NOTICE
OF PRIVACY PRACTICES
THIS NOTICE
DESCRIBES: How Health Information about you may be used,
disclosed, and how you can obtain access to your health information.
PLEASE
REVIEW CAREFULLY
State and Federal laws require us to maintain the privacy of your health
information and to inform you about our privacy practices by providing
you with this Notice. We must follow the privacy practices as described
below. This Notice will take effect April 14, 2003 and will remain in
effect until it is amended or replaced by Central Florida Urology Associates.It
is our right to change our privacy practices provided law permits the
changes. Before we make a significant change, this Notice will be amended
to reflect the changes and we will make the new Notice available upon
request. We reserve the right to make any changes in our privacy practices
and the new terms of our Notice effective for all health information
maintained, created and/or received by us before the date changes were
made. You may request a copy of our Privacy Notice at any time by contacting
our Privacy Officer, Janie DeVan. Information on contacting us can
be found at the end of this Notice.
TYPICAL
USES AND DISCLOSURES OF HEALTH INFORMATION
We will keep your health information confidential, using it only
for the following purposes:
Treatment:
We
may use your health information to provide you with our professional
services. We have established “minimum necessary or need to know”
standards that limit various staff members’ access to your health
information according to their primary job functions. Everyone on our
staff is required to sign a confidentiality statement.
Disclosure:
We
may disclose and/or share your healthcare information with other health
care professionals who provide treatment and/or service to you. These
professionals will have a privacy and confidentiality policy like this
one. Health information about you may also be disclosed to your family,
friends and/or other persons you choose to involve in your care, only
if you agree that we may do so.
Payment:
We
may use and disclose your health information to seek payment for services
we provide to you. This disclosure involves our business office staff
and may include insurance organizations or other businesses that may
become involved in the process of mailing statements and/or collecting
unpaid balances.
Emergencies:
We
may use or disclose your health information to notify, or assist in
the notification of a family member or anyone responsible for your care,
in case of any emergency involving your care, your location, your general
condition or death. If at all possible we will provide you with an opportunity
to object to this use or disclosure. Under emergency conditions or if
you are incapacitated we will use our professional judgment to disclose
only that information directly relevant to your care. We will also use
our professional judgment to make reasonable inferences of your best
interest by allowing someone to pick up filled prescriptions, x-rays
or other similar forms of health information and/or supplies unless
you have advised us otherwise.
Healthcare
Operations:
We
will use and disclose your health information to keep our practice operable.
Examples of personnel who may have access to this information include,
but are not limited to, our medical records staff, outside health or
management reviewers and individuals performing similar activities.
Required
by Law:
We may use and/or disclose your health information when we are required to do so by law through official request such as; Court or administrative orders, subpoena, discovery request or other lawful process. We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.
Abuse or
Neglect:
We
may disclose your health information to appropriate authorities if we
reasonably believe that you are a possible victim of abuse, neglect,
or domestic violence or the possible victim of other crimes. This information
will be disclosed only to the extent necessary to prevent a serious
threat to your health or safety or that of others.
Public Health
Responsibilities:
We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.
Marketing
Health-Related Services:
We
will not use your health information for marketing purposes unless we
have your written authorization to do so.
National
Security:
The
health information of Armed Forces personnel may be disclosed to military
authorities under certain circumstances. If the information is required
for lawful intelligence, counterintelligence or other national security
activities, we may disclose it to authorized federal officials.
Appointment
Reminders:
We
may use or disclose your health information to provide you with appointment
reminders, including, but not limited to, voicemail messages, postcards
or letters.
YOUR PRIVACY RIGHTS AS OUR PATIENT
Access:
Upon
written request, you have the right to inspect and get copies of your
health information (and that of an individual for whom you are a legal
guardian.) There will be some limited exceptions. If you wish to examine
your health information, you will need to complete and submit an appropriate
request form. Contact our Privacy Officer for a copy of the Request
Form. You may also request access by sending us a letter to the address
at the end of this Notice. Once approved, an appointment can be made
to review your records. Copies, if requested, will be $ 1.00 for each
page up to 25 pages and $00.25 per page thereafter. If you prefer a
summary or an explanation of your health information, we will provide
it for a fee. Please contact our Business Officer Manager for a fee
and/or for an explanation of our fee structure.
Amendment:
You
have the right to amend your healthcare information, if you feel it
is inaccurate or incomplete. Your request must be in writing and must
include an explanation of why the information should be amended. Under
certain circumstances, your request may be denied.
Non-routine
Disclosures:
You
have the right to receive a list of non-routine disclosures we have
made of your health care information. (When we make a routine disclosure
of your information to a professional for treatment and/or payment purposes,
we do not keep a record of routine disclosures: therefore these are
not available.) You have the right to a list of instances in which we,
or our business associates, disclosed information for reasons other
than treatment, payment or healthcare operations. You can request non-routine
disclosures going back 6 years starting on April 14, 2003. Information
prior to that date would not have to be released. (Example: If you
request information on May 15, 2004, the disclosure period would start
on April 14, 2003 up to May 15, 2004. Disclosures prior to April 14,
2003 do not have to be made available.)
Restrictions:
You
have the right to request that we place additional restrictions on our
use or disclosure of your health information. We do not have to agree
to these additional restrictions, but if we do, we will abide by our
agreement except in emergencies. Please contact our Privacy Officer
if you want to further restrict access to your health care information.
This request must be submitted in writing.
QUESTIONS
AND COMPLAINTS
You
have the right to file a complaint with us if you feel we have not complied
with our Privacy Policies. Your complaint should be directed to our
Privacy Officer. If you feel we may have violated your privacy rights,
or if you disagree with a decision we made regarding your access to
your health information, you can complain to us. In writing: Request
a Complaint Form from our Privacy Officer and/or Front Office Supervisor.
We support your right to the privacy of your information and will not
retaliate in any way if you choose to file a complaint with us or with
the U.S. Department of Health and Human Services.
HOW TO CONTACT
US
Practice Name: Central Florida Urology Associates
Privacy Officer: Janie DeVan, Practice Administrator/Privacy Officer
Telephone: 407-332-7700 ext. 111
Fax: 407-332-9749
Send us
an email
Address: 210 Rinehart Rd, Suite 1000, Lake Mary Florida 32746
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