The law protects the relationship between a client and a psychotherapist and psychiatrist, and information cannot be disclosed without written permission.
Suspected child abuse or dependant adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim. If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in insuring their safety.
If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.
1. Uses and Disclosures for Treatment, Payment and Healthcare Operations Holistic Mental Health Clinic practitioners may use or disclose your Protected Health Information (PHI) for treatment, payment and healthcare operation 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” is when a Holistic Mental Health Clinic practitioner provides, coordinates or manages your healthcare and other services related to your healthcare. An example of treatment would be when a Rehabpros practitioner consults with another healthcare provider, such as your family physician or another psychiatrist, psychologist, licensed mental health professionals, unlicensed mental health professional, mental health intern, State of Florida Department of Education, Division of Vocational Rehabilitation (DVR) Counselors and DVR Support staff or Private agencies providing services to you as part of Vocational Rehabilitation Services. “Payment” is when Holistic Mental Health Clinic obtains reimbursement for your healthcare. Examples of payment are when The Holistic Mental Health Clinic discloses your PHI to your health insurer or other third party payer such as DVR to obtain reimbursement for your healthcare or to determine eligibility or coverage. “Healthcare Operations” are activities that relate to the performance and operation of Holistic Mental Health Clinic practice. Examples of healthcare 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 Holistic Mental Health Clinic office, clinic, practice group, etc, such as sharing, employing, applying, utilizing, examining and analyzing information that identifies you. “Disclosure” applies to activities outside of Rehabpros office, clinic, practice group, etc, such as releasing, transferring or providing access to information about you to other parties.
2. Uses and Disclosures Requiring Authorization Holistic Mental Health Clinic may use or disclose PHI for purposes outside of treatment, payment and healthcare 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 a Holistic Mental Health Clinic practitioner is asked for information for purposes outside of treatment, payment and healthcare operations, Holistic Mental Health Clinic will obtain an authorization from you before releasing this information. Holistic Mental Health Clinic will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes Holistic Mental Health Clinic practitioners have made about your conversations during a private, group, joint or family counseling session. These notes are kept separate from the rest of your medical record because they 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) Holistic Mental Health Clinic has relies 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.
3. Uses and Disclosures with Neither Consent nor Authorization Holistic Mental Health Clinic may use or disclose PHI without your consent or authorization in the following circumstances:
• Child Abuse: If a Holistic Mental Health Clinic practitioner knows or has reasonable cause to suspect that a child is abused, abandoned or neglected by a parent, legal guardian, caregiver or other person responsible for the child’s welfare, the law requires that the Holistic Mental Health Clinic practitioner report such knowledge or suspicion to the Florida Department of Child and Family Services.
• Adult and Domestic Abuse: If a Holistic Mental Health Clinic practitioner knows, or has reasonable cause to suspect that a vulnerable adult (disabled or elderly) had been or is being abused, neglected or exploited, that Holistic Mental Health Clinic practitioner is required by law to immediately report such knowledge or suspicion to the Central Abuse Hotline,
• Health Oversight: If a complaint is filed against a Holistic Mental Health Clinic practitioner with the Florida Department of Health on behalf of the Board of Psychiatry, Psychology or Mental Health Professionals, the Department has the authority to subpoena confidential mental health information from Holistic Mental Health Clinic 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 Holistic Mental Health Clinic 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 Holistic Mental Health Clinic that your 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 or physical harm to yourself, to other individuals, or to society, Holistic Mental Health Clinic practitioners 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, Holistic Mental Health Clinic practitioners 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.
• Vocational Rehabilitation Services: If you are referred though Division of Vocational Rehabilitation Services, Holistic Mental Health Clinic practitioners are required to provide written reports and telephonic consultations with the DVR counselor regarding but not limited to progress in treatment, psychological limitations as they relate to a successful vocational outcome, work readiness and prognosis for return to work.
4. Patient’s Rights and Psychotherapist’s Duties Patient’s Rights:
• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, Holistic Mental Health Clinic practitioners are 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 communication of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing a Holistic Mental Health Clinic practitioner. 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 R Holistic Mental Health Clinic 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, Holistic Mental Health Clinic will discuss with you the details of the request process.
• Right to Amend: You have the right to request an amendment of the PHI for as long as the PHI is maintained in the record. Holistic Mental Health Clinic may deny your request. On your request, a Holistic Mental Health Clinic practitioner 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, a Holistic Mental Health Clinic practitioner will discuss with you the details of the accounting process.
• Right to a Paper Copy: you have a right to obtain a paper copy of the notice from a Holistic Mental Health Clinic practitioner upon request, even if you have agreed to receive the notice electronically.
• Holistic Mental Health Clinic is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI,
• Holistic Mental Health Clinic reserves the right to change the privacy policies and practices described in this notice. Unless Holistic Mental Health Clinic notifies you of such changes, however, Holistic Mental Health Clinic practitioners are required to abide by the terms currently in effect.
• If Holistic Mental Health Clinic revise these policies and procedures you will be notified by mail.
5. Office Policies It is the policy of Holistic Mental Health Clinic to charge for services that are outside the scope of your professional visit.
• Missed Appointments: You will be charged the entire amount of your regular office visit fee if you cancel your appointment with less than 24 hours notice unless an emergency situation occurred. If you are receiving services through DVR your record of participation will be documented to your DVR Counselor.
• Letter/Form Completion: There will be a $40.00 fee for a simple letter, i.e. school, employment, etc, There will be a $60.00 fee for forms completion. There will be a $125.00 fee for large forms/letter/reports, i.e. disability, court, etc.
• Therapeutic Phone Calls: There will be a $10.00 fee for phone consultations from 6 to 14 minutes in length and a $25.00 fee for phone consultations of 15 minutes or longer.
• Photocopying: There will be a charge of $0.50 per page whether it is for copies to be mailed to your attorney, insurance companies for disability, forwarding copies of records to other physicians outside the scope of your treatment. These charges are not covered by insurance companies or DVR and will be the responsibility of the patient.
6. Questions and Complaints If you have questions regarding this notice, disagree with a decision made by a Holistic Mental Health Clinic practitioner about access to your records, or have other concerns about your privacy rights, you may contact Lynn Nelson at 727-510-9616. If you believe that your privacy rights have been violated and wish to file a complaint with Rehabpros office you may send your written complaint to Lynn Nelson c/o Holistic Mental Health Clinic, 6161 Dr. MLK JR Street N Suite 204, St. Petersburg, FL 33703. You may also send a written complaint to the Secretary of the U. S. Department of Health and Human Services. You have specific rights under the Privacy Rule. Holistic Mental Health Clinic, nor any of their practitioners, will retaliate against you for exercising your right to file a complaint.
This notice will go into effect July 27, 2013. Holistic Mental Health Clinic reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that The Holistic Mental Health Clinic maintain. Holistic Mental Health Clinic will provide you with a revised notice by mail if applicable.