Tampa Psychology

Brian Nussbaum, Psy.D.

tampapsychology.com

brian@tampapsychology.com

(813) 545-7754

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.

Uses & Disclosures for Treatment, Payment, & Health Care Operations

I may use or disclose the protected health information (PHI) in your record for treatment, payment, & health care operations with your consent. Examples of PHI in your record are your history, reasons you came for treatment or evaluation, diagnosis, treatment plan, progress notes, other health care providers' records, test scores & school records, medication information, legal matters, & billing/insurance information. Treatment is when I provide or manage your health care with another health care provider. Payment is when I obtain reimbursement for your healthcare by inquiring about eligibility for insurance or receiving insurance reimbursement Health Care Operations are activities that relate to the operation of my practice.

Uses and Disclosures Requiring Your Authorization

I may use your PHI for purposes outside of treatment, payment, and health care operations only when I obtain a written authorization from you that permits specific disclosures to specific individuals. You may revoke such an authorization at any time in writing. You may not revoke an authorization if have relied on that authorization to already release information or if the authorization was obtained as a condition of obtaining insurance coverage, and the law allows the insurer to contest an insurance claim.

Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose your PHI without your consent or authorization in the following situations:

Child Abuse: If know. or have reasonable cause to suspect. that a child is abused, abandoned, or neglected by a parent legal custodian, caregiver or other person responsible for the child's welfare, the law requires that I report such knowledge or suspicion to the Florida Department of Child and Family Services.

Adult and Domestic Abuse: If know, or have reasonable cause to suspect, that a vulnerable adult (disabled or elderly) has been or is being abused, neglected, or exploited, I am required by law to immediately report such knowledge or suspicion to the Central Abuse Hotline.

Health Oversight: If a complaint is filed against me with the Florida Department of Health on behalf of the Board of Psychology, the Department has the authority to subpoena confidential mental health information from me 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 I 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 me that you are opposing the subpoena or a court order. The privilege does not apply when you 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 of physical harm to yourself, to other individuals, or to society. I 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, I 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.

There may be additional disclosures of PHI that I am required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.

Patient's Rights & Psychologist's Duties

You have the right to:

Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am 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 communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. 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 my 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, I will discuss with you the details of the request process.

Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I 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 I will discuss with you the details of the accounting process.

Right to a Paper Copy - You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Psychologist's Duties:

I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

If I revise my policies and procedures, I will send you a copy of the change.

Questions & Complaints

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 directly by phone (813) 545-7754 or discuss this during your appointment time. If you believe that your privacy rights have been violated and wish to file a complaint with me/my office, you may send your written complaint addressed to me at Brian@tampapsychology.com. 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. I will not retaliate against you for exercising your right to file a complaint.

Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on the date that you sign the client services agreement. I will limit the uses or disclosures that I will make as follows:

It is my general policy not to release information about sessions involving other parties without the consent of each individual involved. This would include family sessions, couple or marital sessions, parent sessions or sessions where you are not present.

I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by emailing the revisions to you. In the future, I may modify the Notice of Privacy Practices. You may obtain a copy of the latest revision from this office at 813-545-7754 or on my website at www.tampapsychology.com.