FLORIDA SPINECARE CENTER NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND RELEASED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact the practice manager.

Who Will Follow This Notice

This notice describes our practice’s privacy practices and that of:

• Any physician or health care professional authorized to enter information into your medical chart.
• All areas of the practice.
• All employees, staff and other office personnel.
• All those individuals, sites and locations follow the terms of this notice. In addition, these individuals, sites and locations may share medical information with each other or with third party medical specialists for treatment, payment, or office operations purposes described in this notice.
  

Our Pledge Regarding Medical Information

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at our medical office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our office.

This notice will tell you about the ways in which we may use and release medical information about you. We also describe your rights and certain obligations we have regarding the use and release of medical information.

We are required by law to:

• make sure that medical information that identifies you is kept private
• give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• follow the terms of this notice that is currently in effect.

How We May Use and Release Medical Information About You

The following categories describe different ways that we use and disclose medical information. Not every use or release category will be listed. However, all of the ways we are permitted to use and release information will fall within one of the categories.

• For Treatment. We may use medical information about you to provide you with medical treatment or services. We may release medical information about you to the practice’s office personnel who are involved in taking care of you at the office or elsewhere. We also may release medical information about you to people outside our office who may be involved in your care after you leave the office, such as family members or others we use to provide services that are part of your care provided you have consented to such release. These entities include third party physicians, hospitals, nursing homes, pharmacies or clinical labs with whom the office consults or makes referrals.
• For Payment. We may use and release medical information about you so that the treatment and services you receive at the medical office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about medical procedures you received at the office so your health plan will pay us or reimburse you for the services. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
• For Health Care Operations. We may use and release medical information about you for medical office operations. These uses and releases are necessary to run the medical office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many medical office patients to decide what additional services the office should offer, what services are not needed, and whether certain new treatments are effective. We may also release information to physicians, nurses, and other office personnel for review and learning purposes.
• Appointment Reminders. We may use and release medical information to contact you as a reminder that you have an appointment for treatment or medical care at the office.
• Treatment Alternatives. We may use and release medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
• Health-Related Benefits and Services. WE may use and release medical information to tell you about health-related benefits or services that may be of interest to you.
• Individuals Involved In Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care provided you have consented to such release. We may also give information to someone who helps pay for your care. In addition, we may release medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
• As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.
• To Avert a Serious Threat to Health or Safety. We may use and release medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any release, however, would only be to someone able to prevent the threat.

Special Situations

• Health Oversight Activities. We may release medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for government to monitor the health care system, government programs and compliance with civil rights laws.
• Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may release medical information about you in response to a court or administrative order. We may also release medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
• Coroners, Medical Examiners and Funeral Directors. We may also release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the office to funeral directors as necessary to carry out their duties.
  

Your Rights Regarding Medical Information About You.

You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to our office manager. If you request a copy of the information, there will be a fee for the costs of copying, mailing, and other office supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances.
• Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the medical office. To request an amendment, your request must be made in writing and submitted to the office manager. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for the medical office;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.
• Right to an Accounting of Disclosures. You have the right to request an “accounting of Disclosures.” This is a list of the releases we made of medical information about you.

To request this list of disclosures, you must submit your request in writing to our medical records department. Your request must state a time period which may not be longer than six years and may not include dates before 4/13/03. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

• Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or release about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we release about you to someone who is involved in your care or the payment of your care, like a family member or friend. For example, you could ask that we not use or release information about a surgery you had.

We are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to our office. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, release or both; and (3) to whom you want the limits to apply, for example, releases to your spouse.

• Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the office manager. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice from our front office staff. You may obtain a copy of this notice at our website, www.flspinecare.com.

Changes To This Notice.

We reserve the right to change this notice. We reserve the right 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 copy of the current notice in the office. The notice will contain on the first page, in the top left hand corner, the effective date. In addition, each time you register we will offer you a copy of the current notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the office or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our practice manager. All complaints must be submitted in writing.

You will not be penalized or retaliated against for filing a complaint.

Other Uses of Medical Information

Other uses and releases of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or release medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or release medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any release we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

FLORIDA SPINECARE CENTER
ACKNOWLEDGEMENT FORM

Our notice of Privacy Practices provides information about how we may use and release protected health information about you. You have the right to review our Notice before signing this form. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy by writing our practice or requesting a copy from our front desk staff.

You have the right to request that we restrict how protected health information about you is used or released for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

By signing this form, you consent to our use and release of protected health information about you for treatment, payment and health care operations as described in our Notice. You have the right to revoke this consent, in writing, except where we have already made releases in reliance on your prior consent.

PATIENT NAME

(PRINT) _________________________________________

(SIGNATURE) _________________________________________

DATE: _________________________________________

WITNESS: _________________________________________

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