Child Client Intake Form (Page 8 of 8) in pdf

HOPE COUNSELING CENTERS

Phone: (863) 292-8292

Winter Haven Office

Fax: (863) 292-8283

160 Ave E., N.W.

Winter Haven, FL 33881

SUMMARY NOTICE OF PRIVACY PRACTICES

THIS IS A SUMMARY OF OUR NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES HOW PROTECTED

HEALTH INFORMATION (PHI) ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET

ACCESS TO THIS INFORMATION.

Our pledge to protect your privacy:

Hope Counseling Centers is committed to protecting the privacy of your protected health information. Your care and

treatment is recorded in a record. So that we can best meet your mental health needs, we share your record with the

providers involved in your care. We share your information only to the extent necessary to collect payment for the

services we provide, to conduct our business operations, and to comply with the laws that govern mental health care. We

will not use or disclose your information for any other purpose without your permission.

Client Rights - You have the following rights regarding your protected health information:



To request to inspect and obtain a copy of your records, subject to certain limited exceptions;



To request to add an addendum to or correct your record;



To request an accounting of Hope Counseling Centers’ disclosures of your information;



To request restrictions on certain uses or disclosures of your information;



To request that we communicate with you in a certain way or at a certain location;



And to receive a copy of the full version of our Notice of Privacy Practices.

We may use and disclose protected health information about you for the following purposes:



To provide you with mental health treatment and services;



To bill and receive payment for the treatment and services you receive;



For functions necessary to run Hope Counseling Centers and assure that our clients receive quality care;



And as required or permitted by law.

There are additional situations where we may disclose medical information about you without your authorization,

such as:



For workers’ compensation or similar programs;



For public health activities such as:

o Abuse/neglect of a child, elderly person, or a disabled person

o Serious threat to health or safety or self or others (e.g. imminent threat for suicide or homicide)



To a health oversight agency, such as the Florida Department of Health Services;



In response to a court or administrative order, subpoena, warrant or similar process;



To law enforcement officials in certain limited circumstances;



To a coroner, medical examiner or funeral director; and



To organizations that handle organ, eye, or tissue procurement or transplantation.

Our Notice may be revised or updated from time to time. Please see our full Notice of Privacy Practices for a more

detailed description of our privacy practices, your rights regarding you medical information, and pertinent contact

information.

For further information about the full Notice of Privacy Practices, please contact: Hope Counseling Centers at

(863) 709-8110. A complete version of this notice is available on our website at:

/privacy

Offices:

Lakeland | Winter Haven | Daytona | Tampa

Child Client Intake Form Page 8

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