referral form

advanced health community and services
Please fill out the referral form below. Once the form has been submitted, our Intake Department will contact you as soon as possible. You can also contact us directly at: (954) 367-2840
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HIPAA Compliance Notice

The Health Insurance Portability and Accountability Act (HIPAA) signed into federal law in 1996 and as amended from time-to-time, establishes national standards safeguarding patient rights to privacy. HIPAA sets forth the scope and limits of the circumstances under which personal healthcare information may be used, specifying when and with whom protected healthcare information is permitted to be transacted, and under what conditions, levels of code uniformity, and security standards. It provides patients with expanded access to their personal medical records, while improving protection and restricting the ways in which their medical and related financial records can be used by third parties.
The law applies to all providers of healthcare services. Advance Health and Community Services respects the privacy and security of legally-protected health information, and understands the importance of keeping this information confidential and secure. As providers of behavioral and primary care health and pharmacy services, Advance Health and Community Services and its founders and affiliates are committed to the highest standards of effective and ethical standards of care for all of our consumers, and to compliance with patient rights as set forth in HIPAA. We provide initial and annual training on applicable HIPPA regulations for all personnel in our system and perform annual risk assessments, conducting investigations when warranted by circumstance.If you would like to learn more about patient health information, patient rights under HIPAA, and how we use and protect health information, please Contact Us.
(954) 367 2840
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We respect your privacy. We are required by law to maintain the privacy of “protected health information” about you, to notify you of our legal rights, to follow the privacy policies described in this notice, to notify you of any breach of your Protected Health Information, and to adhere to this Notice of Privacy Practices. When a revision to this notice is made, we will post a notice at each location and on our website so that you can request the revised copy.

“Protected Health Information” means any information that we create or receive that identifies you and relates to your health or payment for services to you.

Your Information

We will use your protected health information and disclose it to others as necessary to provide treatment to you. Here are some examples:

  • Various members of our staff may see your clinical record in the course of our care for you. This includes clinical assistants, nurses, physicians, case managers and other therapist.
  • It may be necessary to send blood samples to a laboratory for analysis to help us evaluate your medical condition.
  • We may provide information to your health plan or another treatment provider in order to arrange for a referral or clinical consultation. We will use or disclose your protected health information as needed to arrange for payment for service to you.

For example, information about your diagnosis and the service we render is included in the bills that we submit to your health insurance plan. Your health plan may require health information in order to confirm that the service rendered is covered by your benefit program and medically necessary.

It may also be necessary to use or disclose protected health information for our health care operations or those of another organization that has a relationship with you.

For example, our quality assurance staff reviews records to be sure that we deliver appropriate treatment of high quality. Your health plan may wish to review your records to be sure that we meet national standards for quality of care.

Our Policy:

We will obtain a general written permission to use and disclose your protected health information for treatment, payment or health care operations purposes.

You will be asked to sign a Consent form to permit all such uses and disclosures of your information.

- and –

We will obtain specific written permission for every disclosure of protected health information to third parties other than for payment purposes.

You will be asked to sign an Authorization form for disclosure to each person or organization that receives the information.

Emergencies. If there is an emergency, we will disclose your protected health information as needed to enable people to care for you.

Disclosure to your family and friends. If you are an adult, you have the right to control disclosure of information about you to any other person, including family members or friends.  If you ask us to keep your information confidential, we will respect your wishes. But if you don’t object, we will share information with family members or friends involved in your care as needed to enable them to help you.

Disclosure to health oversight agencies. We will disclose protected health information to certain government agencies, including the State of Florida Department of Children and Families.

Disclosures to child protection agencies. We will disclose protected health information as needed to comply with state law requiring reports of suspected incidents of child abuse or neglect.

Other disclosures without written permission. There are other circumstances in which we may be required by law to disclose protected health information without your permission. They include disclosures made:

  • Pursuant to court order;
  • To public health organizations;
  • To law enforcement officials in some circumstances;
  • To correctional institutions regarding inmates;
  • To federal officials for lawful military or intelligence activities;
  • To Medical examiners;
  • To researches involved in approved research projects; and
  • As otherwise required by law

Other disclosures. We will follow the provisions of 42 CFR Part 2 governing disclosure of protected health information. Except for the circumstances described above, we will not disclose protected health information to a third party without your written permission. Is a request for disclosure of your client record is received, you will be contacted and asked whether you wish to authorize disclosure. If you refuse to authorize disclosure, or it is not possible for us to contact you, we will not disclose your information without a court order. Each request for disclosure will have a specific name and address to which the information will be sent. We will never ask you to sign a non-specific release of information form.

Your Legal Rights: Right to request confidential communication. You may request that communications to you, such as appointment reminders, bills, or explanations of health benefits be made in a confidential manner. We will accommodate any such request, as long as you identify your preferred method.

Right to request restrictions on use and disclosure of your information. You have the right to request restrictions on our use of your protected health information for particular purposes, or our disclosure of that information to certain third parties. We are not obligated to agree to a request restriction, but we will consider your request. Requests may be made in writing to the Quality Management Department.

Right to revoke a Consent or Authorization. You may revoke a written Consent or Authorization for us to use or disclose your protected health information. The revocation will not affect any previous use or disclosure of your information.

Right to review and copy record. You have the right to see records used to make decisions about you. We will allow you to review your record unless a clinical professional determines that such review would create a substantial risk of physical harm to you or someone else. If another person provided information about you to our clinical staff in confidence, that information may be removed from the record before it is shared with you. We will also delete any protected health information about other people. To make a request, you can complete a request at our Medical Records Department or you can make it through the staff you usually work with. A reasonable fee for this service may be charged for copies.

Right to “amend” record. If you believe your record contains an error, you may request a change in writing to the Quality Management Department. If there is a mistake, a note will be entered in the record to correct the error. If your request is not due to an error, you will be told that the information is not an error and will be allowed the opportunity to add a short statement to the record explaining why you believe the information should be removed.

Right to an accounting. You have the right to an accounting of disclosures of your protected health information. This does not include disclosures that you authorize, or disclosures that occur for treatment, payment or health operations. If requested by law enforcement authorities who are conducting a criminal investigation, we will suspend accounting of disclosures made to them. Requests can be made in writing to the Medical Records Department.

How to Exercise Your Rights

Questions about our policies and procedures, requests to exercise individual rights, and complaints should be directed to the Director of Quality Management who can be reached at (954) 367-2840.

Personal Representatives. A “personal representative” of a patient may act on their behalf in exercising their privacy rights. This includes the parent or legal guardian of a minor. In some cases, adolescents who are “mature minors” may make their own decisions about receiving treatment and disclosure of protected health information about them. If an adult is incapable of acting on his or her own behalf, the personal representative would ordinarily be his or her spouse or another member of the immediate family. An individual can also grant another person the right to act as his or her personal representative in an advance directive or living will.

Complaints/Grievances If you have any compliant or concerns about our privacy policies or practices, please submit a Complaint to our Quality Management Department. Complaints should be submitted in writing on our Grievance Form. Forms are available at all locations in the reception area. Send the complaint to:

Quality Management Department: 8910 Miramar Parkway, Suite 207. Miramar, FL, 33025

You can also submit a compliant to the United States Department of Health and Human Services. Send you compliant to:

Office for Civil Rights

U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C. 20201

OCR Hotlines-Voices: 1 800-368-1019



Disability Rights FLA 1 800 342-0823

Broward DCF 954 762-3700

Dade DCF 305 377-5029