Dr. Kimberly S. Benson
HIPAA Notice of Privacy Practices
(Effective January 1, 2019)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This HIPAA Notice of Privacy Practices (the “Notice”) contains important information regarding your medical information. Our current Notice is posted at www.drkimberlybenson.com. You also have the right to receive a paper copy of this Notice and may ask us to give you a copy of this Notice at any time. If you received this Notice electronically, you are entitled to a paper copy of this Notice. If you have any questions about this Notice please contact the party listed in Part 7, below. The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) imposes numerous requirements on health plans and health care providers regarding how certain individually identifiable health information – known as protected health information or PHI – may be used and disclosed. This Notice describes how Sarasota Addiction Specialists, Inc. (SAS), and any third party that assists SAS, may use and disclose your protected health information for treatment, payment, or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights to access and control your protected health information. “Protected health information” is information that is maintained or transmitted by Dr. Benson, which may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services. We understand that medical information about you and your health is personal. We are committed to protecting medical information about
you and will use it to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request of it. This Notice applies to all of the medical records SAS maintains. Your personal doctor or health care provider may have different policies or notices regarding his/her use and disclosure of your medical information. We are required by law to abide by the terms of this Notice to: •Make sure that medical information that identifies you is kept private. •Give you this Notice of our legal duties and privacy practices with respect to medical information about you. •Follow the terms of the Notice that is currently in effect. 1.HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU HIPAA generally permits use and disclosure of your health information without your permission for purposes of health care treatment, payment activities, and health care operations. These uses and disclosures are more fully described below. Please note that this notice does not list every use or disclosure, instead it gives examples of the most common uses and disclosures. •Treatment: When, and as appropriate, we may use or disclose medical information about you to facilitate medical treatment or services. We may disclose medical information about you to health care providers, including doctors, nurses, technicians or other personnel who are involved in taking care of you. For example, your primary counselor may speak with his/her clinical supervisor in order to seek information regarding your care. Any staff member within SAS will only receive the amount of information he/she needs in order to provide you with services. •Payment: We will disclose health information about you in order to be reimbursed for services we provide to you. This includes determinations of insurance eligibility, coverage, and other utilization
review activities. For example, prior to providing services, we may need to provide your health insurance carrier with information about your condition to determine if your treatment with SAS will be covered. When we submit the bill to your health insurance carrier, we will provide the carrier with information regarding the services that you received. SAS contracts with a variety of agencies, such as Central Florida Behavioral Health Network, Florida’s Department of Children and Families, the U.S. Probation Office, and the Florida Department of Corrections for payment for services provided in some programs. Your information will only be submitted to the appropriate organizations for administrative and payment purposes. •Health Care Operations: When, and as appropriate, we may use and disclose medical information about you for health care operations. Health care operations include all of the support functions that are related to treatment and payment such as quality assurance activities, compliance programs, audits for licensure, contracts and accreditation, business planning, administrative activities, legal services, and fraud and abuse detection programs. For example, staff members working within the Medical Records Department may need to access your information in order to ensure the chart is complete and accurate. Clinical staff members review the charts of other clinical staff members as part of our Quality Improvement Process to ensure that you receive quality care. Your health information may be disclosed to external entities in order for Dr. Benson to remain licensed and accredited. Florida’s Department of Children and Families routinely audits client charts in order to ensure that clients are receiving appropriate care. The Commission on Accreditation of Rehabilitation Facilities (CARF) provides Dr. Benson with national accreditation and part of its accreditation process involves the review of client records. We will always try to ensure that the medical information used or disclosed will
be limited to a “Designated Record Set” and to the “Minimum Necessary” standard, including a “Limited Data Set,” as defined in HIPAA and ARRA (as defined in Part 3, below) for these purposes. We may also contact you to provide information about treatment options or alternatives or other health-related benefits and services that may be of interest to you. OTHER PERMITTED USES AND DISCLOSURES •Disclosure to Others Involved in Your Care: We may disclose medical information about you to a relative, a friend or to any other person you have authorized, provided the information is directly relevant to that person’s involvement with your health care or payment for that care. For example, if a family member or a caregiver calls us with prior knowledge of a claim and asks us to help verify the status of a claim, we may agree to help them confirm whether or not the claim has been received and paid. •Medical Emergency: If you have a medical emergency while on SAS property, or if you are engaged in a SAS authorized/sponsored activity while off-site while you are a client of a SAS residential treatment program, and are unable to provide consent, we may release your information to emergency medical services in order for you to receive emergency medical care. •Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries or illness. •To Comply with Federal and State Requirements: We will disclose medical information about you when required to do so by federal, state or local law. For example, we may disclose medical information, when required by the U.S. Department of Labor or other government agencies that regulate us, to federal, state and local law enforcement officials in response to a judicial order, subpoena or other lawful
process, and to address matters of public interest as required or permitted by law (for example, reporting child abuse and neglect, threats to public health and safety and for national security reasons). We are required to disclose medical information about you to the Secretary of the U.S. Department of Health and Human Services if the Secretary is investigating or determining compliance with HIPAA or to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law. We may disclose your medical information to a health oversight agency for activities authorized by law (such as audits, investigations, inspections and licensure). •To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, we may disclose medical information about you in a proceeding regarding the licensure of a physician. •Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. •Business Associates: We may disclose your medical information to our business associates. We have contracted with entities (defined as “business associates” under HIPAA) to help us administer your benefits. We will enter into contracts with these entities requiring them to only use and disclose your health information as we are permitted to do so under HIPAA. •Appointments and reminders: We may use your information to try to contact you if you miss an appointment or if you have been on a
waiting list for a treatment slot. These contacts may be by telephone. Dr. Benson's actual phone number does not appear on caller ID so no one will know that we tried to contact you. We will not leave a voice mail message with any information that could identify Dr. Benson, unless we have your express permission to do so. •Other Uses: If you are an organ donor, we may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or toan organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. We may release your medical information to a coroner or medical examiner. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your information to the correctional institution or law enforcement official. Authorization Uses and disclosures other than those described in this Notice will require your written authorization. You may revoke your authorization at any time; however you cannot revoke your authorization for disclosures upon which SAS has already acted. The privacy laws of Florida or other federal laws might impose a stricter privacy standard. If these stricter laws apply and are not superseded by federal preemption rules under the Employee Retirement Income Security Act of 1974, then Dr. Benson will comply with the stricter law. Except for the instance described above, SAS will not release any information about you without a written authorization for the specific disclosure. SAS will request a written authorization from you, even if the disclosure is at your request. If you are participating in a treatment program as a requirement of satisfying your responsibility to the criminal justice or family safety systems, you will be asked to sign an authorization form specifically to that entity. If you choose not to provide an authorization, we may decline to provide you with services. Following your
discharge from treatment, we would like to follow-up with you to see how you are doing. Additionally, if your treatment was paid for by the State of Florida (all or in part), the state would like to contact you by telephone so that you may provide feedback about our organization and the care that you received. This information is used to improve the quality of our services, and any information that you provide is treated as confidential information. The Consent to Participate in Follow-up form allows us to keep a record of your willingness to participate in these follow-up opportunities. If you are willing to participate, please sign the form in the space provided in the middle portion of the form. If you do not wish to participate, please check the box at the bottom of the form and in the space available. Your treatment will not be affected by your choice to participate or not to participate. At time of discharge, you will be granted the opportunity to sign-up and receive information regarding alumni organization activities. If you miss this opportunity and would like to be a member of or receive information about alumni organization, please contact Dr. Benson Marketing Coordinator at 941-444.6560. Changes in our Privacy Practices Dr. Benson reserves the right to change its privacy practices. These changes will be applied to all protected health information that Dr. Benson already has about you as well as any information Dr.Benson received on or after the effective date of the change. Dr.Benson will provide you with a revised and updated copy of this notice if our privacy practices materially change. This notice will be provided at your next visit or next appointment with your counselor. 2.YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding medical information we maintain about you:
- Right to Inspect and Copy: You have the right to inspect and obtain a copy of your medical information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Your Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by SAS. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend any of the following information: •Information that is not part of the medical information kept by or for you. •Information that was not created by us, unless the person or entity that created the information is no longer available to make the amendment. •Information that is not part of the information which you would be permitted to inspect and copy. •Information that is accurate and complete. •Psychotherapy notes. •Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. •Your Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures” (i.e., a list of certain disclosures SAS has made of your health information). Generally, you may receive an accounting of disclosures if the disclosure is required by law, made in connection with public health activities, or in similar
situations as those listed above as “Other Permitted Uses and Disclosure’s”. You do not have a right to an accounting of disclosures where such disclosure was made: •For treatment, payment, or health care operations. •To you about your own health information. Incidental to other permitted disclosures. •Where authorization was provided. •To family or friends involved in your care (where disclosure is permitted without authorization). •For national security or intelligence purposes or to correctional institutions or law enforcement officials in certain circumstances. •As part of a limited data set where the information disclosed excludes identifying information. To request this list or accounting of disclosures from a non-electronic health record, you must submit your request which shall state a time period, which may not be longer than six years and may not include dates before January 1, 2019. Your request should indicate in what form you want the list (for example, paper or electronic). Notwithstanding the foregoing, you may request an accounting of disclosures as it pertains to your “electronic health record” (i.e., an electronic record of health-related information on you that is created, gathered, managed and consulted by authorized health care clinicians and staff), provided that you must submit your request and state a time period which may be no longer than three years prior to the date on which the accounting is requested. In the case of any electronic health record created on your behalf as of January 1, 2019, this paragraph shall apply to disclosures made on or after January 1, 2019. In the case of any electronic health record created on your behalf after January 1, 2019, this paragraph shall apply to disclosures made on or after the later of January 1, 2019 or the date SAS acquired the electronic health record. You may request
an accounting of disclosures in paper or electronic format. If a paper format is requested, the first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. If an electronic format is requested, we may charge you for the labor costs in responding to the request. •Your Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery that you had. We are not required to agree to your request. If SAS does agree to a request, a restriction may later be terminated by your written request, by agreement between you and Dr.Benson (including orally), or unilaterally by Dr.Benson for health information created or received after Dr.Benson has notified you that it has removed the restrictions and for emergency treatment. To request restrictions, you must make your request in writing and must tell us the following information: •What information you want to limit. •Whether you want to limit our use, disclosure, or both. •To whom you want the limits to apply (for example, disclosures to your spouse). •Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your
request must specify how or where you wish to be contacted. You must make any of the requests described above, to the party listed in Part 7, below. 3.BREACH NOTIFICATION Pursuant to changes to HIPAA mandated by the Health Information Technology for Economic and Clinical Health Act of 2009 and the regulations promulgated thereunder (collectively, “the HITECH Act”) under the American Recovery and Reinvestment Act of 2009 (“ARRA”), this Notice also reflects new federal breach notification requirements imposed on SAS in the event that your “unsecured” protected health information (as defined under the HITECH Act) is acquired by an unauthorized party. We understand that medical information about you and your health is personal and we are committed to protecting your medical information. Furthermore, we will notify you following the discovery of any “breach” of your unsecured protected health information as defined in the HITECH Act (the “Notice of Breach”). Your Notice of Breach will be in writing and provided via first-class mail, or alternatively, by e-mail if you have previously agreed to receive such notices electronically. Otherwise, if the breach involves: •10 or more individuals for whom we have insufficient or out-of-date contact information, then we will provide substitute individual Notice of Breach by either posting the notice on the SAS web site on the internet or by providing the notice in major print or broadcast media where the affected individuals are likely to reside. •Less than 10 individuals for whom we have insufficient or out-of-date contact information, then we will provide substitute Notice of Breach by an alternative form. Your Notice of Breach shall be provided without unreasonable delay and in no case later than 60 days following the discovery of a breach and shall include, to the extent possible:
- A description of the breach. •A description of the types of information that were involved in the breach. •The steps you should take to protect yourself from potential harm. •A brief description of what we are doing to investigate the breach, mitigate the harm, and prevent further breaches. •Our relevant contact information. Additionally, for any substitute Notice of Breach provided via web posting or major print or broadcast media, the Notice of Breach shall include a toll-free number for you to contact us to determine if your protected health information was involved in the breach. 4.COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with SAS or with the Secretary of the Department of Health and Human Services. To file a complaint with SAS, submit your complaint in writing to the party listed in Part 7, below. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 5.OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you grant us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we may be required to retain our records. 6.EFFECTIVE DATE The effective date of this Notice is January 1, 2019.
7.CONTACT Informational correspondence relating to the contents of this Notice should be directed as follows: Attn: Director of Quality Improvement SAS, Inc. 715 North Washington Blvd Suite E Sarasota, FL 34236 941-343.7244