HIPPA  and Florida State Notice of Privacy Practices

NOTICE:
I keep a record of the health care services I provide you. You may ask me to see and copy that record. You may also ask me to correct that record. I will not disclose your record to others unless you direct me to do so or unless the law authorizes or compels me to do so. You may see your record or get more information about it at:

Dr. Yves S. Eveillard, MD, Adult Psychiatry,
PO BOX 840013 Hollywood, Florida 33084

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.
Your health record contains personal information about you and your health. State and Federal law protects the confidentiality of this information. Protected Health Information (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical and mental health, or condition, and related health care services. If you suspect a violation of these legal protections, you may file a report to the appropriate authorities in accordance with Federal and State regulations.
I am required by law to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices with respect to your PHI. This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will make available a revised Notice of Privacy Practices by sending you an electronic copy, sending a copy to you in the mail upon your request, or providing one to you in person.
How I am permitted to Use and Disclose Your PHI
For Treatment. I may use medical and clinical information about you to provide you with treatment services.
For Payment. I may use and disclose medical information about you so that I can receive payment for the treatment services provided to you.
For Healthcare Operations. I may use and disclose your protected PHI for certain purposes in connection with the operation of my professional practice, including supervision and consultation.
Without Your Authorization. State and Federal law also permits me to disclose information about you without your authorization in a limited number of situations, such as with a court order.
With Authorization. I must obtain written authorization from you for other uses and disclosures of your PHI. You may revoke such authorizations in writing in accordance with 45 CFR. 164.508(b)(5).

Disclosure Statement and Agreement for Services
Dr. Yves S. Eveillard, MD, Adult Psychiatrist

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Examples of How I May Use and Disclose Your PHI
Listed below are examples of the uses and disclosures that I may make of your PHI. These examples are not meant to be a complete list of all possible disclosures, rather, they are illustrative of the types of uses and disclosures that may be made.
Treatment. Your PHI may be used and disclosed by me for the purpose of providing, coordinating, or managing your health care treatment and any related services. For example, this may include coordination or management of your health care with a third party, consultation or supervision activities with other health care providers, or referral to another provider for health care services.
Payment. I may use your PHI to obtain payment for your health care services. For example, this may include providing information to a third party payor, or, in the case of unpaid fees, submitting your name and amount owed to a collection agency.
Healthcare Operations. I may use or disclose your PHI in order to support the business activities of my professional practice. For example, this may include; disclosures to others for health care education, or to provide planning, quality assurance, peer review, or administrative, legal, financial, or actuarial services to assist in the delivery of health care, provided I have a written contract with the business that prohibits it from re-disclosing your PHI and requires it to safeguard the privacy of your PHI. I may also contact you to remind you of your appointments.
Other Uses and Disclosures That Do Not Require Your Authorization
Required by Law. I may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. Examples of this type of disclosure include healthcare licensure related reports, public health reports, and law enforcement reports. Under the law, I must make certain disclosures of your PHI to you upon your request. In addition, I must make disclosures to the US Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of privacy rules.
Health Oversight. I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors) and peer review organizations performing utilization and quality control. If I disclose PHI to a health oversight agency, I will have an agreement in place that requires the agency to safeguard the privacy of your information.
Abuse or Neglect. I may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect. However, the information we disclose is limited to only that information which is necessary to make the initial mandated report.
Deceased Patients. I may disclose PHI regarding deceased patients for the purpose of determining the cause of death, in connection with laws requiring the collection of death or other vital statistics, or permitting inquiry into the cause of death.
Research. I may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; and (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations.

Disclosure Statement and Agreement for Services
Dr. Yves S. Eveillard, MD, Adult Psychiatrist

3

Criminal Activity or Threats to Personal Safety. I may disclose your PHI to law enforcement officials if I believe that you have committed criminal activity, or that you have committed, or intent to commit, an act that threatens the health or safety of yourself or any third party.
Compulsory Process. I may disclose your PHI if a court of competent jurisdiction issues an appropriate order, and if the rule of privilege has been determined not to apply. I may disclose your PHI if I have been notified in writing at least fourteen days in advance of a subpoena or other legal demand, no protective order has been obtained, and I have a reasonable basis to believe that you have received notice of and an opportunity to respond to the discovery demand, and a competent judicial officer has determined that the rule of privilege does not apply.
Essential Government Functions. I may be required to disclose your PHI for certain essential government functions. Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.
Law Enforcement Purposes. I may disclose your PHI to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person’s death, if I suspect that criminal activity caused the death; (5) when I believes that protected health information is evidence of a crime that occurred on my premises; and (6) in a medical emergency not occurring on my premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.
Psychotherapy Notes. I must obtain your authorization to use or disclose psychotherapy notes with the following exceptions. I may use the notes for your treatment. I may also use or disclose, without your authorization, the psychotherapy notes for my own training, and to defend myself in legal or administrative proceedings initiated by you, for the US Department of Health and Human Services, or the State of Washington, to investigate or determine my compliance with the applicable laws and regulations including the HIPAA Privacy Rules, to avert a serious and imminent threat to public health or safety, to a health oversight agency for lawful oversight, for the lawful activities of a coroner or medical examiner or as otherwise required by law.
Uses and Disclosures of PHI With Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization.
I will not make any uses or disclosures of your psychotherapy notes other than as specified above, I will not use or disclosure your PHI for marketing purposes and I will not sell your PHI without your authorization. You may revoke your authorization in writing at any time. Such revocation of authorization will not be effective for actions I may have taken in reliance on your authorization of the use or disclosure.
Your Rights Regarding Your PHI
You have the following rights regarding PHI that I maintain about you. Any requests with respect to these rights must be in writing. A brief description of how you may exercise these rights is included.
  HIPPA  and Florida State Notice of Privacy Practices

Disclosure Statement and Agreement for Services
Dr. Yves S. Eveillard, MD, Adult Psychiatrist

4

Right of Access to Inspect and Copy. You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as I maintain the record. A “designated record set” contains medical and billing records and any other records that I use for making decisions about you. Your request must be in writing. I may charge you a reasonable cost-based fee for the copying and transmitting of your PHI. I can deny you access to your PHI in certain circumstances. In some of those cases, you will have a right of recourse to the denial of access. Please contact me if you have questions about access to your medical record.
Right to Amend. You may request, in writing, that I amend your PHI that has been included in a designated record set. In certain cases, I may deny your request for an amendment. If I deny your request for amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
Right to an Accounting of Disclosures. You may request an accounting of disclosures made for treatment purposes or made as a result of your authorization, for a period of up to six years, excluding disclosures made to you. I may charge you a reasonable fee if you request more than one accounting in any 12-month period. Please contact me if you have questions about accounting of disclosures.
Right to Request Restrictions. You have the right to ask me not to use or disclose any part of your PHI for treatment, payment or health care operations or to family members involved in your care. Your request for restrictions must be in writing and I am not required to agree to such restrictions. Please contact me if you would like to request restrictions on the disclosure of your PHI. You also have the right to restrict certain disclosures of your PHI to your health plan if you pay out of pocket in full for the health care I provide to you.
Right to Opt Out. You have the right to chose not to receive fundraising communications from me. I do not contact clients for fundraising purposes.
Right to Notice of Breach. You have the right to be notified of any breach of your unsecured PHI.
Right to Request Confidential Communication. You have the right to request to receive confidential communications from me by alternative means or at an alternative location. I will accommodate reasonable written requests. I may also condition this accommodation by asking you for information regarding how payment will be handled or specification of an alternative address or other method of contact. Please contact me if you would like to make this request.
Right to a Copy of this Notice. You have the right to obtain a copy of this notice from me. Any questions you have about the contents of this document should be directed to me.
Contact Information
I act as my own Privacy and Security Officer. If you have any questions about this Notice of Privacy Practices, please contact me. My contact information is:
Dr. Yves S. Eveillard, MD, Adult Psychiatry
PO BOX 840013, Hollywood, Florida 33084
Complaints
If you believe I have violated your privacy rights, you may file a complaint in writing with me, as my own Privacy Officer, as specified above. You also have the right to file a complaint in writing to the Florida Department of Health or to the US Secretary of Health and Human Services. I will not retaliate against you in any way for filing a complaint.
Effective Date
July 01, 2013

Consent for Treatment
By signing this document, you are attesting that you have received, read, fully understand and consent to the disclosures, terms, and conditions above, and that you are consenting to participation in counseling, psychotherapy, or medication management services provided by
Dr. Yves S. Eveillard, MD.
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Patient                                                   Date

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Print Name

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Dr. Yves S. Eveillard, MD,                    Date
  HIPPA  and Florida State Notice of Privacy Practices