Brighter Pathways © 2018
P.O. Box 372217
Satellite Beach, FL 32937
Licenses: SS00305 ~ MH02676 ~ PCE-9
Happy News: Part-time Reopening!
New Location: Satellite Beach, FL 32937
Primary Services: Gifted Psycho-Educational Reports
Federally Mandated Document
Appointment reminders and notification when an appointment is canceled or rescheduled;
As may be required by law;
For public health purposes such as reporting of child or elder abuse or neglect; reporting reactions to medications; infectious disease control; notifying authorities of suspected abuse, neglect, or domestic violence (if you agree or as required by law);
Mental health oversight activities, e.g., Audits, inspections or investigations of administration and management of Brighter Pathways;
Lawsuits and disputes (We will attempt to provide you advance notice of subpoena before disclosing information from your record.)
Law enforcement (e.g., in response to a court order or other legal process) to identify or locate an individual being sought by authorities; about victim of a crime under restricted circumstances; about a death that may be the result of criminal conduct; about criminal conduct that occurred in the practice; when emergency circumstances occur relating to a crime;
To prevent a serious threat to health or safety;
To carry out treatment and health care operations functions through transcription and billing services;
To military command authorities if you are a member of the armed forces or a member of a foreign military authority;
National security and intelligence activities;
Protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations.
Psychotherapy notes that are kept separate from the medical record have special protection and require authorization for release, with certain exceptions.
Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information.
Protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations
For disclosures concerning health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment, special restrictions may apply.
Psychiatric information. If needed for your diagnosis or treatment in a mental health program, psychiatric information may be disclosed. Certain limited information may be disclosed for payment purposes.
HIV-related information. HIV-related information may be disclosed for purposes of treatment or payment.
Substance abuse treatment. If you are treated in a specialized substance abuse program, your special authorization will be needed for most disclosures, not including emergencies.
Right to request restriction. You may request limitations on your mental health information we may disclose, but we are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Right to confidential communications. You may request communications in a certain way or at a certain location, but you must specify how or where you wish to be contacted.
Right to inspect and copy. You may have the right to inspect and copy your mental health information regarding decisions about your care; however, psychotherapy notes may not be inspected and copied. We may charge a fee for copying, mailing, and supplies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed mental health professional chosen by Brighter Pathways, Inc. Brighter Pathways, Inc. will comply with the outcome of the review.
Right to request clarification of the record. If you believe that the information we have about you is incorrect or incomplete you may ask to add clarifying information. You may ask for a form for that purpose and the form will require certain specific information. Brighter Pathways, Inc. is not required to accept the information that you propose.
Right to accounting of disclosures. You may request a list of the disclosures of your mental health information that have been made to persons or entities other than for treatment or health care operations in the last six (6) years, but not prior to April 14, 2003.
Right to a copy of this Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. You may print out a copy of this notice from any clinical website we provide.
6. REQUIREMENTS REGARDING THIS NOTICE. Brighter Pathways is required to provide
you with this Notice that governs our privacy practices. Brighter Pathways may change
its policies or procedures in regard to privacy practices. If and when changes occur,
the changes will be effective for mental health information we have about you as
well as any information we receive in the future. Any time you come in to Brighter
Pathways for an appointment, you may ask for and receive a copy of the Privacy Notice
that is in effect at the time.
7. COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with Brighter Pathways or with the HHS Office of Civil Rights. You will not be penalized or retaliated against in any way for making a complaint. Contact: Call Brighter Pathways, Inc. and ask to speak to the person responsible for privacy. If you have a complaint; if you have any questions about this notice; if you wish to request restrictions on uses and disclosure for health care treatment or operations; you may obtain any of the forms mentioned to exercise your individual rights described above.
Patient Name (Print) __________________________________________________________
Parent Name (Print)___________________________________________________________
Signature (Parent, or patient if 18 or older): ______________________________________
Relationship to patient: (parent, guardian, power of attorney)_______________
P.O. Box 372217 ~ Satellite Beach, FL 32937
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