- Privacy Notice -
100 Wallace Avenue | Suite 130 | Sarasota, FL 34237 | Ph. 941-343-2742 | Fax 941-343-2743
Federica Priano, Ph.D. Licensed Psychologist – Neuropsychologist
NOTICE OF PRIVACY PRACTICE 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.
Effective date of this Notice: April 14, 2003
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 (PHI) 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.
• We verify insurance coverage prior to your first appointment and obtain prior
authorization and pre-certification 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
which 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 PHI by delivering the request
in writing to our office. We are not required to grant the request, but we will comply with any
• Obtain a paper copy of the Notice of Privacy Practices for PHI by making a request at our
• 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 PHI 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
• 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 PHI.
• 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.
• 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 authorization 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
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: Federica Priano at
941-343-2742 in person or in writing, during normal business hours. She will provide you
with assistance on the steps to take to exercise your rights.
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 your reasonable 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 PHI 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.
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: Federica Priano at 941-343-
2742. You may also file a complaint by mailing or e-mailing it to the Secretary of Health and
Human Services at 202-619-0257. 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.
Uses and Disclosures with neither Consent or Authorization
The provider may use or disclose PHI without your consent or authorization in the following
Abuse and Neglect
We may disclose your protected health information to public authorities as allowed by law to report
abuse or neglect.
Federal law allows us to release your protected health information to appropriate health oversight
agencies or for health oversight activities.
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.
Serious Threats to Health or Safety
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.
If you are seeking compensation through Workers Compensation, we may disclose your protected
health information to the extent necessary to comply with laws relating to Workers Compensation.
Other Uses and Disclosures
We have Business Associates with whom we may share your PHI.
• 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.
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.
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.
We may use and disclose your PHI to assist in disaster relief efforts.
We may disclose your PHI to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
We 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.
As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
If you are an inmate of a correctional institution, we may disclose to the institution or agents there of your PHI necessary for your health and the health and safety of other individuals.
We may disclose your PHI 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.
For Specialized Governmental Functions
We may disclose your PHI 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 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.
We may maintain a website that provides information about our business. This Notice is on the website.
By signing below, I acknowledge that I have received a copy of the Notice of Privacy Practices.
Patient Name (Please Print)
Patient Patient Signature Date
Signature of Personal Representative of Patient Date
Description of Representative’s Authority to Act on behalf of Patient