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.