Hipaa Form

Notice of Psychologists' Policies & Private Practices to Protect the Privacy of Your Health Information

This notice describes how psychological and medical information about you may be used and disclosed and how you Can get access to this information. Please review it carefully.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

II. Uses and Disclosures Requiring Authorization

III. Uses and Disclosures with Neither Consent nor Authorization

IV. Patient’s Right and Psychologist’s Duties

V. Complaints

VI. Effective Date, Restrictions and Changes to Private Policy

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

David B. Miller, Psy.D., P.A. may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify  these terms, here are some definitions:

“PHI” refers to information in your health record that could identify you.

"Treatment, Payment and Health Care Operations"

Treatment is when David B. Miller, Psy.D., P.A. provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when David B. Miller, Psy.D., P.A. consults with another health care provider, such as your family physician or another psychologist. Payment is when David B. Miller, Psy.D., P.A. obtains reimbursement for your healthcare.
Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, businessrelated matters such as audits and administrative services, and case management and care coordination.

“Use” applies only to activities within my practice group, such as sharing, employing, utilizing, examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of my practice group. Such as releasing, transferring, or
providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

David B. Miller, Psy.D., P.A. may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when David B. Miller, Psy.D., P.A. is asked for information for purposes outside of
treatment, payment and health care operation, we will obtain an authorization from you before releasing your psychotherapy notes. “Psychotherapy notes” are notes that I have made about our conversation during a private, group, joint, or family counseling session, which David B. Miller, Psy.D., P.A. has kept separate from the rest of your medical record. These notes are given a greater
degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each
revocation in in writing. You may not revoke an authorization to the extent that (1) David B. Miller,
Psy.D., P.A. have relied on that authorization; or (2) if the authorization was obtained as a condition
of obtaining insurance coverage, and the law provides the insurer to the right to contest the claim
under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances.

Child Abuse: If David B. Miller, Psy.D., P.A. knows or has 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 David B. Miller, Psy.D., P.A. knows or has reasonable cause to suspect, that a vulnerable adult (disabled or elderly) has been or is being abused, neglected, or exploited, David B. Miller, Psy.D., P.A. are required by law to immediately report such suspicion to the Central Abuse Hotline.

Health Oversight: If a complaint is filed against David B. Miller, Psy.D., P.A. 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 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.

Serous Threat to Health or Safety: When you present a clear and immediate probability of physical harm to yourself, to other individuals, or to society, David B. Miller, Psy.D., P.A. 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, David B. Miller, Psy.D., P.A. 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 person.

IV. Patient's Right and Psychologist's Duties
Patient's Rights:

Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, David B. Miller, Psy.D., P.A. is 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 being seen. Upon your request, David B. Miller, Psy.D., P.A. will send your bills to another location).

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. David B. Miller, Psy.D., P.A. may deny your request. On your request, David B. Miller, Psy.D., P.A. 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, David B. Miller, Psy.D., P.A. 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 David B. Miller, Psy.D., P.A. upon request, even if you have agreed to receive the notice electronically. 

Psychologist's Duties:

David B. Miller, Psy.D., P.A. is 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.

David B. Miller, Psy.D., P.A. reserves the right to change the privacy and practices described in this notice. Unless David B. Miller, Psy.D., P.A. notifies you of such changes, however, David B. Miller, Psy.D., P.A. is required to abide by the terms currently in effect.

If David B. Miller, Psy.D., P.A. revises the policies and procedures, David B. Miller, Psy.D., P.A. will notify you in writing with a revised notice via mail.

If you are concerned that I have violated your privacy rights, or you disagree with a decision David
B. Miller, Psy.D., P.A. has made about access to your records, you may contact the Security of
Department of Health & Human Services.
VI. Effective Date, Restrictions and Changes to Private Policy
This notice will go into effect on

V. Complaints

If you are concerned that I have violated your privacy rights, or you disagree with a decision David B. Miller, Psy.D., P.A. has made about access to your records, you may contact the Security of Department of Health & Human Services.

VI. Effective Date, Restrictions and Changes to Private Policy

HIPAA FORM

Notice of Psychologists' Policies & Private Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
  • David B. Miller, PSY.D., P.A.
    Diplomate, American Board of Professional Pyschology
    Board Certified, American Board and Academy of Psychoanalysis
    LIcensed Psychologist FL & CA
    Practice of Clinical Psychology and Contemporary Psychoanalysis
    Boca Regional Hospital Physician #2076
    5295 Town Center Road, Suite 401
    Boca Raton, FL 33486
    (561) 362-3739
    www.drdavidbmiller.com

  • This notice will go into effect on
  • David B. Miller, Psy.D., P.A. reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that the office maintains. David B. Miller, Psy.D., P.A. will provide you with a revised notice by mail.
  • MM slash DD slash YYYY

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