Amelia Island Orthopedics

Notice of Privacy Practices

THE HIPAA PRIVACY RULE 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. We have summarized our responsibilities and your rights on this first page. For a complete description of our privacy practices, please review this entire notice.

Our Responsibilities:

Our medical practice is required to:
• Maintain the privacy of your health information.
• Provide you with this notice of our legal duties and privacy practice with respect to information we collect and maintain about you.
• Abide by the terms of this notice.

Your Rights:

As a patient of our practice, you have several rights with regard to your health information including the following:
• The right to request that we not use or disclose your health information in certain ways.
• The right to request to receive communications in an alternative manner or location.
• The right to access and obtain a copy of your health information.
• The right to request an amendment to your health information.
• The right to an accounting of disclosures of your health information.

We reserve the right to change our privacy practices and to make the new provisions effective for all health information we maintain. Should our privacy practices change, we will post the changes in our office. A copy of the revised notice will be available after the effective date of the changes upon request.

We will not use or disclose your health information without your authorization, except as described in this notice.

If you have question or would like additional information, you may contact the privacy officer at 904-261-8787.

Understanding Your Health Record/Information

Each time you visit a medical facility, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, 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.
• a means of communication among the many health professionals who contribute to your care.
• a legal document describing the care you received.
• a means by which you or a third party payer can verify that services billed were actually provided.
• a tool in educating health professionals.
• a source of data for medical research.
• a source of information for public health officials who oversee the delivery of health care in the United States.
• a source of data for facility planning and marketing.
• a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where and why others nay access your health information and make more informed decisions when authorizing disclosure to others.

How We Will Use or Disclose Your Health Information

1. Treatment: We will use or disclose your health information for treatment purposes to other health care providers such as your referring physician. This information will be used to determine the course of treatment for you.

2. Payment: We will use or disclose your health information as required for payment of services rendered by the physicians of Amelia Island Orthopaedics. For example, a bill may be sent to a third party payer such as Medicare, and accompanying the bill may be information that identifies you as well as your diagnosis, procedures and supplies used.

3. Healthcare operations: We will use or disclose your health information for our regular health operations. For example, employees of Amelia Island Orthopaedics may use information in your health record to assess the care and treatment provided in an effort to continue to improve the quality of the healthcare and service we provide.

Most forms of disclosure will require written authorization from you prior to releasing your personal health information. There are a few exceptions where authorization is not required for disclosure. These are:

• We may disclose health information authorized by and to the extent necessary to comply with laws relating to workers compensation.

• State health agencies require providers to report to them when patients have certain communicable diseases, even if the patient does not want the information reported.

• The Food and Drug Administration (FDA) requires providers to report certain information about medical devices that break or malfunction.

• Some states require physicians and other caregivers who suspect child abuse or domestic violence to report it to the police.

• Police have the right to request certain information about patients to investigate crimes.

• The courts have the right to order providers to release certain patient information.

• Providers must report cases of suspicious deaths or suspected crime victims.

Your Health Information Rights

Although your health record is the physical property of Amelia Island Orthopaedics, the information in your health record belongs to you. You have the following rights:

• You may request that we not use or disclose your health information related to treatment, payment and/or general healthcare operations to a particular family member, other relative or close personal friend. We ask that such requests be made in writing. Although we will consider your request, please be aware that we are under no
obligation to accept it or to abide by it. For more information about this right, see 45 Code of Federal Regulations (C.F.R.) 164.522(a).

• You may revoke an authorization to use or disclose health information, except to the extent that the action has already been taken. Such requests must be made in writing.

• You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the time frames established by law. You may make such requests orally or in writing, however, in order to better respond to your request we ask that you make such requests in writing. If you request to have copies made, we will charge you a reasonable fee as outlined in the Florida Administrative Code. For more information about this right, see 45 C.F.R. 164.524.

• If you believe that any health information in your record is incorrect or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing and must provide a reason to support the amendment.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact our privacy officer at 904-261-8787.

If you believe that your privacy rights have been violated, you may file a complaint with us in writing or file a complaint with the secretary of the federal Department of Health and Human Services. There will be no retaliation for filing a complaint.

Effective Date: 14 April 2003

Notice of Privacy Practices Signature Form

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