Notice of Privacy Practices

This notice pertains to the independent practice of Jeffrey Gedney, Psy.D. It describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully.

Uses and disclosures for Treatment, Payment and Operations (TPO)

I may use or disclose your protected health information (PHI; information in your health record that could identify you) for the purpose of providing and planning treatment, obtaining payment and to conduct operations of my practice, with your consent as specified in the Patient Contract.

Uses and Disclosures of Your Protected Health Information

Uses and Disclosure Requiring Your Authorization

- In special instances I may be asked to provide specific information to others. For example, it may be important to communicate treatment progress with your primary care physician. In such instances I will obtain your written authorization before releasing this information. Also, I will need to obtain an authorization before releasing Psychotherapy Notes. “Psychotherapy Notes” include notes made about analyses of conversations during a private, group, joint or family counseling session, which would be kept separate from the rest of your medical record. However, note that it is my office policy not to keep “Psychotherapy Notes,” as thus defined. Instead, I maintain Progress Notes which document your care. These include diagnosis and relevant treatment information, symptoms complaints and information about treatment plans and progress. Progress Notes are routinely disclosed to insurance companies for the purpose of TPO.

- You may revoke authorizations for the release of PHI at any time, in writing. However, you may not revoke an authorization if I have already relied on it for TPO or insurance coverage.

Uses and Disclosures Not Requiring Your Authorization

Some PHI can be disclosed without your written authorization as allowed by law. Those circumstances include:

1. For Safety and Health:

- Child Abuse: If I 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 I 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.

- 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.

- 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 your confidential mental health information, relevant to that complaint.

2. For Legal Purposes:

- Litigation: If you have a pending personal injury claims such as auto accident, malpractice claim or other situations in which you are eligible to collect damages, your entire records may be subject to disclosure by subpoena or court order and are subject to full disclosure to the payor of any claims I file for services on your behalf. You may object, in writing, to a subpoena for such records. In the case of an Independent Medical Examination which is being conducted on behalf of a third party, any information is subject to disclosure to that third party. However, you may have additional rights under State law.

- Court Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis, treatment or records, such information is protectected under state law. I will not release this information unless: 1) you or your legal representative provide authorization, 2) a subpoena is filed, of which you have been properly notified and you have not indicated to me that you are opposing the subpoena, or 3) as ordered by the court. This protection does not apply when you are being evaluated for a third party (for example a disability determination), or where the evaluation is court ordered. You will be informed in advance if this is the case.

- Worker’s Compensation: If you file a worker’s compensation claim your employer, the insurance carrier, an authorized qualified rehabilitation provider, or the attorney for the employer or insurance carrier may request from me records relevant to the claim.

- Forensic Evaluation at the Request of Your Attorney: In most circumstances, such evaluations if arranged for and paid through your attorney’s office retain a special status of attorney-client privilege until such information is disclosed by your attorney or used for legal purposes. Such evaluations are not protected by rights established under HIPAA.

- Government: I may disclose the PHI information of military personnel and veterans to government benefit programs relating to eligibility and enrollment.

- Law Enforcement: I may disclose health information for law enforcement purposes and special governmental functions only as required by Federal, State or Local law.

3. For the Management of Services:

- Business Associates: I have Business Associates with whom I may share your PHI. Examples include those who proved coverage while I are out of town, answering services as necessary or collection agencies/attorneys. I enter into agreements with such associates such that they are also obligated to respect the privacy of you PHI.

- Communication with Family: If a family member or close friend calls for scheduling, payment, or changing appointments and in my best judgment I do not believe you would object, I may communicate minimal necessary information to facilitate scheduling, payments and appointments. With your signed consent I may communicate to any other person you identify as participating in your care (example, family members or close friends) minimal necessary health information relevant to that person’s involvement in your care unless you specifically object (rescind your authorization) or in an emergency. Unless you notify me otherwise, I may leave messages on your home phone regarding scheduling or payment.

- Marketing: I may contact you 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.

- Health Research: I may use your PHI to conduct or participate in research studies. In such cases any personal identifying information shall be removed. For example, I may collect outcome data on group treatment approaches or I may use data from you record to conduct a study of coping patterns to pain treatments.

- Correctional Institution: If you are an inmate of a correctional institution, I may disclose to the institution or agents there of your PHI necessary for your health and the health and safety of other individuals.

Patient’s Rights

- You have the right to restrict the use and disclosure of your PHI to carry out treatment, payment or health care operations. You may also limit disclosure to individual involved with your care, however I am not required to agree to the restriction.

- You have the right be assured that your information will be kept confidential. You may 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 your are seeing me. Upon your request, I will send your bills to another address.

- You have the right to request an amendment of PHI for as long as the PHI is maintained in the record, however there are instances in which I may deny this request.

- 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 a long as the PHI is maintained in the record.

- You generally have the right to receive a summary of certain disclosures of PHI regarding you. On your request I will discuss with you the details of the process.

- You have the right to receive a paper copy and/or an electronic copy of this notice.

I reserve the right to bill for professional time involved in explaining or reviewing these procedures with you, however this is unusual and such billing will be discussed and agreed upon in advance.

Psychologist’s Duties

- I am required by law to maintain the privacy of PHI and to provide you with a notice of this duty 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 notify returning patients upon their first visit following the change.

Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to you records, or have other concerns or complaints about your privacy rights, or feel that your rights have been violated, please feel free to contact me at (352) 339-4008 to discuss your concerns. You may also send a written complaint to the Department of Health’s Inspector General at 4052 Bald Cypress Way, BIN A03, Tallahassee, FL 32399-1704, telephone 850-245-4141 and with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue S.W. ,Washington, D.C. 20201, telephone 202-619-0257. The complaint must describe the acts or omissions that you believe violate your privacy rights, and be filed within 180 days of when you knew or should have known that the act or omission occurred.

Effective Date

This Notice of Privacy Practices is effective beginning January 1, 2003, and shall be in effect until a new Notice of Privacy Practices is posted.