Licensed Psychologist |  www.garyhowellpsyd.com  |  
2109 E. Palm Ave., #201 
813.419.PsyD (7793)

Privacy & Confidentiality Policy

Confidentiality & Privacy Policy

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

  • Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
  • If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in insuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.


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, & healthcare 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 permit specific disclosures to specific individuals. You may revoke such an authorization at any time in writing. You may not revoke an authorization if I 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:

   • As required during an investigation by law enforcement agencies
   • In response to legal proceedings
   • To prevent a serious threat to public health or safety

   • To workers’ compensation or similar programs for processing of claims

   • For required disclosures about victims of abuse or neglect
   • When required or otherwise allowed by law


Patient’s Rights & Psychologist’s Duties

You have the right to:

   • Inspect & obtain a copy of the PHI in your chart if you provide me with a written request. I am not 

      required to show or allow you to copy your psychotherapy notes. These are not included in your

      PHI. However, I am required to provide a summary of my psychotherapy notes to you if you

      request these in writing. There may be an associated fee. I am not required by Florida law, unless

      subject to a court order, to release any written information or a report on a minor child to anyone,

      including a parent if, in my opinion, this would not be in the best interest of the child.

   • Request restrictions on uses & disclosures of your PHI. However, I am not required to agree to this

      request.
   • Request confidential communications to be delivered in specified ways. For example, you might

      want to be called at a certain phone number or you might want bills sent to a specific address.

   • Request that your PHI be amended. You can request a change in your PHI after reviewing it.

      However, the law does not require me to make this change if I do not agree with it.
   • Request an accounting of disclosures of your PHI.
   • Request a copy of this notice to take with you.


Psychologist’s Duties:
   • I am required by law to maintain the privacy of your PHI and to provide you with this notice of my

      legal duties and privacy practices regarding PHI. This notice is in effect as of April 14, 2003.
   • I may change these privacy policies & practices. Until such time, however, I am required to follow

      the current policy. Revised policies will be available in my office or by calling 813‐419-7793.


Questions & Complaints

If you believe your privacy rights have been violated, you may file a complaint with me or with the Secretary of Health & Human Services. You will be given a “Violation of Privacy Rights Complaint Form”. Filing a complaint will not affect the services you receive from this office.


ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION


The federal government mandated as of April 14, 2003 that all patients are to receive from their health care providers a Notice regarding the protection of their private healthcare information (PHI). PHI is information that is used for treatment, payment, and health care operations. Your signature below acknowledges that you have reviewed and understood my Notice of Privacy Practices.


The Notice of Privacy Practices contains information about the following:

   • How your PHI may be used and disclosed for treatment, payment, & health care operations.

      (These terms are defined in the Notice.)
   • Which uses & disclosures require authorization from you & which do not
   • How you may revoke an authorization you have made

   • Certain rights you have to restrict use & disclosure of PHI, to receive confidential communications

      by alternative means & at alternative locations, to inspect, copy, and amend your records, & to

      have an accounting of disclosures
   • My duties to protect the privacy of your PHI, my right to change the policies in the Notice, and how

      I will inform you of changes

   • Restrictions you or I might place on the use and disclosure of your PHI
   • How you can file a complaint about suspected violations of your privacy rights or about decisions

      regarding access to your PHI In the future, I may modify the Notice of Privacy Practices. You may

      obtain a copy of the latest revision from this office at 813‐419-7793.