Notice of Privacy Policy
THIS NOTICE OF PRIVACY PRACTICES (“NOTICE”) DESCRIBES HOW WE MAY
USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN GET
ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY.
1. ABOUT THIS NOTICE
This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices
describes how we, our Business Associates, and our Business Associates’ subcontractors, may use
and disclose your protected health information (PHI) to carry out treatment, payment, or health
care operations (TPO), and for other purposes that are permitted or required by law. It also
describes your rights to access and control your protected health information.
“Protected Health Information” is information about you, including demographic information, that
may identify you and that relates to your past, present, or future physical or mental health condition
and related health care services.
We are required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)
and other applicable laws to maintain the privacy of your health information, to provide individua ls
with this Notice of our legal duties and privacy practices with respect to such information, and to
abide by the terms of this Notice. We are also required by law to notify affected individua ls
following a breach of their unsecured health information.
2. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, our office staff,
and others outside of our office that are involved in your care and treatment for the purpose of
providing health care services to you, to pay your health care bills, to support the operation of the
physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or
manage your health care and any related services. This includes the coordination or management
of your health care with a third party. For example, your protected health information may be
provided to a physician to whom you have been referred to ensure that the physician has the
necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your
health care services. For example, obtaining approval for a hospital stay may require that your
relevant protected health information be disclosed to the health plan to obtain approval for the
hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in
order to support the business activities of your physician’s practice. These activities include, but
are not limited to, quality assessment, employee review, training of medical students, licensing,
fundraising, and conducting or arranging for other business activities. For example, we may
disclose your protected health information to medical school students who see patients at our
office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to
sign your name and indicate your physician. We may also call you by name in the waiting room
when your physician is ready to see you. We may use or disclose your protected health information,
as necessary, to contact you to remind you of your appointment, and inform you about treatment
alternatives or other health-related benefits and services that may be of interest to you. If we use
or disclose your protected health information for fundraising activities, we will provide you the
choice to opt out of those activities. You may also choose to opt back in.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your
Authorization or Opportunity to Agree or Object
We may use or disclose your protected health information in the following situations without your
authorization or providing you the opportunity to agree or object. These situations include:
Public Health: We may disclose your protected health information for public health activities and
purposes to a public health authority that is permitted by law to collect or receive the information.
For example, a disclosure may be made for the purpose of preventing or controlling disease, injury,
or disability.
Communicable Diseases: We may disclose your protected health information, if authorized by
law, to a person who may have been exposed to a communicable disease or may otherwise be at
risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight agency for
activities authorized by law, such as audits, investigations, and inspections. Oversight agencies
seeking this information include government agencies that oversee the health care system,
government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to a public health authority
that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose
your protected health information if we believe that you have been a victim of abuse, neglect or
domestic violence to the governmental entity or agency authorized to receive such information. In
this case, the disclosure will be made consistent with the requirements of applicable federal and
state laws.
Food and Drug Administration: We may disclose your protected health information to a person
or company required by the Food and Drug Administration for the purpose of quality, safety, or
effectiveness of FDA-regulated products or activities including, to report adverse events, product
defects or problems, biologic product deviations, to track products; to enable product recalls; to
make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any judicial or
administrative proceeding, in response to an order of a court or administrative tribunal (to the
extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena,
discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal
requirements are met, for law enforcement purposes. These law enforcement purposes include (1)
legal processes and otherwise required by law, (2) limited information requests for identification
and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred
as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice,
and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has
occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health
information to a coroner or medical examiner for identification purposes, determining cause of
death or for the coroner or medical examiner to perform other duties authorized by law. We may
also disclose protected health information to a funeral director, as authorized by law, in order to
permit the funeral director to carry out their duties. We may disclose such information in
reasonable anticipation of death. Protected health information may be used and disclosed for
cadaveric organ, eye or tissue donation purposes.
Research: We may disclose your protected health information to researchers when their research
has been approved by an institutional review board that has reviewed the research proposal and
established protocols to ensure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your
protected health information, if we believe that the use or disclosure is necessary to prevent or
lessen a serious and imminent threat to the health or safety of a person or the public. We may also
disclose protected health information if it is necessary for law enforcement authorities to identify
or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or
disclose protected health information of individuals who are Armed Forces personnel (1) for
activities deemed necessary by appropriate military command authorities (2) for the purpose of a
determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to
foreign military authority if you are a member of that foreign military services. We may also
disclose your protected health information to authorized federal officials for conducting national
security and intelligence activities, including for the provision of protective services to the
President or others legally authorized.
Workers’ Compensation: We may disclose your protected health information as authorized to
comply with workers’ compensation laws and other similar legally established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a
correctional facility and your physician created or received your protected health information in
the course of providing care to you.
Under the law, we must disclose your protected health information when required by the Secretary
of the Department of Health and Human Services to investigate or determine our compliance with
the requirements under Section 164.500.
Uses and Disclosures of Protected Health Information that Require Your Prior Written
Authorization
Other uses and disclosures of your PHI will be made only with your written authorization, unless
otherwise permitted or required by law as described below. You may revoke this authorization in
writing at any time. If you revoke your authorization, we will no longer use or disclose your
protected health information for the reasons covered by your written authorization. Please
understand that we are unable to take back any disclosures already made with your authorization.
Your prior written authorization is required for:
• Most uses and disclosures of psychotherapy notes
• Uses and disclosures of PHI for marketing purposes
• Disclosures of PHI that constitute a “sale” of protected health information
We will not use or disclose any of your protected health information that contains genetic
information that will be used for underwriting purposes.
You may revoke the authorization, at any time, in writing, except to the extent that your physician
or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the
authorization.
4. YOUR RIGHTS
The following are statements of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information (fees may apply).
Pursuant to your written request, you have the right to inspect or copy your protected health
information whether in paper or electronic format. Under federal law, however, you may not
inspect or copy the following records: Psychotherapy notes, information compiled in reasonable
anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health
information restricted by law, information that is related to medical research in which you have
agreed to participate, information whose disclosure may result in harm or injury to you or to
another person, or information that was obtained under a promise of confidentiality.
You have the right to request a restriction of your protected health information. This means
you may ask us not to use or disclose any part of your protected health information for the purposes
of treatment, payment or healthcare operations. You may also request that any part of your
protected health information not be disclosed to family members or friends who may be involved
in your care or for notification purposes as described in this Notice of Privacy Practices. Your
request must state the specific restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to your requested restriction except if you request that the
physician not disclose protected health information to your health plan with respect to healthcare
for which you have paid in full out of pocket.
You have the right to request to receive confidential communications. You have the right to
request confidential communication from us by alternative means or at an alternative location. You
have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed
to accept this notice alternatively i.e. electronically.
You have the right to request an amendment to your protected health information. If we
deny your request for amendment, you have the right to file a statement of disagreement with us
and we may prepare a rebuttal to your statement and will provide you with a copy of any such
rebuttal.
You have the right to receive an accounting of certain disclosures. You have the right to receive
an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an
authorization, for purposes of treatment, payment, healthcare operations; required by law, that
occurred prior to April 14, 2003, or six years prior to the date of the request.
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You have the right to receive notice of a breach. We will notify you if your unsecured protected
health information has been breached.
You have the right to obtain a paper copy of this notice from us even if you have agreed to
receive the notice electronically. We will also make available copies of our new notice if you
wish to obtain one.
We reserve the right to change the terms of this notice and we will notify you of such changes
on the following appointment.
5. COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you believe your
privacy rights have been violated by us. You may file a complaint with us by notifying our Practice
Manager/Privacy Officer of your complaint. We will not retaliate against you for filing a
complaint.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our
legal duties and privacy practices with respect to protected health information. We are also
required to abide by the terms of the notice currently in effect. If you have any questions in
reference to this form, please ask to speak with our Practice Manager/Privacy Officer in person or
by phone at our main phone number.
Phone: 833-377-4984
Email: Info@FloridaAdvancedMedicine.com
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