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INFORMED CONSENT FOR SERVICES

This contract governs the way the practices of Palm Beach Psychiatric Experts and or Dr. DeLuca MD, PA, Businesses operate. Please take your time to review this consent carefully. This document is lengthy because it includes the consent for treatment and fees, the prescription and refill policy for controlled substances required by state medical boards, an arbitration agreement, and a notice of privacy practices required by HIPPA.

APPOINTMENTS: All appointments are 1 hour unless previously approved by the clinician. The office hours are 8 am to 6 pm, Monday through Friday, and by special appointment on weekends. The office staff is available to return calls from 8 am to 6 pm Monday through Friday, so please leave a message on the answering machine during those hours. After hours, emergency calls are transferred to the physician's cell phone, who will handle the issue as promptly as possible. If an emergency arises that cannot wait, please call 911 or a crisis hotline.

At the time of booking your appointment and on this form, you are asked to provide a credit card number. You consent to be charged on that credit card for missed appointments. Appointments must be canceled or rescheduled 48 hours in advance to avoid being billed for the service scheduled. Missed appointments are charged the full rate. If you are more than 15 minutes late to your scheduled appointment time, you will have to reschedule for another time and pay for both appointments. This is not a punishment. You purchase our time and we do not double-book. If we do not charge for that time, we could not offer our level of service. You can have a phone or webcam session if you cannot make it to the office on time. Keep in mind that insurance companies will not reimburse for missed appointments.

TELEPSYCHIATRY: Video-conferencing is the next best option after face-to-face contact. Please keep in mind that a computer screen does not allow the clinician to observe body movements and many other non-verbal forms of communication may be missed. Not all patients are appropriate for telepsychiatry, the doctor will determine if you are eligible. Please prepare for a telepsychiatry appointment as if you were attending the office. Place the videoconferencing device setup should mimic the doctor's confidential office with complete privacy and no distractions. It should be in a well-lit room with a very good internet connection. Make sure you are fully dressed and groomed. Not all cases are appropriate for telepsychiatry, the doctor will determine if you are eligible.

When you schedule an appointment, it only guarantees you the time of the clinician. It does not guarantee any specific medications, treatments, or letters. Generally, the first appointment is an evaluation and initial diagnosis, and a therapeutic relationship is formed over time where the diagnosis is refined and treatment approaches are optimized. Treatments are initiated and adjusted over subsequent appointments. The therapeutic relationship requires a certain dynamic, and sometimes a referral to another clinician or a higher level of care is indicated.

Dr. Mark DeLuca, MD Is a general and forensic psychiatrist who sees adolescents to geriatric patients. He sees patients five days a week from 8 am -5 pm with any and all psychiatric diagnoses for psychotherapy, medication management, and forensic/litigation purposes, writing letters for disability, attorneys, capacity, courts, etc. He focuses on somatic and behavioral treatments to improve functioning. He does not participate in any insurance. His schedule is typically fully booked weeks in advance now for several years. New patients typically should follow up one week after the initial appointment time; however, it will depend on several factors including the level of care the patient needs, the amount of outside support the patient has, interest in the suggested plan of care, and mutual availability.

FEES: Dr. DeLuca M.D. shall be compensated at a flat rate of $600.00 per hour for all services. Dane Santoro, P.A., shall be compensated at a flat rate of $400.00 per hour for all services. The services include but are not limited to: a review of materials, research, travel, communication with collateral sources or other professionals, and report writing. Time spent on the phone, communications, meetings with attorneys, report writing, deposition, mediations, court appearance, and traveling are all billed at the same hourly rate. Any time spent on your care is billed at the same hourly rate. Some examples include: speaking on the phone, charting, calling in refills, texting, emailing, writing letters, preparing reports, reviewing records, obtaining prior authorizations from insurance, appeals to insurance, traveling to house calls, and communicating with family, and friends, attorneys or other physicians. Dr. DeLuca & D. Santoro, do not accept any form of insurance reimbursement. Payment is due upon the signing of this engagement letter. The retainer will be applied to your final bill in this matter. Interest will be charged at a rate of 1.5% per month, or the maximum rate allowed by law and you are responsible for all collection fees.

CREDIT CARD PAYMENT FEE: A 3% processing fee will be added to all credit card transactions to cover the actual cost charged by the credit card processor. No fee applies to cash, check, or ACH payments.

MISSED APPOINTMENTS: If you miss an appointment without 48-hour advance cancellation, you agree to pay the regular hourly rate listed above for the provider or physician.

MEDICARE: Dr. DeLuca and D. Santoro have opted out of Medicare. Thus, you agree to enter into a private contract with either, and thus cannot get any reimbursement from Medicare or Medicare supplemental plan for the fees you pay for their services, including your out-of-network benefits. Signing this consent means that you are entering into a private contract with Dr. DeLuca or D. Santoro. You must notify us that you are a Medicare beneficiary or if you become a Medicare beneficiary while under our care so you can re-sign a contract acknowledging the above every two years. This does not affect any of your claims with other physicians, pharmacies, laboratories, or hospitals.

FORENSIC FEES: Dr. DeLuca’s Forensic work is billed at a higher rate of $1,000.00 per hour for all services. This service includes but is not limited to: the review of materials, research, travel, communication with collateral sources or other professionals, and report writing. Time spent on the phone and conversations/ meetings with attorneys, deposition, mediation, and court appearance are all billed at the same hourly rate. Travel expenses will be provided for or reimbursed by the retaining party. The extent and limit of the services provided are determined on a case-by-case basis. There is no minimum fee and this agreement can be terminated at any time. Cancellations, no-shows, and all postponements are charged the full rate of $800 per hour unless they are canceled 48 hours in advance.

LEGAL CIRCUMSTANCES: If legal involvement is anticipated in your case, even if you are not looking for a forensic psychiatrist (e.g. you are applying for disability, receiving disability, seeking damages for emotional distress or you will be needing ongoing reports to the court or a licensing agency about your treatment), this should be stated when scheduling the appointment. This will result in a far better outcome for you, mainly because the level of documentation must be tailored for these purposes. Routine psychiatric and medical documentation can be misinterpreted and even detrimental during litigation.

HOUSE CALLS: Dr. DeLuca will provide house calls to patients who are housebound or require in-home therapy. When we travel to see a patient, our travel time is billed at a higher hourly rate.

OUT-OF-STATE PATIENTS: The doctor-patient relationship of all our patients is based in Florida, and all patients must have at least one encounter with a doctor in Florida. This is a requirement even though the physicians maintain active licenses in several other states, and pharmacies may choose to honor prescriptions even in states where we are not licensed. You should not expect to get controlled substances in any state other than Florida.

ELECTRONIC COMMUNICATIONS: Communication via email, text, instant messenger, fax, phone, voicemail, and video/web conferencing can be used. These forms of communication cannot be guaranteed to be secure, confidential, reliable and or HIPPA compliant. Additionally, the clinician may choose not to respond to the question outside of an appointment. We cannot stress enough that face-to-face contact through a scheduled appointment is the only guaranteed way to communicate with the clinician. All electronic communications can be added to your medical records and you will be charged for the time it takes to place it there. Social media outlets are not an appropriate method of communication regarding anything clinical. Please keep the username and passwords for your emails secure and confidential or don't utilize them with us at all. The same rule applies for the username and password you will be given for our medical records (i.e., Carepaths). You can email the clinician through the patient portal in a HIPPA-compliant fashion.

AUDIO/VIDEO RECORDING: Our offices contain audio-video recording devices in the waiting and treatment areas. The recordings are not part of your medical record and are not generally kept after the doctor has completed documentation of the session. You have the right to refuse to be recorded during treatment sessions; however, you must request this in writing when scheduling an appointment in order for arrangements to be made. Unless you request it in writing, the clinicians may record any patient encounter in or out of the office.

SESSION NOTES: The purpose of our notes is to enable continuity of care from one visit to the next. We are not writing for any audience other than the treating clinician. This means we are not writing for insurance companies, social security, attorneys, or the courts. Many clinicians document their own impressions, feelings, and hypothesis at the time of the session, not facts such as weight, temperature, and blood pressure. These change as the treatment continues, and the diagnosis becomes more clarified. Some of the clinicians document throughout the session and some only document medication changes. If you are not using insurance and do not want there to be any record of the content of your sessions beyond the fact that you attended, you may request this in writing. It is at the clinician's discretion if they feel comfortable treating you with no notes. An alternative is to use a pseudonym on your chart. You will need to use your real name if you are getting prescriptions for controlled substances or using insurance.

CONSUMER ETIQUETTE: Disrespectful, abusive behavior or harassment towards office staff will not be tolerated. If this occurs, the doctor will determine under which circumstances your care at our practices will be immediately terminated.

FRATERNIZATION: The physician-patient relationship is the overriding relationship that exists between the doctors and the patient. If you feel there is a strong preexisting relationship (friend, employee, family) that may affect your decisions, you should seek care elsewhere. If there is no practical treatment alternative, this must be discussed and agreed to before engaging in treatment. In the context of treatment, real feelings develop between the patient and physician. They can be specific to the treating physician or they may be feelings that would occur with any physician (transference). This is part of the treatment and should be discussed. There is never room for romantic enactment between the patient and the current therapist. Additionally, our staff may not become romantically involved with current patients. Finally, there is never a need to give any gifts to the clinicians or staff. If you wish to display a gesture of gratitude, a note or card is appreciated.

GRIEVANCES: If you have a grievance with your clinician, another member of the office staff, or a complaint about one of our policies, we ask that you first communicate this to a member of the staff so they may attempt to resolve the issue. If you air your grievances online on a review site or another public form, you agree that you are forfeiting your rights to patient confidentiality. Online forums can legally be obligated to release the identities of anonymous posters. Additionally, you give our office full permission to respond in detail regarding the subject matter you raised in the same forum.

If a frivolous or dishonest complaint is made outside of our office channels (i.e. to a State Medical Board), you will be liable for all of the costs as well as the forensic hourly rate (higher than the normal rate) for the work spent addressing your allegations.

PRIMARY CARE: All patients need to be under the routine care of a primary care physician. Even if you are seeing a clinician once a week, it does not ensure that your routine health maintenance is being addressed. If the psychiatrist agrees to refill your oral contraceptive, blood pressure or cholesterol-lowering medications etc., it does not imply that they are taking over your primary care. Primary care is a separate specialty that none of our clinicians stay completely current in, even though they may know enough to refill the medication.

SPLIT, SHARED OR COLLABORATIVE TREATMENT: Split treatment typically occurs when a patient is seeing a psychiatrist, Physician Assistant, or Nurse Partitioner for medications and a non-prescribing therapist for psychotherapy. It can also occur when one psychiatrist is managing TMS and another psychiatrist is managing your medications and therapy. Whenever this occurs, there is an increased risk of something falling through the cracks, than when all of your care occurs with one psychiatrist. You may be suicidal, and each clinician assumes you are seeing the other one on a very frequent basis when in fact you are seeing neither. Do not assume that communication or collaboration occurs on a frequent basis between your caregivers. In any form of split treatment, it is the patient’s responsibility to come in at least every week to see a prescribing clinician (not just a therapist) if they are declining, suicidal or psychotic. Dr. DeLuca will be happy to provide TMS or medication services to patients who are seeing therapists or primary care doctors as long as the patient understands it is their responsibility to come in to see the psychiatrist weekly when they are not well.

PRESCRIPTION & REFILL POLICY/MEDICATION DISCLOSURES:

1. When medications are prescribed, patients are generally seen every week, then every other week, then every month, or less frequently as they heal. The frequency is determined at the most recent visit with the prescriber. Do not expect refills in between appointments. Prescriptions are NOT filled on the weekend. Do not expect the physician or pharmacy to request refills for you automatically. If you are taking a controlled substance that requires for example scripts every 30 days and you must see the prescriber before 90 days. It is your responsibility to ask the physician for the scripts for the 90-day period. The longest interval between visits is six months. Even if you are stable on your medication, an evaluation of your progress needs to take place. No medications will be given for canceled or no-show appointments. It is your job to make follow-up appointments at the recommended interval, the clinicians do not chase or hound the patients. This is intentional, as it demonstrates a higher level of engagement by the patient. If you cannot do this, ask for a recommendation for a case manager or family support.

2. All medications can potentially cause uncomfortable and/or serious side effects, and problems may arise from interactions with other drugs or food. An unfortunate risk with some prescriptions is developing dependency and/or diversion of the medication to others. You need to notify your doctor of any emotional or physical adverse effects that arise as a result of medications. Any of the medications you may be prescribed can have severe rare side effects (e.g., serotonin syndrome, neuroleptic malignant syndrome, tardive dyskinesia, diabetes, death). All of these are available on the package insert from the pharmacy or the manufacturer. The clinicians will take all of these into consideration but only discuss with you what you are able to handle at the time (usually just common side effects). If your condition isan anxiety disorder, we generally discourage reading about the medication (online, package insert, pharmacist) until your anxiety has improved and you can discuss this with the psychiatrist.

3. You should not drive or operate heavy machinery while taking medications that may cause drowsiness or impaired cognitive functioning.

4. Always tell every doctor (and new pharmacies) every medication you are taking to avoid physical harm to yourself and not break the law. This includes over the counter medications (e.g. anti-acid, anti inflammatory, cough syrup, vitamins, supplements) that can have toxic interactions with your prescriptions or affect their absorption.

5. You may be asked to bring any unused medications to the office for disposal. Medications should not be discarded before discussing it with the psychiatrist.

6. Medications that require a prescription are governed by federal and state laws, and they are monitored through multiple agencies including: Drug Enforcement Agency, Florida’s Department of Health, Florida Board of Medicine, Florida Board of Pharmacy and Palm Beach Sheriff’s Department. The Prescription Drug Monitoring Program allows us to see controlled substances that have been dispensed anywhere.

7. It is a felony to share, sell, or exchange your medications with anyone for any reason. It is also a felony to forge, falsify, or alter a prescription. This is very dangerous. If you violate these laws, you forfeit your right to doctor-patient confidentiality on these matters, and your conduct will be reported to the police.

8. CONTROLLED SUBSTANCES: Controlled substances generally fall under three classes: stimulants, opiates, and sedatives. There are other controlled substances.
• You must fill these medications within 7 days of the fill date on the script; otherwise, many pharmacies will not fill the prescription. These medications require an electronic or handwritten prescription and that the doctor and pharmacist check a database prior to every refill.
• You can only use one pharmacy for all of your controlled substance medications. In the event that circumstances require the use of another pharmacy, you must notify your doctor immediately and provide them with all pertinent contact information. You will also need to notify both pharmacies of the situation.
• Controlled substances should only be filled in Florida. If you take the prescription to another state, it is likely the pharmacy will not fill the medication.
• Legally FL pharmacies can dispense 90 days of stimulants at a time, but the maximum quantity of stimulant medication that some pharmacies dispense is a 30-day supply. Patients have to be seen within every 90 days, or sooner if the dosage is changed. Never pick up a partial fill from the pharmacy, it means you are forfeiting the remainder of the prescription. Wait for them to have the entire supply before getting your medication.

• Patients on stimulants must have an annual electrocardiogram. Your primary care doctor can do this, or we can arrange it upon request.
• The maximum amount for opiates is a 30-day supply. Patients must be seen every 30 days.
• Patients on Xyrem must be seen every 30 days.
• Patients on Clozapine must be seen every 30 days (even though it is not a controlled substance.)
• Patients on Buprenorphine (Suboxone/Subutex, etc.) require monthly urine drug screens.
• We cannot replace lost or stolen prescriptions of controlled substances without a police report.
• You may be asked to bring your prescribed medications to your appointment or undergo a random prescription compliance check (i.e., pill count) in the middle of the month.
• Dr. DeLuca’s & D. Santoro reserve the right to perform random urine drug screens. This is to ensure that you are taking your medications at the prescribed dosage and not taking other non-prescribed medications or diverting the medication. It is also the current standard of care.

• If you are prescribed controlled substances and do not comply with a pill count or urine drug screen request within 48 hours without good cause, you will be terminated from our practices.

• It is a felony to accept a controlled substance prescription from the same class from any other physician without both doctors’ consent and notification. This is referred to as “Doctor Shopping.”

9. REFILL REQUESTS: Medication refill hours are 8 am to 5 pm, Monday through Friday. Do not expect to have medications filled on the weekends. For emergency refill requests, indicated the nature of the emergency, and why the refill is not being requested during an appointment when calling. It may take up to 48 hours before you receive a response to your request for a prescription refill. Calling on a weekend or after hours raises suspicions that you are avoiding your physician and trying to reach the physician on call. Because your prescription is expected to run out, you  hould make an appointment well in advance. Medications may cause  ithdrawal symptoms when not taken as prescribed. Poor planning on your part does not constitute an emergency on our part. A refill in advance of an appointment takes time to coordinate and it may enquire documentation as well as verification with the prescription monitoring database. Keep in mind that your medication dosages may change at your next scheduled appointment. Please, never allow the pharmacy to send automatic refill requests to our office.

ARBITRATION AGREEMENT: Arbitration means you waive your right to a jury trial. Due to the high costs of medical malpractice insurance and litigation, this office requires every patient sign an arbitration agreement. This means that all potential disputes are resolved through arbitration and not in court. This is mandatory for anyone who chooses to be a patient in our practices. In the event of a dispute of any nature arising between the parties or their heirs at any time, as a result of clinicians providing medical services, advice, treatment, informed consent, prescriptions, tests, and procedures whether in person or by phone, text, writing, internet, in the home, office, hospital or otherwise, including a dispute or an injury from our staff, employees or our property, the parties hereto agree to submit the dispute to binding arbitration under the rules of the Independent American Arbitration Association or any other arbitration company of the physicians’ choosing. An award rendered by the arbitrator(s) shall be final and binding upon the parties and judgment on such award may be entered by either party in the highest court having jurisdiction. Each party hereto specifically waives his/her right to bring the dispute before a court of law and stipulates that this agreement shall be a complete defense to any action instituted in any local, state or federal court or before any administrative tribunal.

CHANGES TO THIS NOTICE: We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We generally update all of our forms once per year. The most current version of the consent form that was made while you are a patient will effectively govern our relationship. This Agreement shall not be amended except in writing or via electronic signature. Should any provision of this Agreement be declared void or ineffective by virtue of any state or federal statute or regulation, or decision of any court or regulatory authority, such declaration shall not invalidate any of the provisions of this Agreement that otherwise remain in full force and effect.

NOTICE OF PRIVACY PRACTICES (HIPAA)

CONFIDENTIALITY: Your information is generally protected and kept confidential. However, there are certain circumstances under which information may be released to other parties without your permission. It is your responsibility to review the HIPAA website for a complete list of disclosures at www.hhs.gov/ocr/privacy/index.html. The following is a partial list of our notice of privacy practices.

We are required by law to maintain the privacy of protected health information, give you this notice of our legal duties and privacy practices regarding your health information, and follow the terms of our notice that are currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:

The following describes the ways we may use and disclose health information that identifies you (“Health Information”). Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our office manager.

For Treatment. We may use and disclose Health Information for your treatment and/or to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care. We may contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. For Payment. We may use and disclose Health Information so that others or we may bill and receive payment from you, an insurance company, or third party for the treatment and services you received. For example, we may give your health plan information about you so that the health plan will pay for your treatment. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care (e.g., family, or close friend).

For Health Care Operations. We may use and disclose Health Information for healthcare operations purposes. These uses and disclosures are necessary to make sure our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the psychiatric care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (e.g., your health plan) for their healthcare operation activities.
1. Insurance: If you are using health insurance for reimbursement of your visits or medications, the information enters into the medical information bureau (www.mib.gov), which may have consequences when applying for other insurance policies (e.g., health, life, long-term care, disability). If your employer provides your health coverage, they may have access to your information as well.
2. Out-of-pocket payments: If you paid out-of-pocket for a specific item or service and did not seek reimbursement from your health insurance, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
3. Payment by another person: If another person is paying for your visits, they have the right to know if you have attended the sessions.
3. Credit card companies: If you contest a visit with a credit card company, they will have access to the documentation from that visit.
4. Social security: If social security requests your records, we will send the entire chart.
5. Court order/subpoena/litigation: Clinicians are required to provide information in response to court orders or subpoenas. Additionally, if treatment is provided as a result of a court order, we are required to release certain information. It would be your attorney’s responsibility to claim privileges  ssociated with the disclosure of your records. It should be noted that all electronic communication is potentially discoverable during litigation.
6. Consultation: Your clinician may consult with other professionals regarding your case or other members of our practices. Please indicate in writing if you would like restrictions placed on what can be shared.
7. Abuse/neglect: When there is reasonable suspicion of current or previous child, adult, elderly, or disabled abuse/neglect, clinicians are required to report this information to certain authorities, persons, and agencies.

8. To avert a serious threat to health or safety: We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public. Disclosures, however, will be made only to someone who may be able to help prevent the threat.
9. Death: After your death, your information is confidential for fifty years. However, the executor of your estate may review your records. You can request in writing that your records be purged after your death. This request needs to be discussed with your estate attorney and be notarized. It is up to the clinician’s discretion whether or not to comply with this request.
10. Business associates: We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
11. Data breach notification purposes: We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.
12. Lawsuits and disputes: If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful processes by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
13. Public health risks: We may disclose Health Information for public health activities. These generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of
recalls of products they may be using; and a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. We will only make this disclosure if you agree or when required or authorized by law.
14. Coroners, medical examiners and funeral directors: We may release Health Information to a coroner
or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.
15. Inmates or Individuals in custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.
16. Workers’ compensation: We may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
17. Military and veterans: If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of the foreign military.
18. Health oversight activities: We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations,
inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
19. Organ and tissue donation: If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes, or tissues to facilitate organ, eye, or tissue donation and transplantation.
20. Couples and family sessions: We encourage family involvement in your care. If you are being seen in couples or family therapy, or if a family member becomes involved in your individual care, the clinician will have to exercise discretion when disclosing information to active participants but cannot promise absolute confidentiality. If there is a strong possibility of divorce or litigation, the physician cannot be an individual therapist and couples therapist for conflicting parties. You are the best judge of when your individual therapist can no longer be your couple’s therapist or your spouse’s individual therapist.
21. Minors: Laws regulate that certain information may or may not be shared with the minor’s legal guardian/parent. This also may be up to the discretion of the treatment provider, especially if the
disclosure would negatively affect the treatment progress with the patient.
22. Natural disasters: We cannot be held responsible for information that may become exposed as a result of inclement weather.
23. Law enforcement: We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement: (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency.
In the state of FL, if the physician thinks you engaged in careless behaviors that are potentially a risk to yourself and others such as driving under the influence, driving with seizures, driving with cognitive impairment, driving while having uncontrolled epilepsy or other threats that are not directed at a specific individual, we are not allowed to tell anyone about those risks. If you express a desire to hurt someone specific or bring in a form from the DMV assessing the safety of your driving, then we are required to report the truth.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask we only contact you by email or at work. To request confidential communications, you must make your request in writing to the office manager. We will accommodate reasonable requests.

RIGHT TO INSPECT AND COPY: You have the right to inspect and copy only part of the medical information that is used to make decisions about your care. This includes medical and billing records but does not include psychotherapy notes, information compiled for use in a civil, criminal, or administrative action or proceeding, and protected health information to which access is prohibited by law. In our records, psychotherapy notes are combined with medication notes and you only have access to the medications, mental status exam and diagnosis. The psychiatric diagnosis is a constant work in progress that is refined the more time the clinician spends with the patient. An initial diagnosis is frequently provisional. We may black out any other components of the note. An alternative, recommended option is to request a note summarizing your care by our practices. We will charge you the usual fees for the time it takes to address your request. In order to inspect and copy medical information, you must submit your request in writing to the office manager. We have up to 30 days to make your protected health information available to you. We may deny your request to inspect and copy under unique circumstances. If you are denied, you may request the denial be reviewed and another licensed health care professional chosen by this practice will review your request and the denial. We will comply with the outcome of that review. We recommend you only review your records in the presence of your clinician after careful discussion.

RIGHT TO AMEND: If you feel that the Health Information, we have is incorrect or incomplete, you may ask us to amend the information. You may write an amendment to the clinician or the office manager and we will add it to your chart. Practically, we cannot erase notes that have already been written in the electronic medical record so the only option is for you or the clinician to add an amendment.

RIGHT TO RECEIVE NOTICE OF A BREACH: You have the right to be notified upon a breach of any of your unsecured Protected Health Information. 

RIGHT TO REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request in writing to your clinician or office manager. We are not required to comply with your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or for health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

SENDING RECORDS: We recommend against releasing your complete psychiatric records to anyone for any reason. Routine psychiatric notes are not written for anyone other than the author and are subject to misinterpretation. Your clinician can prepare a summary of your treatment or a current psychiatric evaluation answering a specific question to a consultant. We will send a complete copy of your records to social security disability with your consent. A copy can be sent to another psychiatrist one time if you are transferring care, and they want to read your entire record. Every clinician we know would prefer a treatment summary. If you release your entire record, be aware that it may take time to paste all past electronic communications into your chart, and you will be charged for the time it takes to place them into the record. The fee for copying and if necessary, redacting psychotherapy notes is $1 a page. We will charge you the usual fees for the time it takes to address and comply with your request. In the event that your account is past due, records will not be released until the account is brought up to date. An alternative is to request pharmacy records.

RIGHT TO AN ACCOUNT OF NON-STANDARD DISCLOSURES: You have the right to request a list of the disclosures we made of medical information about you for purposes other than treatment, payment, or health care operations or for which you provided written authorization. You must submit your request to our practices and indicate the time period for which you want to receive a list of disclosures that is no longer than six years. This excludes the Department of Social Security.

PUBLICATION: We may use information from your records for research, teaching, and publication purposes. We will make it anonymous and keep your identity protected. If you are entered into a prospective clinical trial, separate consent will be required.

RULES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AND OPPORTUNITY TO OBJECT AND OPT OUT:

1. Individuals involved in your care or payment for your care: Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
2. Disaster relief: We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES: The following uses and disclosures of your Protected Health Information will be made only with your written authorization:
1. Uses and disclosures of Protected Health Information for marketing purposes; and
2. Disclosures that constitute a sale of your Protected Health Information
Other uses and disclosures of Protected Health Information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide authorization, you may revoke it at any time by submitting a written revocation to our office manager and we will no longer disclose Protected Health Information under the authorization. However, disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

I have reviewed the information contained within this consent and have been given the opportunity to ask questions regarding the information. I am physically and mentally competent to give consent. I understand that by signing this, I am giving my consent knowingly and voluntarily without any element of force, deceit, duress, or any other form of constraint or coercion.

I understand that my treatment is contingent upon my consenting to this document without modifications. I understand that either myself or someone legally authorized to make health care decisions on my behalf may revoke my consent in writing before or during treatment, except to the extent that our practices have taken all incurred costs of treatment. In signing, I agree to comply with the information contained within, without reservation.