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Patient Forms – Privacy Policy

PLEASE NOTE:

You must read and accept the terms of our privacy policy prior to accessing the client forms on this web site.

NOTICE OF PRIVACY PRACTICES FOR
PROTECTED HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Effective date: September 23, 2013


YOUR PRIVACY RIGHTS HAVE BEEN INCREASED.

You now have the right to restrict certain disclosures of Protected Health Information (PHI) by CPC to your insurance carrier or health plan.

Without this restriction your insurance company or other payer may access your entire record. To exercise this right you must choose to pay out-of-pocket in full. To exercise this right, simply talk to your doctor. You may be surprised by how little this costs.


If you consent, the provider is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, test results, diagnosis, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes are:

An example of use of your health information for payment purposes:

An example of use of your health information for health care operations:


YOUR HEALTH INFORMATION RIGHTS:

The health record and billing records we maintain are the physical property of this office. The information in it, however, belongs to you. You have a right to:

You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and health care operations purposes.

If you want to exercise any of the above rights, please contact: Michael Spellman at 941-753-0064, in person, or in writing, during normal business hours. He will provide you with assistance on the steps to take to exercise your rights.

OUR RESPONSIBILITIES:

The provider is required to:

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice to reflect these changes. You are entitled to receive a revised copy of the Notice by calling or requesting a copy of our Notice or by visiting the office to obtain a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the following person: Michael Spellman at 941-753-0064 You may also file a complaint by mailing or e-mailing it to the Secretary of Health and Human Services at 202-619-0257 We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from our office. We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

Other Uses and Disclosures

Notification
Unless you object in writing, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other persons responsible for your care including any doctor who you inform us is involved in your care, about your location, about your general condition, about your diagnosis and treatment or your death.

Communication with Family
Unless you object in writing we may discuss scheduling and billing with your family member. Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.

Disaster Relief
We may use and disclose your protected health information to assist in disaster relief efforts.

Funeral Directors/Coroners
We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Marketing
Unless you object in writing we e may contact you via mail, email, or phone to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits or services that may be of interest to you.

Fund Raising
Unless you opt-out or object in writing, we may contact you as part of a fund raising effort.

Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health
As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse and Neglect
We may disclose your protected health information to public authorities as allowed or required by law to report abuse or neglect.
Correctional Institutions If you are an inmate of a correctional institution, we may disclose to the institution or agents there of your protected health information necessary for your health and the health and safety of other individuals.

Law enforcement
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health oversight
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, or as directed by a proper court order. To avert a serious threat or health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions
We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Other uses
Other uses and disclosures in addition to those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke that authorization as previously stated.

CPC facilities do make use of Skype, security cameras and other audio and video technologies. Unless you object in writing you are agreeing to permit the use of such technologies.

Website
We may maintain a website that provides information about our business. This Notice is on this website at www.carterpsych.com.

Please submit form below. Upon your agreement with our Privacy Policy, you will then be given access to the Patient Forms. Thank you!

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