NOTICE OF PRIVACY PRACTICES FOR WEST FLORIDA WEIGHT LOSS, A DIVISION OF SURGICAL ASSOCIATES OF WEST FLORIDA, PA
This notice describes how protected health information may be used and disclosed and how you can access this information. Please review this notice.
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Issue Date: April 2003
Understanding Your Medical Record Information
Your Medical Record Information Rights
Examples of Allowable Disclosures for: Treatment, Payment and Healthcare Operations
Acknowledgement of Receipt of This Notice
For More Information or to Report a Problem
At Surgical Associates of West Florida, PA we are committed to treating and using protected health information about you responsibly. This Notice of Privacy Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 2003, and applies to all Protected Health Information (information) as defined by federal regulations.
Your Medical Record Information
Each time you visit Surgical Associates of West Florida, PA, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
- Basis for planning your care and treatment, and the outcomes we achieve,
- Means of communication among the many health professionals who contribute to your care,
- Legal document describing the care you received,
- Means by which you or a third-party payer can verify that services billed were actually provided,
- A source of data for medical research,
- A source of information for public health officials charged with improving the health of this state and the nation.
Understanding what is in your record and how your medical information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your medical information, and make more informed decisions when authorizing disclosures to others.
- Obtain a paper copy of this Notice of Privacy Practices upon request,
- Review or amend your medical records in accordance with Federal Regulations,
- Obtain an accounting of disclosures of your protected health information,
- Request a restriction on certain uses and disclosures of your medical information, and
- Revoke your authorization to use or disclose medical information except to the extent that action has already been taken.
- Maintain the privacy of your medical information,
- Provide you with this notice as to our legal duties and privacy practices with respect to
- medical information that we collect and maintain about you,
- Abide by the terms of this notice,
- Notify you if we are unable to agree to a requested restriction, and
- Accommodate reasonable requests you may have to communicate medical information by alternative means or at alternative locations.
We reserve the right to change our practices and this notice and to make the revised notice effective for protected health information we maintain as required by changes in Federal or State regulations.
We will not use or disclose your medical information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.
We will use your health information for treatment.
For example: Information obtained by a nurse, physician, or other member of our health care team will be recorded in your medical record and used to determine a diagnosis or course of treatment .
We will also provide your primary, referring or specialist physician or a subsequent health care provider with copies of various medical records and reports that should assist him or her in treating you.
We will use your health information for payment.
For example: A claim may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
We will use your health information for our health care operations.
For example: Members of the practice may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of healthcare and service we provide.
Business Associates: There are some services provided in our organization through contacts with business associates. Examples include physician billing, answering and transcription services. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Communication with Family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.
Worker's Compensation: We will use and disclose your protected health information about you for workers' compensation or similar programs which provide benefits for work-related injuries or illness.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law Enforcement: We may disclose information for law enforcement purposes as required by law or in response to a valid subpoena.
Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.
of Receipt of This Notice
You will be asked to provide a signed acknowledgment of receipt of this notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care services will in no way be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide your treatment, and will use and disclose your protected health information for treatment, payment and health care operations when necessary.
If you believe your privacy rights have been violated, you can
file a complaint with the practice's Privacy Officer, or with
the Office for Civil Rights, U.S. Department of Health and Human
Services. There will be no retaliation for filing a complaint
with either the Privacy Officer or the Office for Civil Rights.
The address for the OCR is listed below:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201