the claim under the policy.
I may use or disclose PHI without your consent or authorization in the following circumstances.
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me at (305) 262-0806.
If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to me at 1390 South Dixie Hwy., Suite 1306, Coral Gables, FL 33146.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
This notice will go into effect on April 14, 2003.
I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that the office maintains. I will provide you with a revised notice by mail.