The Health Insurance Portability and Accountability Act (HIPAA)
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED, DISCLOSED AND PROTECTED, AND HOW YOU CAN GET ACCESS TO IT. ALPHA LIFE MENTAL WELLNESS CENTER HIGHLY ENCOURAGE YOU TO REVIEW IT CAREFULLY.
1. Our Responsibility To You
The confidentiality of your personal health information is very important to us. Your health
information includes records that we create and obtain when we provide you care, such as a
record of your symptoms, examination and test results, diagnoses, treatments, and referrals for
further care. It also includes bills, insurance claims, or other payment information that we
maintain related to your care.
This Notice describes how we handle your health information and your rights regarding this
information. Generally, we are required to:
Maintain the privacy of your health information as required by law;
Provide you with this notice of our duties and privacy practices regarding the health information about
you that we collect and maintain; and
Follow the terms of this notice which is currently in effect.
2. How to contact us
After reviewing this Notice, if you need further information or want to contact us for any reason
regarding the handling of your health information, you can us directly at:
Alpha Life Mental Wellness Center
7208 W SAND LAKE RD STE 305
ORLANDO, FL. 32819-5279
3. How We Use And Disclose Your Information
Although under federal law we are permitted to use and disclose personal health information
without your consent or authorization for purposes of treatment, payment, and health care
operations, under Arizona and Florida State law and regulations, we will not release your personal
health information to any third party except in the following circumstances:
A. With your express consent for treatment and payment
This consent may be in writing, oral or implied.
You send us a written request to send a copy of your records to another physician
who may be providing treatment to you
You ask us to call the pharmacy to renew your medication
You ask us to submit a health insurance claim form to your insurance carrier
B. Pursuant to your written authorization, for other than treatment or payment purposes
We receive a request for medical information from your potential employer as may be permitted
By the law or for child abuse and neglect reporting and investigation
C. For Other Health Care Operations
In the course of providing treatment to you, we may need to share your information with our
employees, including students and trainees, and consultants to perform the operations of
our medical office. We will share personal health information with our employees and business
associates’ minimal amount of necessary for them to assist us.
To bill for our services
To set up appointments with you.
4. Other Uses and Disclosures
In addition to uses and disclosures related to treatment, payment, and health care operations, we
also may use and disclose your personal information without your express consent or
authorization for the following additional purposes:
A. Abuse, Neglect, or Domestic Violence
As required or permitted by law, we may disclose health information about you to a state or
federal agency to report suspected abuse, neglect, or domestic violence. If such a report is
optional, we will use our professional judgment in deciding whether or not to make such a report.
If feasible, we will inform you promptly that we have made such a disclosure.
B. Appointment Reminders and Other Health Services
We may use or disclose your health information to remind you about appointments or to inform
you about treatment alternatives or other health-related benefits and services that may be of
interest to you, such as case management or care coordination.
C. Business Associates
We may share health information about you with business associates who are performing
services on our behalf. For example, we may contract with a company to do our billing. Our
business associates are obligated to safeguard your health information. We will share with our
business associates only the minimum amount of health information necessary for them to assist
D. Communicable Diseases
To the extent permitted or required by law, we may disclose information to a public health
official or a person who may have been exposed to a communicable disease or who is otherwise
at risk of spreading a disease or condition.
E. Communications with Family and Friends
We may disclose information about you to a person who is involved in your care or payment for
your care, such as family members, relatives, or close personal friends. In addition, we may
notify a family member, your personal representative, or other person responsible for your care,
of your location, general condition, or death. Any such disclosure will be limited to information
you an opportunity to object before disclosing any such information. If you are unavailable
because, for example, you are incapacitated or because of some other emergency circumstance,
we will use our professional judgment to determine what is in your best interest regarding any
F. Coroners, Medical Examiners and Funeral Directors
In the event of your death, we may disclose health information about you to a coroner or medical
examiner, for example, to assist in identification or determining cause of death. We may also
disclose health information to funeral directors to enable them to carry out their duties.
G. Disaster Relief
We may disclose health information about you to government entities or private organizations
(such as the Red Cross) to assist in disaster relief efforts. If you are available, we will provide
you an opportunity to object before disclosing any such information. If you are unavailable
because, for example, you are incapacitated, we will use our professional judgment to determine
what is in your best interest and whether a disclosure may be necessary to ensure an adequate
response to the emergency circumstances.
H. Food and Drug Administration (FDA)
We may disclose health information about you to the FDA, or to an entity regulated by the FDA,
for example, to report an adverse event or a defect related to a drug or medical device.
I. Health Oversight
We may disclose health information about you for oversight activities that are authorized by
federal or state law, for example, to facilitate auditing, inspection, or investigation related to our
provision of health care, or to the health care system.
J. Judicial or Administrative Proceedings
We may disclose health information about you pursuant to a court order in connection with a
judicial or administrative proceeding, in accordance with our legal obligations.
K. Law Enforcement
We may disclose health information about you to a law enforcement official for certain law
enforcement purposes without your consent but only if you are incapacitated or in an emergency
If you are an unemancipated minor under Florida State law, there may be circumstances in which
we disclose health information about you to a parent, guardian, or other person acting as your parents.
in accordance with our legal and ethical responsibilities.
If you are a parent of an unemancipated representative, we may disclose health information about your
Child to you under certain personal representative in order for your child to receive care from us, we
may disclose your child’s health information to you. In some circumstances, we may not disclose health
information about an unemancipated minor to you. For instance, if your child is legally authorized
to consent to treatment and does not request that you be treated as his or her personal representative,
we will need a written authorization
N. Personal Representative
If you are an adult or emancipated minor, we may disclose health information about you to a
personal representative authorized to act on your behalf in making decisions about your health
O. Public Health Activities
As required or permitted by law, we may disclose health information about you to a public health
authority, for example, to report disease, injury or vital events such as death.
P. Public Safety
Consistent with our legal and ethical obligations, we may disclose health information about you
based on a good faith determination that such disclosure is necessary to prevent a serious and
imminent threat to yourself, to identified individuals and the public, or in an emergency
Q. Required By Law
We may disclose health information about you as required by federal, state or other applicable
R. Specialized Government Functions
We may disclose health information about you for certain specialized government functions, as
authorized by law and depending on the particular circumstances. Examples of specialized
government functions include military activities, determination of veterans benefits and
emergency situations involving the health, safety, and security of public officials.
5. Your Health Information Rights
Under the law, you have certain rights regarding the health information that we collect and
maintain about you. Your right includes the following:
A. Request that we restrict certain uses and disclosures of your health information. We are
not, however, required to agree to all requested restrictions, unless the requested
restriction involves information to be sent to a health plan for payment or health care
operations purposes and the disclosure relates to products or services that were paid for
solely out-of-pocket and such disclosure is not otherwise required by law.
B. Request that we communicate with you by alternative means, such as making records
available for pick-up, or mailing them to you at an alternative address, such as a P.O.
Box. We will accommodate reasonable requests for such confidential communications.
C. Request to review, or to receive a copy of, the health information about you that is
maintained in our files and used to make decisions about your treatment. We will
respond to your request to inspect records within 7days. The standard fee for copying is $1.00 per page.
If we maintain an electronic health record for you, you may request access to your health information in
an electronic format or have the information transmitted electronically to a designated recipient. If we
are unable to satisfy your request, we may instead provide you with a summary of the
information you requested. We will also tell you in writing the reason for the denial and
your right, if any, to request a review of the decision and how to do so.
D. Request that we amend the health information about you that is maintained in our files.
Your request must explain why you believe our records about you are incorrect, or
otherwise require amendment. Ordinarily, we will respond to your request for an
amendment within 60 days. If we are unable to satisfy your request, we will tell you in
writing the reason for the denial and tell you how you may contest the decision, including
your right to submit a statement (of reasonable length) disagreeing with the decision.
This statement will be added to your records.
E. Request a list of our disclosures of your health information. This list, known as a routine
disclosures made for payment, treatment or health care operations purposes or those
made pursuant to a written authorization. However, if we maintain an electronic health
record for you, you may be entitled to receive an accounting of routine disclosures of
your health information. We will ordinarily respond to your request for an accounting of
disclosures within 30 days. We will provide you the accounting free of charge, however
if you request more than one accounting in 12 months.
F. Request a paper copy of this Notice.
In order to exercise any of your rights described above, you must submit your request in writing
to our contact person (see section II above for information). If you have questions about your
rights, please speak with our contact person, available in person or by phone, during normal
6. Notice of Breach of Health Information
In the unlikely event that your health information is inadvertently acquired, accessed, used by or
disclosed to an unauthorized person, we will provide you with written notice of such breach.
The notice will be sent without unreasonable delay and in no case later than 60 calendar days
after discovery of a breach. The notice will be written in plain language and will contain the
following information: (i) a brief description of what happened, the date of the breach, if known,
and the date of discovery; (ii) the type of PHI involved in the breach; (iii) any precautionary
steps you should take; (iv) a description of what we are doing to investigate and mitigate the
breach and prevent future breaches; and (v) how you may contact us to discuss the breach.
The written notice of breach will be sent by regular mail or by email if you have indicated that
you prefer to receive communications from us by email. If the contact information we maintain
for you is insufficient or out-of-date, we may attempt to provide notice to you by telephone or
other permissible alternate method. We will also report the breach to the U.S. Department of
Health and Human Services.
7. To Request Information or File a Complaint
If you believe your privacy rights have been violated, you may file a written complaint by
mailing it or delivering it to our contact person (see section II above). You may complain to the
Secretary of Health and Human Services (HHS) by writing to Office for Civil Rights, U.S.
Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F
Washington, D.C. 20201; by calling 1-800-368-1019; or by sending an email to
OCRprivacy@hhs.gov. We cannot, and will not, make you waive your right to file a complaint
with HHS as a condition of receiving care from us, or penalize you for filing a complaint with
8. Revisions to this Notice of Privacy Practices
We reserve the right to amend the terms of this Notice. If this Notice is revised, the amended
terms shall apply to all health information that we maintain, including information about you
collected or obtained before the effective date of the revised Notice. We will post any revised
Notice in the waiting areas of our office. You will also be able to obtain your own copy of the
revised Notice by contacting us or asking for one at your next visit. If we revise or update the
Notice with a material change, we will re-distribute the Notice to all patients. If the revision or
update is non-material, we will provide the new Notice to all new patients at the first date of
service and to all current patients only upon request.
This Notice will take effect on 05/01/2021