Siesta Addictions Specialists (DBA Sarasota Addiction Specialists; MindSol Wellness Center)

HIPAA Notice of Privacy Practices

(Effective January 1, 2019)


This HIPAA Notice of Privacy Practices (the “Notice”) contains
important information regarding your medical information. Our current
Notice is posted at You also
have the right to receive a paper copy of this Notice and may ask us to
give you a copy of this Notice at any time. If you received this Notice
electronically, you are entitled to a paper copy of this Notice. If you
have any questions about this Notice please contact the party listed in
Part 7, below.The Health Insurance Portability and Accountability Act
of 1996 (“HIPAA”) imposes numerous requirements on health plans
and health care providers regarding how certain individually
identifiable health information – known as protected health information
or PHI – may be used and disclosed.
This Notice describes how Sarasota Addiction Specialists, Inc. (SAS),
and any third party that assists SAS, may use and disclose your
protected health information for treatment, payment, or health care
operations and for other purposes that are permitted or required by
law. This Notice also describes your rights to access and control your
protected health information. “Protected health information” is
information that is maintained or transmitted by SAS, which may
identify you and that relates to your past, present, or future physical or
mental health or condition and related health care services.We
understand that medical information about you and your health is
personal. We are committed to protecting medical information about

you and will use it to the minimum necessary to accomplish the
intended purpose of the use, disclosure, or request of it. This Notice
applies to all of the medical records SAS maintains.Your personal
doctor or health care provider may have different policies or notices
regarding his/her use and disclosure of your medical information.We
are required by law to abide by the terms of this Notice to:
•Make sure that medical information that identifies you is kept private.
•Give you this Notice of our legal duties and privacy practices with
respect to medical information about you.
•Follow the terms of the Notice that is currently in effect.
HIPAA generally permits use and disclosure of your health information
without your permission for purposes of health care treatment,
payment activities, and health care operations. These uses and
disclosures are more fully described below. Please note that this
notice does not list every use or disclosure, instead it gives examples
of the most common uses and disclosures.
•Treatment: When, and as appropriate, we may use or disclose
medical information about you to facilitate medical treatment or
services. We may disclose medical information about you to health
care providers, including doctors, nurses, technicians or other SAS
personnel who are involved in taking care of you. For example, your
primary counselor may speak with his/her clinical supervisor in order
to seek information regarding your care. Any staff member within SAS
will only receive the amount of information he/she needs in order to
provide you with services.
•Payment:We will disclose health information about you in order to be
reimbursed for services we provide to you. This includes
determinations of insurance eligibility, coverage, and other utilization

review activities. For example, prior to providing services, we may
need to provide your health insurance carrier with information about
your condition to determine if your treatment with SAS will be covered.
When we submit the bill to your health insurance carrier, we will
provide the carrier with information regarding the services that you
received. SAS contracts with a variety of agencies, such as Central
Florida Behavioral Health Network, Florida’s Department of Children
and Families, the U.S. Probation Office, and the Florida Department of
Corrections for payment for services provided in some programs. Your
information will only be submitted to the appropriate organizations for
administrative and payment purposes.
•Health Care Operations: When, and as appropriate, we may use and
disclose medical information about you for health care
operations.Health care operations include all of the support functions
that are related to treatment and payment such as quality assurance
activities, compliance programs, audits for licensure, contracts and
accreditation,business planning, administrative activities,legal
services, and fraud and abuse detection programs. For example, staff
members working within the Medical Records Department may need
to access your information in order to ensure the chart is complete
and accurate. Clinical staff members review the charts of other clinical
staff members as part of our Quality Improvement Process to ensure
that you receive quality care. Your health information may be
disclosed to external entities in order for SAS to remain licensed and
accredited. Florida’s Department of Children and Families routinely
audits client charts in order to ensure that clients are receiving
appropriate care. The Commission on Accreditation of Rehabilitation
Facilities (CARF) provides SAS with national accreditation and part of
its accreditation process involves the review of client records.We will
always try to ensure that the medical information used or disclosed will

be limited to a “Designated Record Set” and to the “Minimum
Necessary” standard, including a “Limited Data Set,” as defined in
HIPAA and ARRA (as defined in Part 3, below) for these purposes.
We may also contact you to provide information about treatment
options or alternatives or other health-related benefits and services
that may be of interest to you.
•Disclosure to Others Involved in Your Care: We may disclose
medical information about you to a relative, a friend or to any other
person you have authorized, provided the information is directly
relevant to that person’s involvement with your health care or payment
for that care. For example, if a family member or a caregiver calls us
with prior knowledge of a claim and asks us to help verify the status of
a claim, we may agree to help them confirm whether or not the claim
has been received and paid.
•Medical Emergency:If you have a medical emergency while on SAS
property,or if you are engaged in a SAS authorized/sponsored activity
while off-site while you are a client of a SAS residential treatment
program, and are unable to provide consent, we may release your
information to emergency medical services in order for you to receive
emergency medical care.
•Workers’ Compensation: We may release medical information about
you for workers’ compensation or similar programs. These programs
provide benefits for work related injuries or illness.
•To Comply with Federal and State Requirements: We will disclose
medical information about you when required to do so by federal, state
or local law. For example, we may disclose medical information, when
required by the U.S. Department of Labor or other government
agencies that regulate us, to federal, state and local law enforcement
officials in response to a judicial order, subpoena or other lawful

process, and to address matters of public interest as required or
permitted by law (for example, reporting child abuse and neglect,
threats to public health and safety and for national security reasons).
We are required to disclose medical information about you to the
Secretary of the U.S. Department of Health and Human Services if the
Secretary is investigating or determining compliance with HIPAA or to
authorized federal officials for intelligence, counterintelligence and
other national security activities authorized by law. We may disclose
your medical information to a health oversight agency for activities
authorized by law (such as audits, investigations, inspections and
•To Avert a Serious Threat to Health or Safety: We may use and
disclose medical information about you when necessary to prevent a
serious threat to your health and safety or the health and safety of the
public or another person. Any disclosure, however, would only be to
someone able to help prevent the threat. For example, we may
disclose medical information about you in a proceeding regarding the
licensure of a physician.
•Military and Veterans: If you are a member of the armed forces, we
may release medical information about you as required by military
command authorities. We may also release medical information about
foreign military personnel to the appropriate foreign military authority.
•Business Associates: We may disclose your medical information to
our business associates. We have contracted with entities (defined as
“business associates” under HIPAA) to help us administer your
benefits. We will enter into contracts with these entities requiring them
to only use and disclose your health information as we are permitted
to do so under HIPAA.
•Appointments and reminders:We may use your information to try to
contact you if you miss an appointment or if you have been on a

waiting list for a treatment slot. These contacts may be by telephone.
SAS’s actual phone number does not appear on caller ID so no one
will know that we tried to contact you. We will not leave a voice mail
message with any information that could identify SAS, unless we have
your express permission to do so.
•Other Uses: If you are an organ donor, we may release your medical
information to organizations that handle organ procurement or organ,
eye or tissue transplantation or toan organ donation bank, as
necessary to facilitate organ or tissue donation and transplantation.
We may release your medical information to a coroner or medical
examiner. If you are an inmate of a correctional institution or under the
custody of a law enforcement official, we may release your information
to the correctional institution or law enforcement official.
Uses and disclosures other than those described in this Notice will
require your written authorization. You may revoke your authorization
at any time; however you cannot revoke your authorization for
disclosures upon which SAS has already acted.The privacy laws of
Florida or other federal laws might impose a stricter privacy standard.
If these stricter laws apply and are not superseded by federal
preemption rules under the Employee Retirement Income Security Act
of 1974, then SASwill comply with the stricter law. Except for the
instance described above, SAS will not release any information about
you without a written authorization for the specific disclosure. SAS will
request a written authorization from you, even if the disclosure is at
your request. If you are participating in a treatment program as a
requirement of satisfying your responsibility to the criminal justice or
family safety systems, you will be asked to sign an authorization form
specifically to that entity. If you choose not to provide an authorization,
we may decline to provide you with services. Following your

discharge from treatment, we would like to follow-up with you to see
how you are doing. Additionally, if your treatment was paid for by the
State of Florida (all or in part), the state would like to contact you by
telephone so that you may provide feedback about our organization
and the care that you received. This information is used to improve the
quality of our services, and any information that you provide is treated
as confidential information.The Consent to Participate in Follow-up
form allows us to keep a record of your willingness to participate in
these follow-up opportunities. If you are willing to participate, please
sign the form in the space provided in the middle portion of the form. If
you do not wish to participate, please check the box at the bottom of
the form and in the space available. Your treatment will not be
affected by your choice to participate or not to participate. At time of
discharge, you will be granted the opportunity to sign-up and receive
information regarding SAS alumni organization activities. If you miss
this opportunity and would like to be a member of or receive
information about SAS’s alumni organization, please contact SAS’s
Marketing Coordinator at 941-444.6560.
Changes in our Privacy Practices
SAS reserves the right to change its privacy practices. These changes
will be applied to all protected health information that SAS already has
about you as well as any information SAS received on or after the
effective date of the change. SAS will provide you with a revised and
updated copy of this notice if our privacy practices materially change.
This notice will be provided at your next visit or next appointment with
your counselor.
Youhave the following rights regarding medical information we
maintain about you:

  • Right to Inspect and Copy: You have the right to inspect and obtain a
    copy of your medical information. If you request a copy of the
    information, we may charge a fee for the costs of copying, mailing, or
    supplies associated with your request. We may deny your request to
    inspect and copy in certain very limited circumstances. If you are
    denied access to medical information, you may request that the denial
    be reviewed. Your Right to Amend: If you feel that medical information
    we have about you is incorrect or incomplete, you may ask us to
    amend the information. You have the right to request an amendment
    for as long as the information is kept by SAS. In addition, you must
    provide a reason that supports your request. We may deny your
    request for an amendment if it is not in writing or does not include a
    reason to support the request. In addition, we may deny your request
    if you ask us to amend any of the following information:
    •Information that is not part of the medical information kept by or for
    •Information that was not created by us, unless the person or entity
    that created the information is no longer available to make the
    •Information that is not part of the information which you would be
    permitted to inspect and copy.
    •Information that is accurate and complete.
    •Psychotherapy notes.
    •Information compiled in reasonable anticipation of, or for use in, a
    civil, criminal, or administrative action or proceeding.
    •Your Right to an Accounting of Disclosures: You have the right to
    request an “accounting of disclosures” (i.e., a list of certain disclosures
    SAS has made of your health information). Generally, you may
    receive an accounting of disclosures if the disclosure is required by
    law, made in connection with public health activities, or in similar

situations as those listed above as “Other Permitted Uses and
Disclosure’s”. You do not have a right to an accounting of disclosures
where such disclosure was made:
•For treatment, payment, or health care operations.
•To you about your own health information.•Incidental to other
permitted disclosures.
•Where authorization was provided.
•To family or friends involved in your care (where disclosure is
permitted without authorization).
•For national security or intelligence purposes or to correctional
institutions or law enforcement officials in certain circumstances.
•As part of a limited data set where the information disclosed
excludes identifying information.To request this list or accounting of
disclosures from a non-electronic health record, you must submit your
request which shall state a time period, which may not be longer than
six years and may not include dates before January 1, 2019. Your
request should indicate in what form you want the list (for example,
paper or electronic). Notwithstanding the foregoing, you may request
an accounting of disclosures as it pertains to your “electronic health
record” (i.e., an electronic record of health-related information on you
that is created, gathered, managed and consulted by authorized
health care clinicians and staff), provided that you must submit your
request and state a time period which may be no longer than three
years prior to the date on which the accounting is requested. In the
case of any electronic health record created on your behalf as of
January 1, 2019, this paragraph shall apply to disclosures made on or
after January 1, 2019. In the case of any electronic health record
created on your behalf after January 1, 2019, this paragraph shall
apply to disclosures made on or after the later of January 1, 2019 or
the date SAS acquired the electronic health record. You may request

an accounting of disclosures in paper or electronic format. If a paper
format is requested, the first list you request within a 12-month period
will be free. For additional lists, we may charge you for the costs of
providing the list. We will notify you of the cost involved and you may
choose to withdraw or modify your request at that time before any
costs are incurred. If an electronic format is requested, we may charge
you for the labor costs in responding to the request.
•Your Right to Request Restrictions: You have the right to request a
restriction or limitation on the medical information we use or disclose
about you for treatment, payment, or health care operations. You also
have the right to request a limit on the medical information we disclose
about you to someone who is involved in your care or the payment for
your care, like a family member or friend. For example, you could ask
that we not use or disclose information about a surgery that you
had.We are not required to agree to your request. If SAS does agree
to a request, a restriction may later be terminated by your written
request, by agreement between you and SAS (including orally), or
unilaterally by SAS for health information created or received after
SAS has notified you that it has removed the restrictions and for
emergency treatment. To request restrictions, you must make your
request in writing and must tell us the following information:
•What information you want to limit.
•Whether you want to limit our use, disclosure, or both.
•To whom you want the limits to apply (for example, disclosures to
your spouse).
•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 that we
only contact you at work or by mail.We will not ask you the reason for
your request. We will accommodate all reasonable requests. Your

request must specify how or where you wish to be contacted.You
must make any of the requests described above, to the party listed in
Part 7, below.
3.BREACH NOTIFICATION Pursuant to changes to HIPAA mandated
by the Health Information Technology for Economic and Clinical
Health Act of 2009 and the regulations promulgated thereunder
(collectively, “the HITECH Act”) under the American Recovery and
Reinvestment Act of 2009 (“ARRA”), this Notice also reflects new
federal breach notification requirements imposed on SAS in the event
that your “unsecured” protected health information (as defined under
the HITECH Act) is acquired by an unauthorized party. We
understand that medical information about you and your health is
personal and we are committed to protecting your medical information.
Furthermore, we will notify you following the discovery of any “breach”
of your unsecured protected health information as defined in the
HITECH Act (the “Notice of Breach”). Your Notice of Breach will be in
writing and provided via first-class mail, or alternatively, by e-mail if
you have previously agreed to receive such notices electronically.
Otherwise, if the breach involves:
•10 or more individuals for whom we have insufficient or out-of-date
contact information, then we will provide substitute individual Notice of
Breach by either posting the notice on the SAS web site on the
internet or by providing the notice in major print or broadcast media
where the affected individuals are likely to reside.
•Less than 10 individuals for whom we have insufficient or out-of-date
contact information, then we will provide substitute Notice of Breach
by an alternative form. Your Notice of Breach shall be provided
without unreasonable delay and in no case later than 60 days
following the discovery of a breach and shall include, to the extent

  • A description of the breach.
    •A description of the types of information that were involved in the
    •The steps you should take to protect yourself from potential harm.
    •A brief description of what we are doing to investigate the breach,
    mitigate the harm, and prevent further breaches.
    •Our relevant contact information.Additionally, for any substitute
    Notice of Breach provided via web posting or major print or broadcast
    media, the Notice of Breach shall include a toll-free number for you to
    contact us to determine if your protected health information was
    involved in the breach.
    If you believe your privacy rights have been violated, you may file a
    complaint with SAS or with the Secretary of the Department of Health
    and Human Services. To file a complaint with SAS, submit your
    complaint in writing to the party listed in Part 7, below.All complaints
    must be submitted in writing.You will not be penalized for filing a
    Other uses and disclosures of medical information not covered by this
    Notice or the laws that apply to us will be made only with your written
    permission. If you grant us permission to use or disclose medical
    information about you, you may revoke that permission, in writing, at
    any time. If you revoke your permission, we will no longer use or
    disclose medical information about you for the reasons covered by
    your written authorization. You understand that we are unable to take
    back any disclosures we have already made with your permission,
    and that we may be required to retain our records.
    The effective date of this Notice is January 1, 2019.

7.CONTACT INFORMATIONAll correspondence relating to the
contents of this Notice should be directed as follows:Attn: Director of
Quality Improvement SAS, Inc. 715 North Washington Blvd Suite E
Sarasota, FL 34236 941-444-6560

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