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. ________________________________________________________________________________

If you have any questions about this Notice of Privacy Practices (Notice’) please contact:

Privacy Officer: Angela Zarzycki

Phone # 727-548-0001

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

Protected health information includes demographic and medical information that concerns the past, present, or future physical or mental health of an individual. Demographic information could include your name, address, telephone number, social security number and any other means of identifying you as a specific person.

Protected health information contains specific information that identifies a person or can be used to identify a person. Protected health information is health information created or received by a health care provider, health plan, employer, or health care clearinghouse. Success by Design (‘clinic’) can act as each of the above business types. This medical information is used by Success by Design in many ways while performing normal business activities.

Your protected health information may be used or disclosed by Success by Design for purposes of treatment, payment, and health care operations. Health care professionals use medical information in the clinics or hospital to take care of you. Your protected health information may be shared, with or without your consent, with another health care provider for purposes of your treatment. Success by Design may use or disclose your health information for case management and services. Success by Design may send the medical information to insurance companies, Medicaid, or community agencies to pay for the services provided to you. Your information may be used by certain department personnel to improve the clinic’s health care operations. Success by Design also may send you appointment reminders, information about treatment options or other health-related benefits and services.

Some protected health information can be disclosed without your written authorization as allowed by law. Those circumstances include:

• Reporting abuse of children, adults, or disabled persons.

• Investigations related to a missing child.

• Internal investigations and audits by the clinics divisions, bureaus, and offices. • Investigations and audits by the state’s Inspector General and Auditor General, and the legislature’s Office of Program Policy Analysis and Government Accountability.

• Public health purposes, including vital statistics, disease reporting, public health surveillance, investigations, interventions, and regulation of health professionals.

• District medical examiner investigations; DH8006-SSG-09/2017

• Research approved by Success by Design.

• Court orders, warrants, or subpoenas;

• Law enforcement purposes, administrative investigations, and judicial and administrative proceedings.

Other uses and disclosures of your protected health information by Success by Design will require your written authorization. These uses and disclosures may be for marketing and for research purposes, certain uses and disclosure of psychotherapist notes, and the sale of protected health information resulting in remuneration to Success by Design

This authorization will have an expiration date that can be revoked by you in writing.

INDIVIDUAL RIGHTS

You have the right to request Success by Design to restrict the use and disclosure of your protected health information to carry out treatment, payment, or health care operations. You may also limit disclosures to individuals involved with your care. Success by Design is not required to agree to any restriction.

You have the right to be assured that your information will be kept confidential. Success by Design will contact you in the manner and at the address or phone number you select. You may be asked to put your request in writing. If you are responsible for paying for services, you may provide an address other than your residence where you can receive mail and where we may contact you.

You have the right to inspect and receive a copy of your protected health information that is maintained by the Success by Design within 30 days of the clinic receipt of your request to obtain a copy of your protected health information. You must complete the Authorization to Disclosure Confidential Information form and submit the request to Success by Design. If there are delays in getting you the information, you will be told the reason for the delay and the anticipated date when you will receive your information.

Your inspection of information will be supervised at an appointed time and place. You may be denied access as specified by law.

If you choose to receive a copy of your protected health information, you have the right to receive the information in the form or format you request. If the clinic cannot produce it in that form or format, it will give you the information in a readable hard copy form or another form or format that you and the clinic agree to.

Success by Design cannot give you access to psychotherapy notes or certain information being used in a legal proceeding. Records are maintained for specified periods of time in accordance with the law. If your request covers information beyond that time the Clinic is required to keep the record, the information may no longer be available.

If access is denied, you have the right to request a review by a licensed health care professional who was not involved in the decision to deny access. This licensed health care professional will be designated by Success by Design. You have the right to correct your protected health information. Your request to correct your protected health information must be in writing and provide a reason to support your requested correction. Success by Design may deny your request, in whole or part, if it finds the protected health information:

• Was not created by the clinic.

• Is not protected health information.

• Is by law not available for your inspection.

• Is accurate and complete.

If your correction is accepted, the clinic will make the correction and tell you and others who need to know about the correction. If your request is denied, you may send a letter detailing the reason you disagree with the decision. Success by Design may respond to your letter in writing. You also may file a complaint, as described below in the section titled Complaints.

You have the right to receive a summary of certain disclosures Success by Design may have made of your protected health information. This summary does not include:

• Disclosures made to you.

• Disclosures to individuals involved with your care.

• Disclosures authorized by you.

• Disclosures made to carry out treatment, payment, and health care operations.

• Disclosures for public health.

• Disclosures to health professional regulatory purposes. • Disclosures to report abuse of children, adults, or disabled.

• Disclosures prior to April 14, 2003. This summary does include disclosures made for:

• Purposes of research, other than those you authorized in writing.

• Responses to court orders, subpoenas, or warrants.

You may request a summary for not more than a 6-year period from the date of your request. If you receive this Notice of Privacy Practices electronically, you have the right to a paper copy upon request.

Success by Design may mail or call you with health care appointment reminders.

SUCCESS BY DESIGN DUTIES

Success by Design is required by law to maintain the privacy of your protected health information. This Notice of Privacy Practices tells you how your protected health information may be used and how the clinic keeps your information private and confidential. This notice explains the legal duties and practices relating to your protected health information.

Success by Design has the responsibility to notify you following a breach of your unsecured protected health information. As part of the clinic legal duties this Notice of Privacy Practices must be given to you. The clinic is required to follow the terms of the Notice of Privacy Practices currently in effect. Success by Design may change the terms of its notice. The change, if made, will be effective for all protected health information that it maintains.

New or revised notices of privacy practices will be posted on Success by Design and will be available by email and at Success by Design Also available are additional documents that further explain your rights to inspect and copy and amend your protected health information.

COMPLAINTS

If you believe your privacy health rights have been violated, you may file a complaint with the clinic, or with the Secretary of Department of Health and Human Services. www.hhs.gov/ocr/privacy/hipaa/complaints/index.html

The complaint must be in writing, describe the acts or omissions that you believe violate your privacy rights, and be filed within 180 days of when you knew or should have known that the act or omission occurred. Success by Design will not retaliate against you for filing a complaint.

FOR FURTHER INFORMATION

Requests for further information about the matters covered by this notice may be directed to the person who gave you the notice, to the director or administrator of Success by Design where you received the notice.

EFFECTIVE DATE

This Notice of Privacy Practices is effective beginning July 1, 2013, and shall be in effect until a new Notice of Privacy Practices is approved and posted.

REFERENCES

“Standards for the Privacy of Individually Identifiable Health Information; Final Rule.” 45 CFR Parts 160 through 164. Federal Register 65, no. 250 (December 28, 2000). “Standards for the Privacy of Individually Identifiable Health Information; Final Rule” 45 CFR Part 160 through 164. Federal Register, Volume 67 (August 14, 2002). Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information and Nondiscrimination Act; Other Modifications to the HIPAA Rules, 78 Fed. Reg. 5566 (Jan. 25, 2013).