THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that
requires that all medical and dental records and other individually identifiable health information
used or disclosed by us in any form, whether electronically, on paper or orally, are kept properly
confidential. This Act gives you, the patient, significant new rights to understand and control how
your health information is used. HIPAA provides penalties for covered entities that misuse Protected
Health Information (PHI).
This Notice of Privacy Practices describes how we 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 or condition and
related health care services.
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 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 health care professional has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for 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 activities, employee review activities, and conducting
or arranging for other business activities. We may use or disclose, as needed, your protected
health information to support the business activities of this practice. 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. We may call your home and leave a message (either on an answering machine or with
the person answering the phone) to remind you of an upcoming appointment, the need to schedule
a new appointment or to call our office. We may also mail a postcard reminder to your home address.
If you would prefer that we call or contact you at another telephone number or location, please let us
know. We may use or disclose your protected health information in the following situations without
your authorization. These situations include: as Required By Law, Public Health issues required by
law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration
requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation:
Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates:
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required
by the Secretary of the Department of Health and Human Services to investigate or determine our
compliance with the requirements of HIPAA. Other Permitted and Required Uses and Disclosures
Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.
You may revoke this 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.
Your Rights
The Following is a statement of your rights with respect to your protected
health information. You have the right to inspect and copy your protected health information. Under
federal law, however, you may not inspect or copy the following records; psychotherapy notes;
information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action
or proceeding, and protected health information that is subject to law that prohibits access to protected
health information. You have the right to request a restriction of your 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 you care or
for notification purposes described in this Notice of Privacy Practices. Your request must state the
specific restriction and to whom you want the restriction to apply. Your physician is not required to
agree to a restriction you may request. If your physician believes it is in your best interest to permit
use and disclosure of your protected health information, your protected health information will not
be restricted. You then have the right to use another Healthcare Professional. You have the right to
request to receive confidential communications 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 may have the right to have your physician
amend 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 we have made, if any, of your protected health information. We reserve the right to change
the terms of this Notice and will inform you of any changes. You then have the right to object or
withdraw as provided in this Notice.
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 privacy
officer of your complaint at our office and main telephone number.
We will not retaliate against you for filing a complaint.
This Notice was published and becomes effective on/or before 1/30/2010.
All Urgent Care, 1680 Fiske Blvd Rockledge FL, 32955
321-305-6903
