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TOWN 'N COUNTRY PODIATRY CENTER |
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FOOT CARE CENTER OF TAMPA P.A. |
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7926
West Hillsborough Avenue, Suite G |
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1020
West Hillsborough Avenue |
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Tampa,
Florida 33615 |
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Tampa,
Florida 33603 |
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(813) 885-3668 |
Fax:
(813) 882-0291 |
(813) 238-3631 |
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PLEASE
REVIEW THIS NOTICE CAREFULLY. |
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(c)
Health Care Operations - In order for the
Practice to operate in
accordance with
applicable law and insurance
requirements and in order for the Practice
to continue to provide quality and
efficient care, it may be necessary for
the Practice to compile, use and/or
disclose your PHI. For example, the
Practice may use your PHI in order to
evaluate the performance of the Practice's
personnel in providing care to you. |
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NO
AUTHORIZATION REQUIRED |
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1.
The Practice may use and/or disclose your
PHI, without a written Authorization from
you, in the following instances:
(a) De-identified Information -
Information that does not identify you
and, even without your name, cannot be
used to identify you.
(b) Business Associate - To a business
associate if the Practice obtains
satisfactory written assurance, in
accordance with applicable law, that the
business associate will appropriately
safeguard your PHI. A business associate
is an entity that assists the Practice in
undertaking some essential function, such
as a billing company that assists the
office in submitting claims for payment to
insurance companies or other payers.
(c) Personal Representative - To a person
who, under applicable law, has the
authority to represent you in making
decisions related to your health care.
(d) Emergency Situations -
(i) for the purpose of obtaining or
rendering emergency treatment to you
provided that the Practice attempts to
obtain your Authorization as soon as
possible; or
(ii) to a public or private entity
authorized by law or by its charter to
assist in disaster relief efforts, for the
purpose of coordinating your care with
such entities in an emergency situation.
(e) Communication Barriers - If, due to
substantial communication barriers or
inability to communicate, the Practice has
been unable to obtain your Authorization
and the Practice determines, in the
exercise of its professional judgment,
that your Authorization to receive
treatment is clearly inferred from the
circumstances.
(f) Public Health Activities - Such
activities include, for example,
information collected by a public health
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This
Practice is committed to maintaining the
privacy of your protected health information
("PHI"), which includes information about your
health condition and the care and treatment
you receive from the Practice. The creation of
a record detailing the care and services you
receive helps this office to provide you with
quality health care. This Notice details how
your PHI may be used and disclosed to third
parties. This Notice also details your rights
regarding your PHI. The privacy of PHI in
patient files will be protected when the files
are taken to and from the Practice by placing
the files in a box or brief case and kept
within the custody of a doctor or employee of
the Practice authorized to remove the files
from the Practice’s office. It may be
necessary to take patient files to a facility
where a patient is confined or to a patient’s
home where the patient is to be examined or
treated. |
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AUTHORIZATION TO RELEASE PROTECTED HEALTH
INFORMATION: |
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1. The
Practice may use and/or disclose your PHI
provided that it first obtains a valid
Authorization signed by you. The Authorization
will allow the Practice to use and/or disclose
your PHI for the purposes of:
(a) Treatment - In order to provide you with
the health care you require, the Practice will
provide your PHI to those health care
professionals, whether on the Practice's staff
or not, directly involved in your care so that
they may understand your health condition and
needs. For example, a physician treating you
for a condition or disease may need to know
the results of your latest physician
examination by this office.
(b) Payment - In order to get paid for
services provided to you, the Practice will
provide your PHI, directly or through a
billing service, to appropriate third party
payors, pursuant to their billing and payment
requirements. For example, the Practice may
need to provide the Medicare program with
information about health care services that
you received from the Practice so that the
Practice can be properly reimbursed. The
Practice may also need to tell your insurance
plan about treatment you are going to receive
so that it can determine whether or not it
will cover the treatment expense.
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authority, as authorized by law, to prevent or
control disease.
(g) Abuse, Neglect or
Domestic Violence - To a
government authority if the Practice is
required by law to make such disclosure. If
the Practice is authorized by law to make such
a disclosure, it will do so if it believes
that the disclosure is necessary to prevent
serious harm.
(h) Health Oversight Activities - Such
activities, which must be required by law,
involve government agencies and may include,
for example, criminal investigations,
disciplinary actions, or general oversight
activities relating to the community's health
care system.
(i) Judicial and Administrative Proceeding -
For example, the Practice may be required to
disclose your PHI in response to a court order
or a lawfully issued subpoena.
(j) Law Enforcement Purposes - In certain
instances, your PHI may have to be disclosed
to a law enforcement official. For example,
your PHI may be the subject of a grand jury
subpoena. Or, the Practice may disclose your
PHI if the Practice believes that your death
was the result of criminal conduct.
(k) Coroner or Medical Examiner - The Practice
may disclose your PHI to a coroner or medical
examiner for the purpose of identifying you or
determining your cause of death.
(l) Organ, Eye or Tissue Donation - If you are
an organ donor, the Practice may disclose your
PHI to the entity to whom you have agreed to
donate your organs.
(m) Research - If the Practice is involved in
research activities, your PHI may be used, but
such use is subject to numerous governmental
requirements intended to protect the privacy
of your PHI.
(n) Avert a Threat to Health or Safety - The
Practice may disclose your PHI if it believes
that such disclosure is necessary to prevent
or lessen a serious and imminent threat to the
health or safety of a person or the public and
the disclosure is to an individual who is
reasonably able to prevent or lessen the
threat.
(o) Specialized Government Functions - This
refers to disclosures of PHI that relate
primarily to military and veteran activity.
(p) Workers' Compensation - If you are
involved in a Workers' Compensation claim, the
Practice may be required to disclose your PHI
to an individual or entity that is part of the
Workers' Compensation system.
(q) National Security and Intelligence
Activities - The Practice may disclose your
PHI in order to provide authorized
governmental officials with necessary
intelligence information for national security
activities and purposes authorized by law.
(r) Military and Veterans - If you are a
member of the armed forces, the Practice may
disclose your PHI as required by the military
command authorities. |
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following appointment reminders are used
by the Practice: a) a postcard mailed to
you at the address provided by you; and b)
telephoning your home and leaving a
message on your answering machine or with
the individual answering the phone. |
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DIRECTORY/SIGN-IN LOG
The Practice maintains a directory of and
sign-in log for individuals seeking care
and treatment in the office. Directory and
sign-in log are located in a position
where staff can readily see who is seeking
care in the office, as well as the
individual's location within the
Practice's office suite. This information
may be seen by, and is accessible to,
others who are seeking care or services in
the Practice's offices. |
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FAMILY/FRIENDS
The Practice may disclose to your family
member, other relative, a close personal
friend, or any other person identified by
you, your PHI directly relevant to such
person's involvement with your care or the
payment for your care. The Practice may
also use or disclose your PHI to notify or
assist in the notification (including
identifying or locating) a family member,
a personal representative, or another
person responsible for your care, of your
location, general condition or death.
However, in both cases, the following
conditions will apply:
(a) If you are present at or prior to the
use or disclosure of your PHI, the
Practice may use or disclose your PHI if
you agree, or if the Practice can
reasonably infer from the circumstances,
based on the exercise of its professional
judgment, that you do not object to the
use or disclosure.
(b) If you are not present, the Practice
will, in the exercise of professional
judgment, determine whether the use or
disclosure is in your best interests and,
if so, disclose only the PHI that is
directly relevant to the person's
involvement with your care. |
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AUTHORIZATION
Uses and/or disclosures, other than those
described above, will be made only with
your written Authorization. |
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YOUR
RIGHTS
1. You have the right to:
(a) Revoke any Authorization, in writing,
at any time. To request a revocation, you
must submit a written request to the
Practice's Privacy Officer.
(b) Request restrictions on certain use
and/or disclosure of your PHI as provided
by law. However, the Practice is not
obligated to agree to any requested
restrictions. To request restrictions, you
must submit a written request to the
Practice's Privacy Officer. In your
written request, you must inform the
Practice of what information you want to
limit, whether you want to limit the
Practice's use or disclosure, or both, and
to whom you want the limits to apply. If
the Practice agrees to |
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APPOINTMENT REMINDER
The Practice may, from time to time, contact
you to provide appointment reminders or
information about treatment alternatives or
other health-related benefits and
services that may be of interest
to you. The |
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your request, the Practice will comply with
your request unless the information is needed
in order to provide you with emergency
treatment.
(c) Receive confidential communications or PHI
by alternative means or at alternative
locations. You must make your request in
writing to the Practice's Privacy Officer. The
Practice will accommodate all reasonable
requests.
(d) Inspect and copy your PHI as provided by
law. To inspect and copy your PHI, you must
submit a written request to the Practice's
Privacy Officer. The Practice can charge you a
fee for the cost of copying, mailing or other
supplies associated with your request. In
certain situations that are defined by law,
the Practice may deny your request, but you
will have the right to have the denial
reviewed as set forth more fully in the
written denial notice.
(e) Amend your PHI as provided by law. To
request an amendment, you must submit a
written request to the Practice's Privacy
Officer. You must provide a reason that
supports your request. The Practice may deny
your request if it is not in writing, if you
do not provide a reason in support of your
request, if the information to be amended was
not created by the Practice (unless the
individual or entity that created the
information is no longer available), if the
information is not part of your PHI maintained
by the Practice, if the information is not
part of the information you would be permitted
to inspect and copy, and/or if the information
is accurate and complete. If you disagree with
the Practice's denial, you will have the right
to submit a written statement of disagreement.
(f) Receive an accounting of disclosures of
your PHI as provided by law. To request an
accounting, you must submit a written request
to the Practice's Privacy Officer. The request
must state a time period which may not be
longer than six (6) years. The request should
indicate in what form you want the list (such
as a paper or electronic copy). The first list
you request within a twelve (12) month period
will be free, but the Practice may charge you
for the cost of providing additional lists.
The Practice will notify you of the costs
involved and you can decide to withdraw or
modify your request before any costs are
incurred.
(g) Receive a paper copy of this Privacy
Notice from the Practice upon request to the
Practice's Privacy
Officer.
(h) Complain to the Practice or to the
Secretary of HHS |
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if you believe your
privacy rights have been violated. To file
a complaint with the Practice, you must
contact the Practice's Privacy Officer.
All complaints must be in writing.
(i) To obtain more information on, or have
your questions about your rights answered,
you may contact the Practice's Privacy
Officer, Dr. Barry Blass, at 813-238-3631
or via email at Footdoc@verizon.net . |
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PRACTICE'S REQUIREMENTS
1. The Practice:
(a) Is required by federal law to maintain
the privacy of your PHI and to provide you
with this Privacy Notice detailing the
Practice's legal duties and privacy
practices with respect to your PHI.
(b) Is required by State law to maintain a
higher level of confidentiality with
respect to certain portions of your
medical information that is provided for
under federal law. In particular, the
Practice is required to comply with the
following State statutes:
Section 381.004 relating to HIV testing,
Chapter 384 relating to sexually
transmitted diseases and Section 456.057
relating to patient records ownership,
control and disclosure.
(c) Is required to abide by the terms of
this Privacy Notice.
(d) Reserves the right to change the terms
of this Privacy Notice and to make the new
Privacy Notice provisions effective for
all of your PHI that it maintains.
(e) Will distribute any revised Privacy
Notice to you prior to implementation.
(f) Will not retaliate against you for
filing a complaint. |
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QUESTIONS AND COMPLAINTS |
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You
may obtain additional information about
our privacy practices or express concerns
or complaints to the person identified
below who is the Privacy Officer and
Contact person appointed for this
practice. |
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You
may file a complaint with the Privacy
Officer if you believe that your privacy
rights have been violated relating to
release of your protected health
information. You may, also, submit a
complaint to the Department of Health and
Human Services the address of which will
be provided to you by the Privacy Officer.
We will not retaliate against you in any
way if you file a complaint. |
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EFFECTIVE DATE
This Notice is in effect as of 04/14/2003. |
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