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PRIVACY NOTICE As a client of The Chrysalis Center, you/your child has/have the right to privacy and confidentiality of your/your child’s medical record and treatment information, with a few limited exceptions described in this notice. This right to privacy and confidentiality is protected by federal and state law, as well as by Chrysalis Center policy. This notice describes in detail how The Chrysalis Center protects and safeguards your/your child’s right to privacy and confidentiality. Please review your/your child’s rights carefully, and if you have any questions or concerns, call us using the information listed under “Questions and Concerns” of this notice. We will be happy to answer any questions you may have. I. IN GENERAL It is the duty of The Chrysalis Center to protect and safeguard your private and confidential treatment and medical record information. This means that no person other than you is entitled to your treatment or medical record information, with the few exceptions described below. II. EXCEPTIONS; WHO YOUR INFORMATION MAY BE DISCLOSED TO (a) You The Chrysalis Center must disclose your treatment and medical record information to you. You can either review your treatment and/or medical record information in person or request in writing to obtain access to your information, by calling for an appointment or writing to the Privacy Officer at The Chrysalis Center (address and phone listed in Question and Concern section of this notice). The Chrysalis Center will provide you with copies of your medical record and/or schedule an appointment for you to see your medical record within 14 days of receipt of the request. (b) Your Legal Guardian If you are (1) under 18 years of age and are not emancipated or (2) have been declared mentally incompetent by a Florida court, then it is your legal guardian who is entitled to your Privacy and Confidentiality rights and who has the ability to enforce these rights. Your legal guardian also has the right to access all treatment disclosure made by you. Where there is such legal guardian, in order to protect the confidentiality of therapy disclosures as well as to encourage such disclosures which enhance treatment, we will ask the legal guardian to give us written permission to maintain your confidentiality of therapy disclosures unless you are at risk of imminent harm. (c) For Treatment Purposes, With Your Consent From time to time, we may need to use, disclose, or obtain documented information about you for the purposes of better providing you with evaluation, counseling and referral services. Some, but not all of the information that may be obtained or shared with another provider includes assessments, evaluations, discharge summaries, medical documents, educational reports, etc., but not including progress notes which will not be shared with another provider for treatment purposes. Additionally, at times we will need to communicate verbally with others about your treatment. Such communication regularly occurs between the treatment team, which includes the therapist, psychiatrist, supervisor, the counselor, and any other agencies and parties involved, such as the Department of Children and Families, the school or child care center, other mental health and social service providers, and/or case managers. Other times, you may want us to communicate with your family members as to your treatment. Prior to any documented information being obtained or disclosed, or any verbal communications being made, The Chrysalis Center will obtain your written consent to release or obtain that specific information to each party to whom we release information. Without such written consent, no documents will be obtained or disclosed and no verbal communications will occur. (d) For Health Care Operations, With Your Consent The Chrysalis Center may at times be required to use and disclose your Protected Health Information (PHI) to another agency for purposes such as billing, payment, contracting, authorizing, accrediting, auditing, reviewing, quality improvement, billing, payment or other related health care operation purposes. Protected Health Information includes data such as your name, social security number, date of birth, address and other identifying information. At the start of treatment, we will ask that you give us your consent to release your PHI for the purposes discussed in the previous paragraph. This one consent will cover all such release of PHI for health care operations purposes until your discharge, but you can limit and/or revoke your consent in writing at any time (see the Questions and Concern section of this notice below). Additionally, when releasing your PHI for health care operations purposes, The Chrysalis Center will only release information to the minimum extent necessary to accomplish the purpose of the release. Further, prior to The Chrysalis Center releasing any of your PHI for health care operation purposes, The Chrysalis Center will ensure that an agreement between The Chrysalis Center and the other entity is in place, where the other entity agrees to provide you with the privacy and confidentiality protections required by law and by our agency. (e) For Health and Safety At times, The Chrysalis Center may need to use and disclose your treatment and medical record information to avert a serious and imminent threat to your health or safety or the health or safety of others. When releasing your information under these circumstances, such information will be released only to the minimum extent necessary to avert the threat. When reasonably possible, the Chrysalis Center will attempt to obtain your written consent prior to the release of such information, but does not guarantee that such attempt to obtain consent will be made. Additionally, Florida law requires The Chrysalis Center to report to the Abuse Hotline any suspected child or elderly abuse, neglect, or abandonment. Florida law also requires that we report suspected domestic violence. (f) When Required to Disclose by Law The Chrysalis Center may disclose your treatment and medical record information to the minimum extent necessary when we are required to do so by law, for the purposes of the federal or state regulating body ensuring The Chrysalis Center is complying with all applicable laws and satisfying all of its legal obligations. When reasonably possible, the Chrysalis Center will attempt to obtain your written consent prior to the release of such information, but does not guarantee that such attempt to obtain consent will be made. The Chrysalis Center may also disclose your treatment and/or medical record information to the minimum extent necessary to a law enforcement official if you are a suspect, fugitive, material witness, crime victim, missing person, etc. The Chrysalis Center may additionally disclose the treatment and/or medical record information to the minimum extent necessary if you are an inmate or other person in lawful custody to a law enforcement official or correctional institution under certain circumstances or if it is necessary to assist law enforcement officials to capture an individual who has admitted to participation in a crime or has escaped from lawful custody. (g) For Court Proceedings The Chrysalis Center may be required to use or disclose your treatment and/or medical record information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under other limited circumstances, such as a court order, warrant, or grand jury subpoena, we may disclose your PHI to law enforcement officials. When reasonably possible, the Chrysalis Center will attempt to obtain your written consent prior to the release of such information, but does not guarantee that such attempt to obtain consent will be made. Also, such information will only be released to the minimum extent necessary to satisfy the request. (h)
For Military and National Security (i) For Research, Training or Quality Assurance The Chrysalis Center will not use or disclose any identifying information about you for: research, data, training or quality assurance unless we first (a) disclose to you in writing the purpose of such use, (b) limit the use of your information only to the extent necessary to fulfill such purpose, and (c) receive your written consent to such disclosure. (j) For Media Purposes The Chrysalis Center will not disclose your protected health information to the media without your voluntary and written consent. In the event that you voluntarily or inadvertently disclose, own your own, such confidential information about yourself or another Chrysalis Center client, it is with the understanding that The Chrysalis Center will not be held responsible for claims arising from your communications. (k) For Other Purposes, With Your Consent From time to time, situations may arise where we may need to disclose your confidential information under special circumstances. Such information will not be released unless we first (a) disclose to you in writing the purpose of such use, (b) limit the use of your information only to the extent necessary to fulfill such purpose, and (c) receive your written consent to such disclosure. III. YOUR RIGHTS (a) Duration of Consent; Right to Revoke or Limit Consent to Disclose Information At any time, if you give your written consent to the Chrysalis Center to release your information for any purpose, your written consent to release your information for treatment will remain valid through the length of treatment, unless otherwise noted, or you revoke or limit your consent. You have the right to revoke or limit the consent in writing at any time (see Questions and Concerns section for details). (b) Right to Request Amendments to Your Medical Record You have the right to request that we amend your medical record by writing to the Medical Records department at The Chrysalis Center. The writing must contain a detailed description of the amendments requested and the reasons for such request. Under certain circumstances, we may deny your request to amend your medical record. If The Chrysalis Center does so, we will provide you with a written reason for such denial within 14 days of receipt of the request for amendment. If you are unsatisfied with such response, you may use the procedures set out in the Questions and Concerns section of this Notice, to file an appeal. (c) Right to Request Restrictions on the Use and Disclosure of your PHI You have the right to request that we place certain additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement. However, if you are in need of emergency treatment and the restricted health information is needed to provide the emergency treatment, we may use or disclose that information to a health care provider in order to facilitate the provision of emergency treatment to you. Any agreement we may make to a request for additional restrictions must be in writing and signed by the person authorized to make such an agreement on our behalf. We will not be bound unless the agreement is so memorialized in writing. (d) Right to Request Your PHI Log You have the right to request a copy of your PHI log, which will show you all uses and disclosures of your PHI made by The Chrysalis Center to other parties. Such request can be made in writing to the Privacy Officer at the address listed in the Questions and Grievance section of this notice. (e) Right to Request Confidential Communications You have the right to request that we communicate with you in confidence about your health information at an alternative address or location. To make such request, please make such request in writing to The Chrysalis Center (see Questions and Grievances section). IV. OTHERS’ RIGHTS During the course of treatment with The Chrysalis Center, you may be privileged to the protected health information of other Chrysalis Center clients. When receiving such information, you agree to maintain the privacy of such other client’s protected health information to the same extent as the Chrysalis Center maintains your privacy. V. EFFECTIVE DATE This Privacy Notice takes effect on April 14, 2003 and will remain in effect until a revised notice is issued. A revised notice may be issued if (a) The Chrysalis Center chooses to revise this Privacy Notice or its Policies or (b) federal or state regulations requires The Chrysalis Center to make such revisions. The Chrysalis Center reserves the right to make changes in its privacy practices. Before we make a significant change in our privacy practices which will effect your rights, we will change this notice and send the new one to you and, if you are under 18 years of age, to your legal guardian. V. QUESTIONS AND CONCERNS If at any time you want more information about The Chrysalis Center’s privacy practices, or, have questions or concerns about this Notice or The Chrysalis Center’s Privacy Practices, please contact our Privacy Officer who will answer any questions or concerns you may have. You may also file a grievance with our privacy officer at: The Chrysalis Center, 3521 W. Broward Blvd., 3rd Floor, Fort Lauderdale, FL 33312, 954-587-1008, fax 954-587-0080. Any grievance filed will be investigated by The Chrysalis Center Management Team and the results of such investigation will be forwarded to you within 30 days of the receipt of your grievance. Furthermore, you have the right to submit any of your privacy grievance to the U.S. Department of Health and Human Services at: Secretary of Health and Human Services, 200 Independence Avenue, SW, Washington, D.C. 20201 The Chrysalis Center supports your right to protect the privacy of your treatment information and medical record and will not retaliate in any way if you choose to file a grievance with us or with the U.S. Department of Health and Human Service.   |
The Chrysalis Center 3521 W. Broward Boulevard, 3rd Floor • Ft. Lauderdale, FL 33312 • (954) 587-1008 • Fax: (954) 587-0080 • info@chrysaliscenter.org  |