C3 Institute (Dr. A & Associates) Notice of Policies & Practices to Protect the Privacy of Your PHI

This notice describes how psychological and medical information about you may be used and disclosed and how you can access this information. It contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your protected health information (PHI) used for treatment, payment, and health care operations. Please review it carefully.

OUR PLEDGE ABOUT THE CONFIDENTIALITY OF HEALTH INFORMATION

C3 Institute and its providers and staff (the “Practice”) understand your health information and health care is personal. We are committed to protecting health information about you. Your provider will need to create a record of the care and services you receive from the Practice. This Notice applies to the records of your care generated by this mental health care practice and follows certain legal requirements. This Notice informs you about the ways the Practice may use and disclose health information about you and describes your rights to the health information kept about you and certain obligations the Practice has about the use and disclosure of your health information.

1. Uses and Disclosures for Treatment, Payment, and Health Care Operations (“TPO”)

The Practice may use or disclose your protected health information (PHI) for treatment, payment, and healthcare operations purposes. Below are some definitions to help clarify these terms.
  • “PHI” refers to information in your health record that could identify you, such as your name, date of birth, phone number, or address.
  • “Treatment, Payment and Health Care Operations”
  • Treatment is when we provide, coordinate, or manage your therapy or assessment and other related services. In addition to direct services, this might include consultations with your other healthcare providers, such as your family physician or another psychologist.
  • Payment is when we obtain reimbursement for your healthcare, either directly from you or from a third party.
  • Health Care Operations are activities relating to the Practice’s performance and operation, such as quality assessment and improvement activities, business-related matters, audits and administrative services, and care coordination.
  • “Use” applies only to activities within the Practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • “Disclosure” applies to activities outside of the Practice, such as releasing, transferring, or providing access to information about you to other parties.

2. Uses and Disclosures Requiring Authorization

The Practice may use or disclose PHI for purposes outside of TPO or when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits specific disclosures. When the Practice is asked for information for purposes outside of TPO, authorization from you will be obtained before releasing this information. You may cancel all authorizations at any time, provided each cancellation is in writing. Cancellation of an authorization does not apply to the information that has been released.

3. Uses and Disclosures with Neither Consent nor Authorization

PHI may be disclosed without your consent or authorization in the following circumstances:
  • Child Abuse: If there is cause to believe a child has been or may be abused, neglected, sexually abused, or exploited, the Practice is legally mandated to file a report to the Abuse Hotline operated by the Florida Department of Children and Families.
  • Abuse of a Vulnerable Adult: If there is cause to believe an elderly or disabled person is in a state of abuse, neglect, or exploitation, the Practice is legally mandated to report such to the Abuse Hotline operated by the Florida Department of Children and Families.
  • Health Oversight: If a complaint is filed against the Practice or any of its clinicians or supervisors with the State Department of Health or Board of Psychology, the Board has the authority to subpoena confidential mental health information relevant to that complaint, and the Practice is required to respond to the subpoena.
  • Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged (protected) under state law and will not be released without written authorization from you or your personal or legally appointed representative or by a court order.
  • Serious Threat to Health or Safety: If it is determined there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, relevant confidential mental health information may be released to medical or law enforcement personnel.
  • First Responder Clients: Clients receiving services through a contracted first responder agency should understand that the practice’s primary role is to provide confidential treatment services. The providers will not routinely disclose information to employers, supervisors, command staff, human resources personnel, or agency representatives without the client’s written authorization unless otherwise required or permitted by law.
  • Worker’s Compensation: If you file a worker’s compensation claim, records about your diagnosis and treatment may be disclosed to your employer, employer’s insurance carrier, and/or their attorneys.

4. Certain Uses And Disclosures Require You To Have The Opportunity To Object

  • Disclosures to Family, Friends, or Others: The Practice may provide your PHI to a family member, friend, or another person you indicate is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

5. Text Message Communications

If you choose to communicate with C3 Institute by text message, standard text messaging rates may apply. Text messaging may be used for administrative purposes such as appointment reminders, scheduling, and other non-emergency practice communications. Because text messaging is not a fully secure method of communication, please do not send confidential or urgent clinical information by text. You may opt out of receiving text messages at any time by notifying the Practice or replying STOP when applicable.

6. Certain Uses And Disclosures Of Psychotherapy Notes Require Your Authorization

Psychotherapy Notes: Your Health Care Practitioner may keep “psychotherapy notes” as defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your authorization unless the use or disclosure is:
  • For your provider’s use in treating you.
  • For your provider’s use in training or supervising mental health practitioners.
  • For your provider’s use to defend themselves in legal proceedings instituted by you.
  • For the Secretary of Health and Human Services use to investigate your provider’s compliance with HIPAA.
  • Required by law and the use or disclosure is limited to the requirements of such law.

Patient’s Rights and Provider’s Duties

Patient’s Rights Regarding Your PHI

  • Right to Request Restrictions on certain uses and disclosures of your PHI.
  • Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full.
  • Right to Choose How I Send PHI to You and receive confidential communications by alternative means and at alternative locations.
  • Right to See and Get Copies of Your PHI (other than psychotherapy notes).
  • Right to an Accounting of disclosures made of your PHI.
  • Right to Amend, Correct or Update Your PHI.
  • Right to Get a Paper or Electronic Copy of this Notice.

Provider’s Duties

The Practice is required by law to maintain the privacy of PHI, to give you a notice of our legal duties and privacy practices regarding PHI, and to tell you if your PHI is breached. The Practice reserves the right to revise this Notice and make the revised Notice effective for all protected health information maintained by the Practice.

7. Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Practice: Dr. Allison Agliata, Clinical Director C3 Institute Phone: (813) 473-2278 Email: Allison@DrACoaching.com You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.

8. Civil Rights Notice

C3 Institute (Dr. Allison & Associates) and its providers comply with applicable federal and state civil rights laws and do not discriminate in the provision of services on the basis of race, color, national origin, religion, sex, age, disability, marital status, sexual orientation, gender identity, veteran status, or any other characteristic protected by law.

9. Effective Date, Restrictions, and Changes to Privacy Policy

This Notice is effective June 6, 2026, and applies to the patient upon receipt.