Notice of Privacy Practice

notice of privacy practice

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

This notice applies to the information and records we have about your health care and service you received in your personal file. It describes the ways that the privacy of your information is protected by our workforce members, including volunteers, staff, office personnel, and contractors. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.

Our Legal Obligations

The law also requires us to: abide by the terms of the Notice of Privacy Practices currently in effect; make sure that health information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to health information about you; obtain acknowledgment of receipt of this notice from you; and notify you if your unsecured protected health information is breached.

Uses and Disclosures of Your Protected Health Information

We may use or disclose your protected health information for the following purposes:

· Treatment – the provision, coordination, or management of health care and related services among health care providers or by a health care provider with a third party, consultation between health care providers regarding a patient, or the referral of a patient from one health care provider to another.

· Payment – to bill and collect payment.

· Health care operations – to evaluate the performance of our staff in caring for you and to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.

· We may also contact you as a reminder that you have a scheduled appointment for treatment or medical care.

· To contact you regarding your experience at a facility, including conducting satisfaction surveys, asking you to share feedback regarding your experience with others, and allowing you to be contacted by other providers for the purpose of coordination of care and referrals for services.

· To connect with Health Information Exchanges. Health Information Exchanges contain a summary of your most relevant medical information. Making your medical information available through Health Information Exchanges promotes efficiency and quality of care. You may choose not to allow your medical information to be shared through a Health Information Exchange. If you do not want it to be shared, please contact the Privacy Officer at the phone number listed below. Removal from Health Information Exchanges may cause a delay in the provision of your medical information to your healthcare providers.

There are special situations, which allow us to use or disclose your health information without your permission. These situations include:

· To Avert a Serious Threat to Health or Safety- to prevent a serious threat to the health and safety of yourself, the public or another person.

· Required by Law- when required by federal, state or local law.

· Research – for research projects that are subject to a special approval process, and under supervision of a privacy board or institutional review board.

· Organ and Tissue Donation – we may release information to organizations that handle procurement or transplantation or to a donation bank.

· Current or Previous Military, Veterans, Natural Security and Intelligence Members – when required by military command or other government authorities. We may also release information about foreign military authority.

· Workers’ Compensation- for workers’ compensation or similar programs, which provide benefits for work­ related injuries or illness.

· Public Health Risks – for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non­ accidental physical injuries, reactions to medications or problems with products.

· Health Oversight Activities – for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.

· Lawsuits and Disputes – in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.

· Coroners, Medical Examiners and Funeral Directors- to identify a deceased person or determine the cause of death.

· Volunteers – performing work for us.

· Information Not Personally Identifiable – in a way that does not personally identify you or reveal who you are.

· Business Associates – in order for a business associate to perform the job we have asked them to do. To protect your health information, we require our business associates to enter into a written contract that requires them to appropriately safeguard your information.

· Treatment Alternatives and Other Health-Related Benefits and Services – to tell you about or recommend possible treatment options or alternatives and to tell you about health-related benefits, services or medical education classes that may be of interest to you.

· Individuals Involved in Your Care or Payment of Your Care – unless you object, we may disclose your health information to a family member, a relative, a close friend or any other person you identify, if the information relates to the person’s involvement in your health care to notify the person of your location or general condition or payment related to your health care. In addition, we may disclose your protected health information to a public or private entity authorized by law to assist in a disaster relief effort. If you are unable to agree or object to such a disclosure, we may disclose such information if we determine that it is in your best interest based on our professional judgment or if we reasonably infer that you would not object.

· Directories – We may use a facility directory to inform visitors or callers about your location in the facility and general condition. The directory includes patient name, location in the facility, health condition expressed in general terms that does not communicate specific medical information, and religious affiliation. You have the opportunity to restrict information, to whom it is disclosed, or to opt out. You may inform us orally or in writing. We may provide the appropriate directory information – except for religious affiliation – to anyone who asks for you by name. Religious affiliation may be disclosed to members of the clergy.

· Law Enforcement – for certain law enforcement purposes if permitted or required by law.

We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written authorization. Most uses and disclosures of psychotherapy notes, uses and disclosures for marketing, and disclosures that would be a sale of medical information require your written authorization. If you give us authorization, you may revoke it, in writing, at any time. If you revoke your authorization, we will no longer use or disclose information about you for the reasons covered by your written authorization. However, we cannot take back any uses or disclosures already made with your permission.

If we have HIV or substance use disorder records about you, we cannot release those records without a special signed, written authorization from you. This is different than the authorization and consent mentioned above. In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have both your signed consent and a special written authorization that complies with the law governing HIV or substance use disorder records.

Individual Rights

· You have the right to inspect and copy your health information, either written or electronic, such as medical and billing records, that we use to make decisions about your care. In order to do so, you must submit a written request to inspect and/ or copy your health information. Your request may be denied in certain limited

circumstances. However, if you are denied, you may ask that the denial be reviewed. We will comply with the outcome of the review, usually within 30 days, and may charge a reasonable cost-based fee.

· You have the right to request a correction or change to your health information, paper or electronic, if you believe it is incorrect or incomplete. Your request must be in writing and include a reason to support the request. We may deny your request in writing within 60 days if you ask us to amend information that:

A. We did not create, unless the person or entity that created the information is no longer available to make the amendment.

B. Is not part of the health information that we keep.

C. You would not be permitted to inspect and copy.

D. Is accurate and complete.

· You have the right to request an accounting of disclosures. This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and health care operations. To obtain this list, you must submit your request in writing which states a time period no longer than six years from the date of discharge and does not include dates before April 14, 2003. We may charge you for the costs of providing the list, either electronically or via paper copy. We will provide one accounting for free per year but will charge a reasonable, cost-based fee if you ask for another one within 12 months. However, you may choose to withdraw or modify your request at that time before any costs are incurred.

· You have the right to be assured that your information will be kept confidential. You may request that we communicate with you about medical matters in a certain way or at a certain location.

· You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. We are not required to agree to your request unless the disclosure is to a health plan for a payment or health care operations purpose and the health information relates solely to a health care item or service for which we have been paid out-of-pocket in full.

· You have the right to a paper copy of this notice. If you have agreed to receive it electronically, you are still entitled to a paper copy. You may ask us to give you a copy of this notice at any time by contacting the facility Administrator.

· You have the right to choose someone to make health decisions for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

Changes to This Notice

We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date, as well as online at You are entitled to a copy of the notice currently in effect.


If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint. To file a complaint with our office, or the Secretary of the U.S. Department of Health and Human Services contact the facility at:

c/o 4042 Park Oaks Blvd., Suite 300

Tampa, Florida 33610

Tel: (813) 635-9500

Attn: Privacy Officer

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201 or calling 1-877-696-6775.

For Further Information

Request for further information about information covered in this notice may be directed towards the person who gave you the notice or see .

Effective June 1, 2021

I hereby acknowledge that I have received and read this Notice of Privacy Practices.

Signature: ___________________________________

Printed Name: ________________________________

Date (DD/MM/YYYY): ________________________

Declaration of additional specific individuals we are permitted to disclose your health information to:

Name: ______________________________ Relationship: ______________________

Name: ______________________________ Relationship: ______________________

Name: ______________________________ Relationship: ______________________

Name: ______________________________ Relationship: ______________________