NOTICE OF PRIVACY PRACTICES
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.
Our practice is dedicated to protecting your medical 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. Our practice is required by law to abide by the terms of this Notice.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information (PHI). “PHI” 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.
Our office is required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. To request a revised notice you may call the office and request that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED:
We will use and/or disclose your medical information as part of rendering patient care. Your PHI may also be used and/or disclosed to pay your health care bills and to support the operation of Family Medical Center. Following are examples of the types of uses and disclosures that may be made by our office:
Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes other physicians to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. It may also include but is not limited to home health care services, lab and diagnostic centers, hospitals, nursing homes and rehab centers.
Payment: Your PHI will be used, as needed to obtain payment for your health care services. This includes, but is not limited to, determination of eligibility and benefits, referral authorizations, claims filing and follow up, medical necessity reviews, and utilization reviews.
Healthcare Operations: We may use and/or disclosed as needed your PHI in order to support the business activities of your physician’s practice. These activities include but are not limited to training of students and staff and quality assessment activities. 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 or P.A. We may also call you by name in the waiting room when your provider is ready to see you.
We may also use and/or disclose your information in accordance with federal and state laws for the following purposes:
Appointment Reminders and Treatment Contact.
We may contact you to provide appointment reminders or to request that you call our office for information relevant to your medical treatment. We most often will call the day before at your home phone or work phone. If you are not available we will leave a message either on your answering machine or with the individual answering on your behalf.
Disclosure to Department of Health and Human Services.
We may disclose medical information when required by the United States Department of Health and Human Services as part of an investigation or determination of our compliance with relevant laws.
Family and Friends.
Only with your express verbal or written authorization will we disclose your medical information to family members, other relatives or close personal friends that are directly involved with your medical care.
Unless you object, we may use or disclose your medical information to notify a family member, a personal representative or another person responsible for your care of your location, general condition or death.
We may disclose your medical information to a public or private entity, such as the American Red Cross, for the purpose of coordinating with that entity to assist in disaster relief efforts.
Health Oversight Activities.
We may use or disclose your medical information for public health activities, including the reporting of disease, injury, vital events and the conduct of public health surveillance, investigation and/or intervention. We may disclose your medical information to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions, administrative and/or legal proceedings.
Abuse or Neglect.
We may disclose your medical information when it concerns abuse, neglect or violence to you in accordance with federal and state law.
We may disclose your medical information in the course of certain judicial or administrative proceedings.
We may disclose your medical information for law enforcement purposes or other specialized governmental functions.
Coroners, Medical Examiners and Funeral Directors.
We may disclose your medical information to a coroner, medical examiner or a funeral director.
We may use or disclose your medical information to prevent or lessen a serious threat to the health or safety of another person or to the public.
We may disclose your medical information as authorized by laws relating to workers= compensation or similar programs.
We may disclose your health information to a business associate with whom we contract to provide services on our behalf. To protect your health information, we require our business associates to appropriately safeguard the health information of our patients.
We will not use or disclose your medical information for any other purpose without your written authorization. Once given, you may revoke your authorization in writing at any time. To request a Revocation of Authorization form, you may contact:
Family Medical Center
2863 S. Delaney Avenue
Orlando, FL 32806
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:
You have the following rights with respect to your medical information:
You may ask us to restrict certain uses and disclosures of your medical information. We are not required to agree to your request, but if we do, we will honor it.
You have the right to receive communications from us in a confidential manner.
Generally, you may inspect and copy your medical information. This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records.
You may ask us to amend your medical information. We may deny your request for certain specific reasons. If we deny your request, we will provide you with a written explanation for the denial and information regarding further rights you may have at that point.
You have the right to receive an accounting of the disclosures of your medical information made by our practice during the last six years (or following April 14, 2003), except for disclosures for treatment, payment or healthcare operations, disclosures which you authorized and certain other specific disclosure types.
You may request a paper copy of this Notice of Privacy Practices for Protected Health Information.
You have the right to complain to us and/or to the United States Department of Health and Human Services if you believe that we have violated your privacy rights. If you choose to file a complaint, you will not be retaliated against in any way. To complain to us, please contact:
Privacy Officer Family Medical Center 2863 S. Delaney Avenue Orlando, FL 32806 Telephone: 407.843.1620 Fax: 407.843.5243
If you would like further information regarding your rights or regarding the uses and disclosures of your medical information, you may contact:
Family Medical Center
2863 S. Delaney Avenue
Orlando, FL 32806
THIS NOTICE IS EFFECTIVE AS OF April 1, 2003.
REVISION OF NOTICE OF PRIVACY PRACTICES
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 at our office and will make paper copies of the revised Notice of Privacy Practices available upon request.