Notice of Privacy Practices



3428 Gulf Breeze Parkway

Gulf Breeze, FL  32563                                                                                                  Effective Date: April 14, 2014

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.   If you have any questions about this Notice please contact our Privacy Officer at 850-934-5713

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or healthcare operations and for other purposed that are permitted or required by law. It also describes your rights to access and control your protected health information.  “Protected health information” 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 healthcare services.

Office use and disclosures of protected health information

Your protected health information may be used and disclosed by your Physician, Nurse Practitioner, Physician Assistant, our office staff and others outside of our office (e.g. a billing service, mobile x-ray), who are involved in your care and treatment for the purpose of providing healthcare services to you.  Your protected health information may also be used and disclosed to pay your health care bills. Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared.

Following are examples of the types of uses and disclosures of you protected health information that our office is permitted to make.

Treatment:  We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.

Payment:  Your protected health information will be used and disclosed, as needed, to bill and obtain payment from you, an insurance company, or a third party for your healthcare services provided by us.

Health Care Operations:  We may use and disclose medical information about you for health care operations to assure that you receive quality care.

 Other permitted and required uses and disclosures that may be made without your authorization or opportunity to agree or object

Required By Law:  In compliance with the law and will be limited to the relevant requirements of the law.

Public Health: For Public health activities and purposes to a public health authority permitted by law to collect or receive the information.

Communicable Diseases:  If authorized by law to a person who may have been exposed to a communicable disease or at risk of contracting or spreading the disease or condition.

Health Oversight: To a health oversight agency for activities authorized by law.

Abuse or Neglect:  To a public health authority that is authorized by law to receive reports of abuse or neglect.

Food and Drug Administration:  For the purpose of quality, safety or effectiveness of FDA-regulated products or activities.

Legal Proceedings:  In the course of any judicial or administrative proceeding.

Law Enforcement:  For law enforcement purposes as long as all applicable legal requirements are met.

Coroners, Funeral Directors and Organ Donation:  For identification purposes, to determine cause of death, and to carry out their duties as authorized by law.

Research: To researches when their research has been approved by institutional review board.

Criminal Activity: If discloser will lessen a serious or imminent threat to health or safety of a person or the public.

Military Activity and National Security:  When appropriate conditions apply.

Worker’s Compensation:  As authorized to comply with worker’s compensation laws.

Inmates:  Physician created or received your protected health information in the course of providing care to you.

Uses and disclosures of protected health information based upon your written authorization

Other uses and disclosures of your protected health information will be make only with your written authorization, unless otherwise permitted or required by law as described below.  If you revoke your authorization we will no longer use or disclose your protected health information for the reason covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization and we are required to retain our records of the care we have provided you.

Right to inspect and copy

You have the right to inspect and copy medical information that maybe used to make decisions about your care. Usually this includes medical and billing records, but does it include psychotherapy notes.  Information compiled for use in civil, criminal or administrative action or proceeding, and protected health information to which access is prohibited by law. To inspect and copy medical information that maybe used to make decisions about you, you must submit your request in writing to the Privacy Officer at this practice. If you request a copy of the information, we reserve the right to charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that denial be reviewed. Another licensed health care professional chosen by this practice will review your request and the denial. The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

Right to request restrictions

You have the right to request a restriction or limitation of the medical information we use or disclose about you for treatment, payment, or health care operations or to someone who is involved in you care or the payment for your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.  To request restrictions, you must submit your request in writing to the Privacy Officer at this practice. In your request, you must tell us what information you want to limit. 

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.  To request an amendment, your request must be made in writing and submitted to the Privacy Officer at this practice. In addition, you must provide a reason that supports your request. In addition, we may deny your request if the information was not created by us, is not part of the medical information kept at this practice, is not part of the information which you would be permitted to inspect and copy, or which we deem to be accurate and complete. If we deny your request for amendment, you have the right to file a statement of disagreement with us.  We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Statements of disagreement and any corresponding rebuttals will be kept on file and sent out with any future authorized requests for information pertaining got the appropriate portion of your record.

Right to an accounting of non-standard disclosures

You have the right to request a list of disclosures we made of medical information about you.  To request this list, you must submit your request to the Privacy Officer at this practice.  Your request must state the time period for which you want to receive a list of disclosures that is no longer that six years, and may not include dates before October 1, 2013.  Your request should indicate in what form you want the list (example: on paper or electronically) the first list you request within a 12 month period will be free. For additional lists, we reserve the right to charge you for the cost of providing the list.

Right to a paper copy of this notice

You have the right to a paper 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.  To obtain a paper copy of the current Notice, please request one in writing from the Privacy Officer at this practice.

Your individual rights regarding your medical information

Complaints:  If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at this practice or with the Secretary of the Department of Health and Human Services.  All complains must be submitted in writing.  You will not be penalized or discriminated against for filing a complaint.

Changes to this notice

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective to 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 with the effective date in the upper right corner of the first page.