HIPAA NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION
Effective date: April 10, 2003
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.  

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 employee of the provider's office obtains treatment information about you and records it in a health record.
•   During the course of your treatment, the provider determines that he/she will need to consult with another specialist in the area. He/she will share the information with such specialists and obtain his/her input.

An example of use of your health information for payment purposes:
We submit a request for payment to your health insurance company.   The health insurance company requests information from us regarding services rendered.  We will provide that information to them about you and the care you receive.

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 B. Spellman, Ph.D., at 239-278-3443 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:
•   Maintain the privacy of your health information as required by law
•   Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you
•   Abide by the terms of this Notice
•   Notify you if we cannot accommodate a requested restriction or request
•   Accommodate yourreasonable requests regarding methods to communicate health information to you.

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.

Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office using the form we provide to you upon request.
Revoke any authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

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 B. Spellman, Ph.D. 239-278-3443. You may also file a complaint by mailing or e-mailing it to the Secretary of Health and Human Services. 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.

We verify insurance coverage prior to your first appointment and obtain prior authorization and precertification when required to do so by your policy coverage.

An example of use of your health information for health care operations:
The state licensing authority wants to review records to assure that we have acted consistent with state law regarding your care. In doing so, it wants to take a sampling that includes review of your chart.   At the licensing authority's request, we will provide it with a copy of your chart.

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:
•    Request a restriction on certain uses and disclosures of your protected health information by delivering the request in writing to our office. We are not required to grant the request, but we will comply with any request granted.
•     Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information by making a request at our office.
•     Request that you be allowed to inspect and receive a copy of your health record and billing record. You may exercise this right by delivering the request in writing to our office using the form we provide to you upon request.
•  Appeal a denial of access to your protected health information except in certain circumstances.
•   Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request
•    File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.
Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form we provide to you upon request. The accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request.

Communication with Family
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.

Other Uses and Disclosures
Unless you explicitly request in writing that we do otherwise we will from time-to-time remind you of your scheduled appointments via e-mail, telephone, and/or voicemail.

We have Business Associates with whom we may share your protected health information.

For example, in preparing our annual financial statement, auditors may need to review samples of medical care given. We may disclose your health information to the accounting firm to prepare this material.

For example, during our routine health care operations, we may need to hire computer technicians and software vendors. We may disclose your health information to these vendors to maintain daily functioning in our health care operations.

Notification
Unless you object, 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, about your location, about your general condition, or your death.

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
Under no circumstances will we sell your personal information for marketing purposes.  We may from time-to-time contact you via email, telephone, and/or voice-mail 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.

Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to com

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.ply with laws relating to Workers Compensation.

Abuse and Neglect
We may disclose your protected health information to public authorities as allowed 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, with your consent, 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.

Website
We may maintain a website that provides information about our business. This Notice is on the website.

I have read, understood, and received a copy of
HIPAA NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION from Michael B. Spellman, Ph.D., PA

Signature of Patient Or Responsible Party:                    

Date: