HIPAA

FLORIDA NOTICE FORM

Notice of Psychologists’ Policies & Private Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

I.    Uses and Disclosures for Treatment, Payment, and Health Care Operations

Dr Arnold Pusar, Ph.D, may use or disclose your protected health information (PHI), fortreatment, payment, and health care operations purposes with your consent.

II.    Uses and Disclosures Requiring Authorization

Dr Arnold Pusar, Ph.D, may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained

Patient’s Rights:

Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, Dr Arnold Pusar, Ph.D, is not required to agree to a restriction you request.