Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR PROTECTED HEALTH INFORMATION IS IMPORTANT TO US. THE NOTICE IS BASED ON THE HEALTH INSURANCE AND PORTABILITY ACT AND RELATED FEDERAL REGULATIONS AND CERTAIN RULES OF THE STATE OF FLORIDA.

Our Legal Duty

As your provider, we are required by applicable federal and state laws to maintain the privacy of your protected health information. We want you to be aware of our privacy practices, our legal duties, and your rights concerning your protected health information. We will follow the privacy practices that are described in this notice while it is in effect. This notice takes effect 12/12/2022 and will remain in effect until a revised notice is issued. Revised notices may be sent because:

1. The U.S. Department of Health and Human Services or other government agency informs us of an amendment to the law.

2. We modify the information Contained in the Notice of Privacy Practices. A new Notice of Privacy Practices will be presented before any modifications are put into practice.

3. We modify our business practices. We reserve the right to change our privacy practices and the new terms of this notice at any time, provided that applicable law permits such changes. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all protected health information that we maintain, including protected health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and present the new notice to our clients and child’s parent or guardian at the time of the change.

   You may request a copy of our notice at any time. For more information about our privacy practices or for additional copies of this notice please contact us using the information listed at the end of this notice.

   Individually Identifiable Health Information and Protected Health Information (PHI)

   Individually Identifiable Health Information means:

   Health information created or received by a health care provider, health plan, employer or health care clearinghouse that relates to the past, present or future physical or mental health or condition of an individual, the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and that identifies the individual or there is a reasonable basis to believe the information can be used to identify the individual.

Protected Health Information (“PHI”) means:

Individually identifiable health information that is transmitted, maintained by electronic media, or maintained in any other form (including oral and paper mediums).

How we can use or disclose protected health information without a specific authorization

To you: We must disclose your protected health information to you, described in the Individual Rights section of this notice, below. Additionally, we use and disclose protected health information about you for treatment, payment, and health care operations. For example:

Treatment: We may disclose your protected health information to our treatment staff and independent contractors in order for them to provide treatment and services for you.

Payment: We may use and disclose your protected health information to submit invoices for services provided to you for the purpose of payment for services or accounting for services rendered to funding sources.

Health Care Operations: Our operations as a provider require us to make many uses and disclosures of your protected health information. Some examples are: We may use and disclose your protected health information to conduct quality assessment and improvement activities and to engage in care coordination or case management. This could also include an entity that may access your protected health information when providing services on our behalf (i.e. a business associate). For example: On occasion, we may use health care consultants. We make intake information available to allow them to coordinate care for our clients. We have agreements in place with them to protect the information we share.

Public Health and Safety: We may use and disclose your protected health information to the extent necessary to avert a serious and imminent threat to your health or safety or the health or safety of others. We may disclose your protect health information to a government agency authorized to oversee the health care system or government programs or its contractors, and to public health authorities for public health purposes. We may disclose your protected health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or other crimes.

Required by Law: We may use or disclose your protected health information when we are required to do so by law. For example, we must disclose your protected health information to the U.S. Department of Health and Human Services, Medicaid, Department of Children and Families, or other state agencies upon request for purposes of their determining whether we are in compliance with applicable law or our satisfying applicable contractual and reporting obligations. We may disclose your protected health information when authorized by workers’ compensation or similar laws.

Process and Proceeding: We may disclose your protected health information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under other limited circumstances, such as a court order, warrant, or grand jury subpoena, we may disclose your protected health information to law enforcement officials.

Law Enforcement: We may disclose limited information to law enforcement officials concerning the protect health information of a suspect, fugitive, material witness, crime victim or missing person. We may disclose the protected health information of an inmate or other person in lawful custody to a law official or correctional institution under certain circumstances. We may disclose protected health information to assist law enforcement to capture an individual who has admitted to participation in a crime or has escaped from lawful custody.

To Family and Friends: With your authorization, as noted below, we may disclose your protected health information to family, friends and others. Additionally, if you are unable to authorize such disclosure, but emergency or similar circumstances indicate that disclosure would be in your best interest, we may disclose your protected information to family, friends or others to the extent necessary to help with your health care coverage arrangements.

Other Specific Florida Requirements: We may disclose information to other organizations as required or permitted by Florida Statutes when:

 Mr. and Ms. Mentoring has reasonable cause to suspect abuse or neglect of a child, elderly person, or disable adult.

 Mr. and Ms. Mentoring has reasonable cause to believe a client poses a risk of immediate harm to himself or to someone else.

Uses and disclosures of protected health information permitted only after authorization received

Authorization: You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose not otherwise permitted or required by law. If you give us an authorization, you may revoke it in writing at anytime. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect.

Individual Rights

Access: With limited exceptions, you have the right to review in person or obtain copies of your protected health information. You must make a request in writing to obtain access to your protected health information. We reserve the right to impose reasonable costs associated with this access request as allowed by law.

Amendment: You have the right to request that we amend your protected health information that we have on file. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information, you want amended or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Disclosure Accounting: You have the right to receive a list of instances in which we are our business associates disclosed your protected health information for purpose other than treatment, payment, health care operations and certain other activities, since April 14, 2003. We will provide you with the date on which we made the disclosure, the name of the person or entity to which we disclosed your protected health information, a description of the protected health information we disclosed, the reason for the disclosure, and certain other information. If you request this list more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction Request: You have the right to request that we place certain additional restrictions on our use of disclosure of your protected health information. We are not required to agree to theses additional restrictions, but if we do, we will abide by our agreement. However, if you are in need of emergency treatment and the restricted protected health information is needed to provide the emergency treatment, we may use or disclose that information to a health care provider in order to facilitate the provision of emergency treatment to you. Any agreement we may make to a request for additional restrictions must be in writing and signed by a person authorized to make such an agreement on our behalf. We will be bound unless the agreement is so memorialized in writing.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns about this Notice of Privacy or about our practices, please contact us using the information listed at the end of this notice.

Contact Office: Mr. and Ms. Mentoring
Telephone: 386-333-9018
Address: 1617 Ridgewood Ave., Holly Hill, FL, 32117