SpeechWorks PLLC 3225 S Macdill Avenue Suite 129-333 Tampa Florida 33629-8171 813-361-649

IMPORTANT: 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.
Speechworks is required by law to protect certain parts of your health care information known as Protected Health Information or PHI and give you this Notice of Privacy Practices. This Privacy Notice tells about our privacy practices, and tells you about your rights to you or your childs PHI. You will receive a copy of this notice to keep for yourself. You may view this copy at any time to see what use is made of your records and who gets to see them. A new government rule requires you to be given this notice to sign. Our policy is to make your records safe. Your records are kept in a folder with your name on it. Your records may also be stored on a computer. Your records outline what tests and treatments you have had, and what decisions have been made regarding these tests and treatments. This Privacy Notice is in four parts: 1. What your PHI is, and your rights about that information 2. Who can view your information without your written permission 3. Who cannot view your information unless you give written permission 4. Our policies to protect your PHI Your PHI can be in any of these forms: paper (for example a written report), electronic (for example, e-mails between you and your therapist), or verbal (for example, a conversation between a parent and a therapist about their child). This information may include what tests and treatments you have had, the result of these tests and treatments, and the decisions that were made about these tests and treatments. PHI may include information about past, present, and future payment for health care services. Records may also have information that can be used to identify you such as your name, address, birth date, and social security number. You have rights to your PHI. The first of these rights is that, with certain exceptions, you have the right to view and get a copy of your records. Exceptions include psychotherapy notes, information gathered for legal actions, lab results that the Clinical Laboratory Improvement Act does not allow access to, or when a health care professional believes the information could cause harm to you or to someone else. If you are not allowed to view a part of your records, you have the right to have your denial reviewed by a licensed health care provider for a second opinion. We will give you a written denial in that case and let you know about your appeal rights. We will normally give you access to your information within 30 days of your asking for it. You have the right to ask for information to be changed or added to your PHI if you feel information is not correct or not complete. If the information is added, you can ask that it be sent to people you feel need it. We can deny your request, but only in certain circumstances. For example, if we believe the information is correct and no errors exist, your request will be denied. If your request is denied, you have the right to get the denial in writing, and you can enter a statement saying that you disagree with the denial. You have the right to see a list of people who have seen your PHI in the six years before the date of your request. This list may not include everyone who has seen your records for the use of treatment, payment, or health care operations, when the records have been given to you, when your records have been used for a

facility directory (if your permission has already been given to use them for that reason), for national security or intelligence reasons, or if your records have been viewed by someone allowed to view them with your permission. You have the right to ask us not to use your PHI for treatment, payment, or health care operations, or limit your records from people involved in your care or involved in paying for your care, or from family members or others about your general state, location, or death. You may not have your request granted. If you are allowed to limit the use of your records, these limitations must be followed except in a medical emergency. If you feel the way usual communication takes place about you or your childs protected information could put you in danger, you have the right to ask that communication take place by other ways or locations. For example, you may ask to be reached by using a specific address or phone number, or that written communication be sent in a sealed envelope. Finally, if you have agreed to get this Privacy Notice by e-mail, you have the right to get a paper copy when you ask for one. In most situations, we may use your PHI without your permission, but there are some situations where we may use it only after we get your written permission, if we have to do so by law. Situations where we can use your PHI with and without your permission are described below. We may use PHI for treatment, payment, and health care operations in most cases without your written permission. These are examples of our use of your PHI. For Treatment: This includes things like verbal and written information we get about you and use toward treating you. This information may be used by any therapist at Speechworks involved in your care. We can also use your PHI if your care is transferred to a different therapist. For Payment: This includes any actions we take to get payment for the services we give you, including things like organizing your PHI and giving bills to insurance companies, management of billed claims for services given, medical necessity decisions, operation review, and collection of outstanding bills. For Healthcare Operations: This includes quality assurance activities, licensing, and training programs to make sure our employees meet our standards of care and follow policies and procedures, getting legal and financial services, doing business planning, processing complaints, and making reports that do not individually name or identify you. Speechworks is allowed to use your PHI without your written permission or without giving you the chance to object in certain situations including: For Speechworks use in treating you or in getting payment for services given to you or in other healthcare operations; For the treatment activities of another health care provider; To another health care provider for the payment actions of the provider that gets the information (for example your hospital or insurance company); To another health care provider for their health care operations as long as they have or has had a relationship with you and the PHI deals with that relationship; For health care fraud and abuse discovery or for activities that relate to obedience with the law; To a family member, other relative, or close personal friend, or other person involved in your care if we get your verbal agreement to do so, or if we give you the chance to object to sharing this information and you do not object. We may also give health information to your family, relatives, or close friends if it is in your best interest. In that case, we will only give health information that is relevant to that persons involvement in your care. For example, we may give you an update on therapy progress in front of the person that came with you to the therapy session that day. To a public health authority in certain situations like reporting a birth, death or disease as required by law, as a part of a public health investigation, to report child abuse or neglect or domestic violence, to report undesirable events such as product defects, or to warn a person about possible exposure to a communicable disease as required by law; For health oversight actions including audits or government investigations, inspections, disciplinary activities, and other administrative or judicial actions taken by the government or their contractors by law to monitor the health care system; For judicial and administrative events as necessary by a court or administrative order, or in some cases in response to a subpoena or other legal process;

For law enforcement activities in limited situations, such as when there is a warrant for the request, or when the information is needed to locate a suspect or stop a crime; For military, national defense, and security and other special government jobs; To avoid a serious threat too the health and safety or a person or the general public; For workers compensation purposes and in agreement with workers compensation laws; To coroners, medical examiners, and funeral directors for identifying a dead person, determining cause of death, or carrying on their duties as required by law; If you are an organ donor, we may give information to health organizations that handle getting organs or organ, eye, and tissue transplantation or to an organ donation bank, as necessary to help with an organ donation and transplantation; For research projects, but this will be subject to strict oversight and approvals and health information will only be given when there is a minimal risk to your privacy and safeguards are in place in accordance with the law; We may use or give health information in a way that does not personally identify or tell who you are. Speechworks may also use your PHI to contact you about appointments or information about treatment changes. Any other use of PHI, other than what is listed above will only be made with your written permission and must tell you specifically what information is to be used and how we will use it. We must also get your written permission to use your PHI for marketing reasons, and in order to get psychotherapy notes. You may deny our request at any time in writing except when we have already used or given medical information based on that permission. Speechworks respects your privacy, and treat all health care information about our clients with care under strict policies of confidentiality that all of our staff are committed to following at all times. You have a right to complain to us, or to the Secretary of the United States Department of Health and Human Services if you feel your privacy rights have been violated. You will not be retaliated against in any way for filing a complaint with us or the government. If you have any questions, comments, or complaints, you may contact the privacy officer listed at the end of this Notice.

My signature indicates that I have read Speechworks Notice of Privacy Practices and understand and agree to the content stated therein.

Client or Caregiver Signature

Date

Date Notice Given

HIPAA Privacy Officer Liason-Ashli Givens (813)494-2637 Effective Date: 11/01/08