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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.

I. Our Duty to Safeguard Your Protected Health Information

We understand that medical information about you is
personal and confidential. Be assured that we are
committed to protecting that information. We are required
by law to maintain the privacy of protected health
information and to provide you with this Notice of our
legal duties and privacy practices with respect to protected
health information. We are required by law to abide by
the terms of this Notice, and we reserve the right to change
the terms of this Notice, making any revision applicable to
all the protected health information we maintain. If we
revise the terms of this Notice, we will post a revised
notice and make paper and electronic copies of this Notice
of Privacy Practices for Protected Health Information
available upon request. We are required by law to notify
you in the event of a breach of your protected health
information.

In general, when we release your personal information, we
must release only the information needed to achieve the
purpose of the use or disclosure. However, all of your
personal health information that you designate will be
available for release if you sign an authorization form, if
you request the information for yourself, to a provider
regarding your treatment, or due to a legal requirement.
We will not use or sell any of your personal information
for marketing purposes without your written
authorization.

II. How We May Use and Disclose Your Protected Health Information.

For uses and disclosures relating to treatment, payment, or
health care operations, we do not need an authorization to
use and disclose your medical information:

For treatment: We may disclose your medical
information to doctors, nurses, and other health care
personnel who are involved in providing your health care.
We may use your medical information to provide you with
medical treatment or services. For example, your doctor
may be providing treatment for a heart problem and need
to make sure that you don’t have any other health
problems that could interfere. The doctor might use your
medical history to determine what method of treatment
(such as a drug or surgery) is best for you. Your medical
information might also be shared among members of your
treatment team, or with your pharmacist(s).

To obtain payment: We may use and/or disclose your
medical information in order to bill and collect payment
for your health care services or to obtain permission for an
anticipated plan of treatment. For example, in order for
Medicare or an insurance company to pay for your
treatment, we must submit a bill that identifies you, your
diagnoses, and the services provided to you. As a result,
we will pass this type of health information on to an
insurer to help receive payment for your medical bills.

For health care operations: We may use and/or
disclose your medical information in the course of
operating our practice. For example, we may use your
medical information in evaluating the quality of services
provided or disclose your medical information to our
accountant or attorney for audit purposes.

In addition, unless you object, we may use your health
information to send you appointment reminders or information about treatment alternatives or other health
related benefits that may be of interest to you. For
example, we may look at your medical record to determine
the date and time of your next appointment with us, and
then send you a reminder to help you remember. Or, we
may look at your medical information and decide that
another treatment or a new service we offer may interest
you.

We may also use and/or disclose your medical information
in accordance with federal and state laws for the following
purposes:

  • We may disclose your medical information to law
    enforcement or other specialized government
    functions in response to a court order, subpoena,
    warrant, summons, or similar process.
  • We may disclose medical information when a law
    requires that we report information about
    suspected abuse, neglect or domestic violence, or
    relating to suspected criminal activity, or in
    response to a court order. We must also disclose
    medical information to authorities who monitor
    compliance with these privacy requirements
  • We may disclose medical information when we
    are required to collect information about disease
    or injury, or to report vital statistics to the public
    health authority. We may also disclose medical
    information to the protection and advocacy
    agency, or another agency responsible for
    monitoring the health care system for such
    purposes as reporting or investigation of unusual
    incidents.
  • We may disclose medical information relating to
    an individual’s death to coroners, medical
    examiners or funeral directors, and to organ
    procurement organizations relating to organ, eye,
    or tissue donations or transplants.
  • In certain circumstances, we may disclose
    medical information to assist medical/psychiatric
    research
  • In order to avoid a serious threat to health or
    safety, we may disclose medical information to
    law enforcement or other persons who can
    reasonably prevent or lessen the threat of harm, or to help with the coordination of disaster relief
    efforts.
  • If people such as family members, relatives, or
    close personal friends are involved in your care or
    helping you pay your medical bills, we may
    release important health information about your
    location, general condition, or death.
  • We may disclose your medical information as
    authorized by law relating to worker’s
    compensation or similar programs.
  • We may disclose your medical information in the
    course of certain judicial or administrative
    proceedings.

Other uses and disclosures of your medical
information:

State Health Information Exchange: We may make your
health information available electronically to other
healthcare providers outside of our facility who are
involved in your care.

Electronic Patient Chart Sharing: We may make your
health information available electronically to other
healthcare providers outside of our facility who are
involved in your care.

Treatment Alternative: We may provide you notice of
treatment options or health related services that improve
your overall health.

Appointment Reminders: We may contact you as a
reminder about upcoming appointments or treatment.

The following uses and disclosure of PHI require
your written authorization:

  • Marketing
  • Disclosures for any purposes which require the
    sale of your information
  • Release of psychotherapy notes: Psychotherapy
    notes are the notes by a mental health professional
    for the purposes of documenting a conversation
    during a private session. This session could be
    with an individual or a group. These notes are kept
    separate from the rest of the medical record and do not include; medications and how they affect
    you, start and stop time of sessions, types of
    treatments provided, results of test, diagnosis,
    treatment plan, symptoms, prognosis.

Other uses and disclosures of PHI not covered by this
Notice, or by the laws that apply to us, will be made only
with your written authorization. If you provide permission
to use or disclose medical information about you, you may
revoke that permission, in writing, at any time. You
understand that we are unable to take back any disclosures
we have already made with your permission, and that we
are required to retain our records of the care that we
provided you.

III. Your Rights Regarding Your Medical Information.

You have several rights with regard to your health
information. If you wish to exercise any of these rights,
please contact our Medical Records Department in our
office. Specifically, you have the following rights:

  • Right to Request Restrictions – You have the
    right to ask that we limit how we use or disclose
    your medical information. We require that any
    requests for use or disclosure of medical
    information be made in writing. Written notice
    must be sent to the attention of the Office
    Manager at the practice and address indicated in
    the header of this Notice. We will consider your
    request, but in some cases, we are not legally
    required to agree to these requests. However, if we
    do agree to them, we will abide by these
    restrictions. We will always notify you of our
    decisions regarding restriction requests in writing.
    We will not ask you the reason for your request.
    For example, for services you request no
    insurance claim be filed and for which you pay
    privately, you have the right to restrict disclosures
    for these services for which you paid out of
    pocket. You have the right to ask that we send
    you information at an alternative address or by
    alternative means. Your request must specify how
    or where you wish to be contacted. You have the
    right to opt out of communications for fundraising
    purposes
  • Right to Access, Inspect and Copy – With a
    few exceptions (such as psychotherapy notes or
    information gathered for judicial proceedings), you have a right to inspect and copy your
    protected health information if you put your
    request in writing. If we deny your access, we will
    give you written reasons for the denial and explain
    any right to have the denial reviewed. We may
    charge you a reasonable fee if you want a copy of
    your health information. You have a right to
    choose what portions of your information you
    want copied and to have prior information on the
    cost of copying. Consent is required prior to use
    or disclosure of an individual’s psychotherapy
    notes or the use of the individuals PHI for
    marketing purposes
  • Right to Amend – If you believe that there is a
    mistake or missing information in our record of
    your medical information you may request that we
    correct or add to the record. Your request must be
    in writing and give a reason as to why your health
    information should be changed. Any denial will
    state the reasons for denial and explain your rights
    to have the request and denial, along with any
    statement in response that you provide, appended
    to your medical information. If we approve the
    request for amendment, we will amend the
    medical information and so inform you.
  • Right to an Accounting of Disclosures – In
    some limited circumstances, you have the right to
    ask for a list of the disclosures of your health
    information we have made during the previous six
    years. The list will not include disclosures made
    to you; for purposes of treatment, payment or
    healthcare operations, for which you signed an
    authorization or for other reasons for which we are
    not required to keep a record of disclosures. There
    will be no charge for up to one such list each year.
    There may be a charge for more frequent requests
  • Right to a Paper Copy of This Notice – You have
    a right to receive a paper copy of this Notice
    and/or an electronic copy from our Web site. If
    you have received an electronic copy, we will
    provide you with a paper copy of the Notice upon
    request.

IV. Our Responsibilities:

  • We are required by law to maintain the privacy
    and security of your protected health information.
  • We will let you know promptly if a breach occurs
    that may have compromised the privacy or
    security of your information.
  • We must follow the duties and privacy practices
    described in this notice and give you a copy of it.
  • We will not use or share your information other
    than as described here unless you tell us we can in
    writing. If you tell us we can, you may change
    your mind at any time and notify us in writing.

Questions and Complaints:

If you want more information about our privacy
practices or have questions or concerns, we encourage
you to contact us

If you think we may have violated your privacy rights,
or you disagree with a decision we made about access
to your medical information, we encourage you to
speak or write to our Privacy Officer.

If you have questions about this Notice or any
complaints about our privacy practices, please
contact:

Office of the HIPAA Privacy and Security Officer

Phone: 1.866.825.1606
1501 Yamato Road
Suite 200 West
Boca Raton, FL 33431

If you want more information about our privacy
practices or have questions or concerns, we encourage
you to contact us.

If you think we may have violated your privacy rights,
or you disagree with a decision we made about access
to your medical information, we encourage you to
speak or write to our Privacy Officer.

You also may file a written complaint with the
Secretary of the U.S. Department of Health and Human Services at the Office for Civil Rights’ Region
IV office.

Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
Email to OCRComplaint@hhs.gov

We will take no retaliatory action against you if you
make complaints, whether to us or to the Department
of Health and Human Services. We support your right
to the privacy of your health information.

VI. Effective Date:

This Notice was effective on January 1, 2019.

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