(b)   Payment – To get paid for services provided to you, the Practice may provide your PHI, directly or through a billing service, to a third party who may be responsible for your care, including insurance companies and health plans.  If necessary, the Practice may use your PHI in other collection efforts with respect to all persons who may be liable to the Practice for bills related to your care.  For example, the Practice may need to provide your insurance plan with information about health care services that you received from the Practice so that the Practice can be reimbursed.  The Practice may also need to tell your insurance plan about treatment you are going to receive so that it can determine whether or not it will cover the treatment expense.

(c)    Health Care Operations – To operate in accordance with applicable law and insurance requirements, and to provide quality and efficient care, the Practice may need to compile, use and disclose your PHI.  For example, the Practice may use your PHI to evaluate the performance of the Practice’s personnel in providing care to you.

OTHER EXAMPLES OF HOW THE PRACTICE MAY USE YOUR

PROTECTED HEALTH INFORMATION

(a)    Advice of Appointment and Services –The Practice may, from time to time, contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.  We may use and disclose medical information to contact you.  This contact may be by phone, in writing, e-mail, or otherwise, and may involve the leaving of an e-mail, a message on an answering machines, or otherwise which could (potentially) be received or intercepted by others.

(b)    Directory/Sign-In Log – The Practice may, from time to time, maintain a sign-in log at its reception desk for individuals seeking care and treatment in the office.  The sign-in log is located in a position where staff can readily see who is seeking care in the office, as well as the individual’s location within the Practice’s office suite.  This information may be seen by, and is accessible to, others who are seeking care or services in the Practice’s offices.

(c)    Family/Friends – The Practice may disclose to a family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person’s involvement with your care or the payment of your care.  The Practice may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply:

(i)                  If you are present at or prior to the use or disclosure of your PHI, the Practice may use or disclose your PHI if you agree, or if the Practice can reasonably infer from the circumstances, based on the exercise of its professional judgment, that you do not object to the disclosure.

(ii)                If you are not present, the Practice will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person’s involvement with your care.

OTHER USE & DISCLOSURES WHICH MAY

BE PERMITTED OR REQUIRED BY LAW

            The Practice may also use and disclose your PHI without your consent or authorization in the following instances:

(a)    De-identified Information – The Practice may use and disclose health information that may be related to your care but does not identify you and cannot be used to identify you.

(b)   Business Associate - The Practice may use and disclose PHI to one or more of its business associates if the Practice obtains satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI.  A business associate is an entity that assists the Practice in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies.

(c)    Personal Representative - The Practice may use and disclose PHI to a person who, under applicable law, has the authority to represent you in making decisions related to your health care.

(d)   Emergency Situations - The Practice may use and disclose PHI for the purpose of obtaining or rendering emergency treatment to you provided that the Practice attempts to obtain your Consent as soon as possible: The Practice may also use and disclose PHI to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation.

(e)    Public Health Activities - The Practice may use and disclose PHI when required by law to provide information to a public health authority to prevent or control disease.

(f)     Abuse, Neglect or Domestic Violence - The Practice may use and disclose PHI when authorized by law to provide information if it believes that the disclosure is necessary to prevent serious harm.

(g)    Health Oversight Activities - The Practice may use and disclose PHI when required by law to provide information in criminal investigations, disciplinary actions, or other activities related to the community’s health care system.

(h)    Judicial and Administrative Proceeding - The Practice may use and disclose PHI in response to a court order or a lawfully issued subpoena.

(i)      Law Enforcement Purposes - The Practice may use and disclose PHI, when authorized, to a law enforcement official.  For example, your PHI may be the subject of a grand jury subpoena, or if the Practice believes that your death was the result of criminal conduct.

(j)     Coroner or Medical Examiner - The Practice may use and disclose PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death.

(k)   Organ, Eye or Tissue Donation - The Practice may use and disclose PHI if you are an organ donor to the entity to whom you have agreed to donate your organs.

(l)      Research - The Practice may use and disclose PHI subject to applicable legal requirements if the Practice is involved in research activities.

(m)  Avert a Threat to Health or Safety - The Practice may use and disclose PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the threat.

(n)    Specialized Government Functions - The Practice may use and disclose PHI when authorized by law with regard to certain military and veteran activity.

(o)   Worker’s Compensation - The Practice may use and disclose PHI if you are involved in a Worker’s Compensation claim to an individual or entity that is part of the Worker’s Compensation system.

(p)   National Security and Intelligence Activities - The Practice may use and disclose PHI to authorized governmental officials with necessary intelligence information for national security activities.

(q)   Military and Veterans - The Practice may use and disclose PHI if you are a member of the armed forces, as required by the military command authorities.

AUTHORIZATION

            Uses and/or disclosures, other than those described above, will be made only with your written Authorization.

YOUR RIGHTS

You have the right to:

(a)    Revoke any Authorization or consent you have given to the Practice, at any time.  To request a revocation, you must submit a written request to the Practice’s Privacy Officer.

(b)   Request special restrictions on certain uses and disclosures of your PHI as authorized by the law.  In general, this relates to your right to request special restrictions concerning disclosures of your PHI regarding uses for treatment, payment and operational purposes under the Privacy  Rule, Section 164.522(a) and restrictions related to disclosure to your family and other individuals involved in your care under Privacy Rule, Sections 164510(b).  Except in certain instances, the Practice may not be obligated to agree to any requested restrictions.  To request restrictions, you must inform the Practice of what information you want to limit, whether you want to limit the Practice’s use and disclosure, or both, and to whom you want the limits to apply.  If the Practice agrees to your request, the Practice will comply with your request unless the information is needed in order to provide you with emergency treatment.

(c)    Receive confidential communications or PHI by alternative means or at alternative locations as provided by Privacy Rule, Section 164.522(b).  For instance, you may request all written communications to you marked “Confidential Protected Health Information.”  You must make your request in writing to the Practice’s Privacy Officer.  The Practice will accommodate all reasonable requests.

(d)   Inspect and copy your PHI as provided by federal law (including Privacy Rule, Section 164.524) and state law.  To inspect and copy your PHI, you must submit a written request to the Practice’s Privacy Officer.  The Practice can charge you a fee for the cost of copying, mailing or other supplies associated with your request.  In certain situations that are defined by law, the Practice may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written denial notice.

(e)    Amend you PHI as provided by federal law (including Privacy Rule, Section 164.526) and state law.  To request an amendment, you must submit a written request to the Practice’s Privacy Officer.  You must provide a reason that supports your request.  The Practice may deny your request, if the information to be amended was not created by the Practice (unless the entity that created the information is no longer available), if the information id not part of your PHI maintained by the Practice, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete.  If you disagree with the Practice’s denial, you will have the right tot submit a written statement of disagreement.

(f)     Receive an accounting of disclosures of your PHI as provided by federal law (including Privacy Rule Section 164.528) and state law.  To request an accounting, you must submit a written request tot he Practice’s Privacy Officer.  The request must state a time period, which may not be longer than six (6) years and may not include dates before April 14, 2003.  The request should indicate in what form you want the list (such as a paper or electronic copy).  The first list you request within a twelve (12) month periods will be free, but the Practice may charge you for the cost of providing additional lists.  The Practice will notify you of the costs involved and you can decide to with draw or modify your request before any costs are incurred.

(g)    Receive a paper copy of the Privacy Notice from the Practice (as provided by the Privacy Rule Section 164520(b)(1)(iv)(F)) upon request to the Practice’s Privacy Officer.

(h)    Complain to the Practice or to the Secretary of HHS (as provided by Privacy Rule Section 164.520(b)(1)(vi)) if you believe your privacy rights have been violated.  To file a complaint with the Practice, you must contact the Practice’s Privacy Officer.  All complaints must be in writing.

To obtain more information about your privacy rights or if you questions you want answered about your privacy rights (as provided by Privacy Rule Section 164.520(b)(2)(vii)), you may contact the Practice’s Privacy Officer as follows:

Name:                         Jeanne Faught

Address:                     7600 Dr. Phillips Blvd. Suite 74

                                    Orlando, FL 32828

Telephone No.:           407-226-0609 

PRACTICE’S REQUIREMENTS

The Practice:

(a)    Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI.

(b)   Under the Privacy Rule, May be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law.

(c)    Is required to abide by the terms of this Privacy Notice.

(d)   Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.

(e)    Will post a copy of the current notice in the Practice.  The notice will contain on the first page, in the top right-hand corner, the date of the last revision and effective date.  In addition, each time you visit the Practice for treatment or health care services you may request a copy of the current notice in effect prior to implementation.

(f)     Will not retaliate against you for filing a complaint.

EFFECTIVE DATE

This Notice is in effect as of 04/14/03.

PATIENT ACKNOWLEDGEMENT

            By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.

                                                                        Patient

                                                                        Print Name:                                                     

                                                                        Date:                /           /