For your convenience, we have put links to forms that we use in our practice on this page. There are some forms that each new patient needs to complete, and the rest of the forms are organized according to practitioner. You can print out and complete the relevant forms prior to coming in for your first appointment. If you have any questions, please do not hesitate to contact us at 352-337-0551.
In order to access these forms, you will need a recent version of the Adobe Acrobat Reader. Most users will already have this program installed on their computers. Click on one of the above form links. If the form does not open, you can download the latest (free) version of the Adobe Acrobat Reader program HERE. With the Acrobat Reader program installed, clicking on the form's link should display the form in a new browser window and you can print it. In some instances, some of our forms will allow users to enter the required information into the form on screen after which it may be printed. Again, some forms cannot be completed on screen and must be printed and completed by hand (preferably in blue or black ink).
Notice of Psychotherapist's Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW HEALTH, PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We may use or disclose or be required to disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent.
To help clarify these terms, here are some definitions:
"PHI" refers to information in your health record that could identify you.
"Use" applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
"Disclosure" applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
We may use or disclose PHI for purposes outside of treatment, payment, and health care operations only when your appropriate authorization is obtained. An "authorization" is written permission that permits only specific disclosures above and beyond your general consent. In those instances when we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes for any purpose except as noted otherwise herein.
"Psychotherapy notes" are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. If we are counseling with you conjointly with another person or persons, we must have written authorization from every participant in those joint or family sessions, unless federal or state law requires us to do otherwise.
You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
If we begin seeing you with any other family member or relationship partner, and if we agree that we will have one or more session(s) or have communications with you individually without the other member(s) or partner(s) participating, your signature on the informed consent form provided to you before or at the time of our first session is an acknowledgment and agreement that we will use my own discretion and professional judgment in determining what information may be shared with those other counseling participants and will operate as a release that allows us to disclose this information without further authorization or consent.
We may use or disclose PHI without your consent or authorization in the following circumstances:
If we know, or have reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver or other person responsible for the child's welfare, the law requires that we report such knowledge or suspicion to the Florida Department of Child and Family Services.
If we know, or have reasonable cause to suspect, that a vulnerable adult (disabled or elderly) has been or is being abused, neglected, or exploited, we am required by law to immediately report such knowledge or suspicion to the Central Abuse Hotline.
If a complaint is filed against us with the Florida Department of Health on behalf of the Board of Psychology, the Department has the authority to subpoena confidential mental health information from us relevant to that complaint.
If you are involved in a court proceeding and a request is made for information about your diagnosis or treatment and the records thereof, such information is privileged under state law, and we will not release information without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified and you have failed to inform us that you are opposing the subpoena or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
When you present a clear and immediate probability of physical harm to yourself, to other individuals, or to society, we may communicate relevant information concerning this to the potential victim, appropriate family member, or law enforcement or other appropriate authorities.
If you file a worker's compensation claim, we must, upon request of your employer, the insurance carrier, an authorized qualified rehabilitation provider, or the attorney for the employer or insurance carrier, furnish your relevant records to those persons.
You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request and may be unable to abide by it in emergency situations. If we cannot agree on the issue of restrictions, you are free to go elsewhere; however, once you agree to particular restrictions, you must abide by them. We cannot agree to limit uses/disclosures that are required by law.
You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. We must agree to your request as long as it is reasonably easy for us to do so. There may be an additional charge if we comply with your request.
Unless your access is restricted for clear and documented treatment reasons, you have the right to inspect or obtain a copy (or both) of your PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, we will discuss with you the details of the request process. Requests must be made in writing and will be responded to within 30 days. A reasonable charge may be made for copying requested records, but may be waived, depending on your circumstances. We will notify you of any charges before such copies are made.
You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, we will discuss with you the details of the accounting process. We may require requests for accountings to be in writing. Certain disclosures will not be included and disclosures made prior to January 1, 2007 will not be included. Records will be retained for six years unless federal or state law alters the maximum time require for records retention.
You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.
We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
If we revise our policies and procedures, we will provide you with a written notification, by mail, of those revisions on or before the effective date.
If you are concerned that we have violated your privacy rights, or if you are dissatisfied with our privacy policies or procedures, you may file a complaint with our practice by mail as described below and you will not be retaliated against for filing a complaint. You also may file a written compliant with the Office for Civil Rights (OCR) at:
Atlanta Federal Center
61 Forsyth Street SW, Suite 3B70
Atlanta, GA 30303-8909
The person to contact for further privacy related information is:
The Haile Psychiatry and Psychotherapy Group, Inc.
5214 SW 91st Terrace, Suite A
Gainesville, FL 32608
This notice will go into effect on January 1, 2007. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice by mail on or before the effective date.