Office Information: Notice of Privacy Practices
Notice of Privacy Practices
East Coast Orthopaedics
1201 East Sample Road
Pompano Beach, Florida 33064
Tel: (954) 942-4433 • Fax: (954) 942-0448
Consent For Use And Disclosure Of Health Information
Section A: Patient Giving Consent
Name
Address
Telephone Social Security
Section B: To the Patient: Please read the following
statements carefully
Purpose of Consent. By signing this form, you will consent
to our use and disclosure of your protected health information to
carry out treatment, payment activities and healthcare operations.
Notice of Privacy Practices. You have the right
to read our Notice of Privacy Practices before you decide whether
to sign this Consent. Our Notice provides a description of our treatment,
payment activities and healthcare operations, of the uses and disclosures
we may make of your protected health information, and of other important
matters about your protected health information. A copy of our Notice
accompanies this Consent. We encourage you to read it carefully
and completely before signing this Consent.
We reserve the right to change our privacy practices as described
in our Notice of Privacy Practices. If we change our privacy practices,
we will issue a revised Notice of Privacy Practices, which will
contain the changes. Those changes may apply to any of our protected
health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including
any revisions of our Notice, at any time by contacting:
Contact Person: Michele (Office Manager)
Address: 1201 E Sample Road, Pompano Beach, Florida 33064
Telephone: (954) 942-4433 Fax: (954) 942-0448
Right to Revoke. You will have the right to revoke
this Consent at any time by giving us written notice of your revocation
submitted to the Contact Person listed above. Please understand
that revocation of this Consent will not affect any action we took
in reliance on this Consent before we received your revocation,
and that we may decline to treat you or to continue treating you
if you revoke this Consent.
Signature
I, _____________________, have had full opportunity to read and
consider the contents of this Consent form and your Notice of Privacy
Practices. I understand that, by signing this Consent form, I am
giving my consent to your use and disclosure of my protected health
information to carry out treatment, payment activities and healthcare
operations.
Signature:____________________________ Date:___________________
Notice of Privacy Practices
This Notice Describes How Health Information About You May Be Used
And Disclosed And How You Can Get Access To This Information. Please
Review It Carefully. The Privacy of Your Health Information Is Important
To Us.
Our Legal Duty
We are required by applicable federal and state law to maintain
the privacy of your health information. We are also required to
give you this Notice about our privacy practices, our legal duties,
and your rights concerning your health information. We muse follow
the privacy practices that are described in this Notice while it
is in effect. This notice takes effect on 4/13/03 and will remain
in effect until we replace it.
We reserve the right to change our privacy practices and the terms
of this Notice at any time, provided such changes are permitted
by applicable law. We reserve the right to make the changes in our
privacy practices and the new terms of our Notice effective for
all health information that we maintain, including health information
we created or received before we made the changes. Before we make
a significant change in our privacy practices, we will change this
Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information
about our privacy practices, or for additional copies of this Notice,
please contact us using the information listed at the end of this
Notice.
Uses and Disclosures of Health Information
We use and disclose health information about you for treatment,
payment and healthcare operations; for example:
Treatment. We may use or disclose your health information to a physician
or other healthcare provider providing treatment to you.
Payment. We may use and disclose your health information
to obtain payment for services we provide to you.
Healthcare Operations. We may use and disclose your health information
in connection with out healthcare operations. Healthcare operations
include quality assessment and improvement activities, reviewing
the competence or qualifications of healthcare professionals, evaluating
practitioner and provider performance, conducting training programs,
accreditation, certification, licensing or credentialing activities.
Your Authorization. In addition to our use of your
health information for treatment, payment of healthcare operations,
you may give us written authorization to use your health information
or to disclose it to anyone for any purpose. If you give us an authorization,
you may revoke it in writing at any time. Your revocation will not
affect any use or disclosures permitted by your authorization while
it was in effect. Unless you give us a written authorization, we
cannot use or disclose your health information for any reason except
those described in this Notice.
To Your Family and Friends. We must disclose your
health information to you, as described in the Patient Rights of
this Notice. We may disclose your health information to a family
member, friend or any other person to the extent necessary to help
with your healthcare or with payment for your healthcare, but only
if you agree that we may do so.
Persons Involved in Care. We may use or disclose
health information to notify, or assist in the notification of (including
identifying or locating) a family member, your personal representative
or another person responsible for your care, of your location, your
general condition, or death. If you are present, then prior to use
or disclosure of your health information, we will provide you with
an opportunity to object to such uses or disclosures. In the event
of your incapacity or emergency circumstances, we will disclose
health information based on a determination using our professional
judgment disclosing only health information that is directly relevant
to the person’s involvement in your healthcare. We will also
use our professional judgment and our experience with common practice
to make reasonable inferences of your best interest in allowing
a person to pick up filled prescriptions, medical supplies, x-rays
or other similar forms of health information.
Marketing Health-Related Services. We will not use your
health information for marketing communication without your written
authorization.
Required by Law. We may use or disclose your health
information when we are required to do so by law.
Abuse or Neglect. We may disclose your health information
to appropriate authorities if we reasonably believe that you are
a possible victim of abuse, neglect or domestic violence or the
possible victim of other crimes. We may disclose your health information
to the extent necessary to avert a serious threat to your health
or safety or the health or safety of others.
National Security. We may disclose to military
authorities the health information of Armed Forces personnel under
certain circumstances. We may disclose to authorized federal officials
health information required for lawful intelligence, counterintelligence
and other national security activities. We may disclose to correctional
institution or law enforcement officials having lawful custody of
protected health information of inmate or patient under certain
circumstances.
Appointment Reminders. We may use or disclose your health
information to provide you with appointment reminders (such as voicemail
messages, postcards or letters).
Patient Rights
Access. You have the right to look at or get copies
of your health information, with limited exceptions. You may request
that we provide copies in a format other than photocopies. We will
use the format you request unless we cannot practicably do so. You
must make a request in writing to obtain access to your health information.
You may obtain a form to request access by using the contact information
listed at the end of this Notice. We will charge you a reasonable
cost-based fee for expenses, such as copies and staff time. You
may also request access by sending us a letter to the address at
the end of this Notice. If you request copies, we will charge you
$0.50 for each page and $____ per hour of staff time to locate and
copy your health information, and postage if you want the copies
mailed to you. If you request an alternate format, we will charge
a cost-based fee for providing your health information in that format.
Contact us using the information listed at the end of this Notice
for a full explanation of our fee structure.
Disclosure Accounting. You have the right to receive
a list of instances in which we or our business associates disclosed
your health information for purposes, other than treatment, payment,
healthcare operations and certain other activities, for the last
six (6) years, but not before April 14, 2003. If you request this
accounting more than once in a twelve (12) month period, we may
charge you a reasonable, cost-based fee for responding to these
additional requests.
Restriction. You have the right to request that we place additional
restrictions on our use or disclosure of your health information.
We are not required to agree to these additional restrictions, but
if we do, we will abide by our agreement (except in an emergency).
Alternative Communication. You have the right to
request that we communicate with you about your health information
by alternative means or to alternative locations. You must make
your request in writing. Your request must specify the alternative
means or location, and provide satisfactory explanation how payments
will be handled under the alternative means or location you request.
Amendment. You have the right to request that we
amend your health information. Your request must be in writing,
and it must explain why the information should be amended. We may
deny your request under certain circumstances.
Electronic Notice. If you receive this Notice on or website or by
electronic mail (e-mail), you are entitled to receive this Notice
in written form.
Questions And Complaints
If you want more information about our practices or have questions
or concerns, please contact us.
If you are concerned that we may have violated your privacy rights,
or you disagree with a decision we made about access to your health
information or in response to a request you made to amend or restrict
the use or disclosure of your health information or to have us communicate
with you by alternative means or at alternative locations, you may
complain to us by using the contact information listed at the end
of this Notice. You also may submit a written complaint to the U.S.
Department of Health and Human Services. We will provide you with
the address to file your complaint with the U.S. Department of Health
and Human Services upon request.
We support our right to the privacy of your health information.
We will not retaliate in any way if you choose to file a complaint
with us or with the U.S. Department of Health and Human Services.
Contact Office: Michele (Office Manager)
Address: 1201 East Sample Road, Pompano Beach, Florida 33064
Tel: (954) 942-4433 • Fax: (954) 942-0448
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