JANUARY 1, 2013

 

THE ATTACHED 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.

 

This Notice is not intended to alter or limit any other consents for treatment or procedures the patient may sign during the time the patient is provided care at this clinic.

UNDERSTANDING YOUR MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are

committed to protecting your medical information. Each time you visit a hospital, physician, or

other health care provider, they document information about you and your visit. Typically, this

record contains, among other information, your name, symptoms, health history, examination and

test results, diagnoses, current and future treatment, and billing-related information (“Medical

Information”). This Medical Information is used to provide you with quality care and to comply

with certain legal requirements.

This Notice will tell you how we may use and disclose Medical Information about you. It also

describes your rights and certain obligations we have regarding the use and disclosure of your

Medical Information.

We are required by law to:

  • Maintain the privacy of your Medical Information.
  • Provide you with this Notice of our legal duties and privacy practices with respect to

information we collect and maintain about you.

  • Follow the terms of this Notice or a Notice that is in effect at the time WESTON MEDICAL CLINIC , INC , WESTON MEDICAL CLINIC & COSMETIC CENTER, and PHANOR CALLE, MD uses or discloses your Medical Information.

USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION

The following categories describe different ways in which we may use and disclose your Medical

Information. With respect to use and disclosure of your Medical Information for Treatment,

Payment and Health Care Operations, we may share your Medical Information with any of the

entities referenced in this Notice, or any physician or other health care provider as allowed by law

For Treatment. We may use your Medical Information to provide, coordinate or manage your

medical treatment and related services. Your Medical Information can be shared with physicians,

nurses, technicians and others involved in your care and these individuals will collect and

document information about you in your medical record. To assure immediate continuity of care,

we may disclose information to a physician or other health care provider who will be assuming

your care. For example, different departments may share your Medical Information to coordinate

the different services you may need such as prescriptions, lab work, meals and X-rays or other

diagnostic tests.

For Payment. We may use and disclose your Medical Information so that the treatments and

services you receive may be billed and payment may be collected from you, an insurance

company or a third party. For example, we may need to give information about the procedure you

received to your health plan so your health plan will pay us or reimburse you for the procedure. We also may tell your health plan about a treatment you are going to receive to obtain prior approval

or to determine whether your plan will cover the treatment.

 

 

NOTICE OF PRIVACY PRACTICES

 

For Health Care Operations. We may use and disclose your Medical Information in connection

with our health care operations including, but not limited to the following:

  • Quality assessment and improvement activities.
  • Related functions that do not include treatment.
  • Competence or qualification reviews of health care professionals.
  • Training programs, accreditation, certification, licensing or credentialing activities.

 

Individuals Involved in Your Care or Payment for Your Care. We may disclose the minimum

necessary Medical Information about you to a family member, other relative, close personal

friend or any other person you identify who is involved in your medical care. We also may

disclose the minimum necessary information to someone who helps pay for your care. In an

emergency or other situation where you are not able to identify your chosen person(s) to receive

communications about you, we may exercise our professional judgment to determine whether

such a disclosure is in your best interest, who is the appropriate person(s) and what Medical

Information is relevant to their involvement with your health care. We may also disclose your

Medical Information to an organization, such as the American Red Cross which is assisting in a

disaster relief effort, so that your family can be notified about your condition, status and location.

Research. Under certain circumstances, we may use or disclose your Medical Information to

identify you as a potential candidate for a research study that has been approved by an

Institutional Review Board. This approval is given after an evaluation of a proposed research

project and its uses of Medical Information, and always with an effort to balance the requirements

of sound research with patients’ need for privacy of their Medical Information. We may disclose

Medical Information about you to people preparing to conduct a research project, for example,

to help them look for patients with specific medical needs, so long as the Medical Information

they review does not leave the site

NOTICE OF PRIVACY PRACTICES

 

To Avert a Serious Threat to Health or Safety. As required by law, we may disclose Medical

Information about you when necessary to prevent a serious threat to your health or safety or the

health and safety of the public or another person. Any disclosure of this kind, however, would be

made only to someone able to help prevent the threat.

Business Associates. We provide some services through other persons or companies that need

access to your health information to carry out these services. The law refers to these persons or

companies as our Business Associates. We may disclose, as allowed by law, your health

information to our Business Associates so that they can do the job we have contracted with them

to do. Examples of Business Associates include companies that assist with billing services or

copying medical records. We may send other business associates called registries (such as a

Cancer Registry) summarized information about patients who have been treated with similar

problems such as cancer or trauma, to help physicians improve the quality of care for other

patients with similar problems. We require through a written contract that our Business

Associates use appropriate safeguards to ensure the privacy of your Medical Information.

 

Other Communications with You. We may use and disclose your Medical Information to contact

you at the address and telephone numbers you give us about scheduled or canceled appointments

with your physicians or other health care team members, registration or insurance updates, billing

and/or payment matters, information about patient care issues, treatment choices and follow-up

care instruction, and other health-related benefits and services that may be of interest to you.

Unless you tell us otherwise, we may leave messages about appointments or other reminders on

your telephone or with a person who answers the phone.

 

NOTICE OF PRIVACY PRACTICES

 

Special Situations

Lawsuits and Disputes. We may disclose your Medical Information in the course of a judicial and

administrative proceeding, in response to an order of a court or other tribunal to the extent that

such disclosure is authorized and, in certain conditions, in response to a subpoena, discovery

request or other lawful process.

Law Enforcement. We may disclose your Medical Information to the police or other law

enforcement officials as part of law enforcement activities, in investigations of criminal conduct,

in response to a court order, in emergency circumstances, or when otherwise required to do so by

law.

Coroners, Medical Examiners and Funeral Directors. We may release Medical Information

about you to a coroner or medical examiner as necessary to identify a deceased person or to

determine the cause of death. We also may release your Medical Information to funeral directors

as necessary for them to carry out their duties.

Organ and Tissue Donation. If you are an organ donor, we may release your Medical

Information to organizations that obtain organs or handle organ, eye or tissue transplantation. We

may also release your Medical Information to an organ bank to arrange for organ or tissue

donation and transplantation.

Military and Veterans. If you are a member of the military or a veteran, we may release your

Medical Information to the proper authorities so they may carry out their duties under the law.

Inmates. If you are an inmate in a correctional institution or in the custody of a law enforcement

official, we may disclose Medical Information about you to the correctional institution or law

enforcement official as necessary so that their duties can be carried out under the law.

Workers Compensation. We may disclose your Medical Information as allowed or required by law relating to workers’ compensation benefits for work-related injuries or illness or to

other similar programs.

Public Health Activities. We may be required to report your Medical Information to authorities to

help prevent or control disease, injuries or disability. This may include using your Medical

Information to report certain diseases, injuries and birth and death information. This also may

include reporting certain drug reactions with products or notification of product recalls. We also

may be required to report to your employer certain work-related illnesses or injuries so that your

workplace can be monitored for safety. The appropriate government authorities may also be

notified if we believe a patient has been the victim of child or elder abuse, neglect or domestic

violence. These reports will be made in compliance with state and federal law and will be limited

to the requirements of the law.

 

NOTICE OF PRIVACY PRACTICES

 

Health Oversight Activities and Specialized Government Functions. We may disclose your

Medical Information to local, state or federal government authorities or agencies that oversee

health care systems and ensure compliance with the rules of government health programs, such as

Medicare or Medicaid and, under certain circumstances, to the U.S. Military or U.S. Department

of State.

Marketing. We will not use or disclose your Medical Information for marketing purposes without

your written authorization.

Uses and Disclosures Not Covered in this Notice. Other uses and disclosures of your Medical

Information will be made only with your written permission unless otherwise permitted or

required by law. If you provide us with permission to use or disclose Medical Information about

you, you may revoke that permission in writing at any time. If you revoke your permission, we

will no longer use or disclose Medical Information about you for the reasons covered by your

written permission. Please understand that we are unable to take back any disclosures already

made with your permission and that we are required to retain the records of the care provided to

you.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights regarding the Medical Information we maintain about you:

Right to Inspect and Copy. You have the right to see and obtain a copy of your Medical

Information. This includes medical and billing records, but does not include psychotherapy notes.

To see and/or obtain copies of this information, you must submit your request in writing. The Authorization for Release of Patient Health

Information form is available from the medical records department at WESTON MEDICAL CLINIC, INC .

If you request a copy of your Medical Information, we may charge a reasonable fee for the costs

of copying and mailing or for other expenses associated with complying with your request. We

may deny your request to see and/or obtain copies of your Medical Information in very limited

circumstances. If you are denied access to your Medical Information, you may request that the

denial be reviewed. A licensed health care professional chosen by WESTON MEDICAL CLINIC , INC, WESTON MEDICAL CLINIC & COSMETIC CENTER , AND PHANOR CALLE, MD 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 decision that is the outcome of the review.

Right to Amend. If you feel that the Medical Information we have on record is inaccurate or

incomplete, you have the right to request an amendment as long as the information is kept by or

for WESTON MEDICAL CLINC, INC , WESTON MEDICAL CLINIC & COSMETIC CENTER and PHANOR CALLE, MD. If the Medical Information is kept by another hospital or provider, we

cannot act on your request. You must contact them directly. Your request for an amendment must

be in writing and must state the reasons for the request. The written request can be made on the

Request for Amendment to the Record form available in the medical records department at WESTON MEDICAL CLINIC, INC . We may deny your request for an amendment if it is not in

 

NOTICE OF PRIVACY PRACTICES

 

writing or does not include a reason to support the request. We are not obligated to make all

requested amendments, but will give each request careful consideration. If your request is denied,

you have the right to send a letter of objection that will then be attached to your permanent

medical record. Please note that even if we accept your request, we may not delete any

information already documented in your medical record.

Right to an Accounting of Disclosures. You have the right to ask us for an “accounting of

disclosures

 

It will not cover Medical Information that was given to you or your personal

representative or to others with your permission. In addition, it will not cover Medical

Information that was given in order to:

  • Provide or arrange care for you;
  • Facilitate payment for your healthcare services; and/or
  • Assist WESTON MEDICAL CLINIC , INC, WESTON MEDICAL CLINIC & COSMETIC CENTER and PHANOR CALLE. MD in its operations.

Your request for an accounting of disclosures must be made on the Request for Accounting of

Disclosures form available in the medical records department WESTON MEDICAL CLINIC , INC, . The list will include only the disclosures made for the time period indicated in your

request, but may not exceed a six-year period or include dates before April 14, 2003. The first list

you request within a 12-month period will be free. For additional lists, we may charge you for the

reasonable costs associated with providing the list. We will notify you of costs involved. You

may choose to withdraw or modify your request at any time before costs are incurred.

Right to Request Restrictions. You have the right to ask us to restrict or limit the Medical

Information we use or disclose about you for treatment, payment or healthcare operations. In

addition, if you pay for a particular service in full, out-of-pocket, on the date of service, you may

ask us not to disclose any related Medical Information to your health plan. Unless required by

law, we are not required to agree to all requests. If we do agree, we will comply unless the

information is needed to provide emergency treatment.

Right to Request Confidential Communications. You have the right to ask us to communicate

with you about medical matters in a certain way or at a certain location. For example, you may

ask that we contact you only by sending materials to a P.O. Box instead of your home address.

We will not ask the reason for your request and we will accommodate all reasonable requests.

Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of this Notice. Upon your request, you may at any time obtain a paper

copy of this Notice. To do so, please contact the WESTON MEDICAL CLINIC , INC site HIPAA Coordinator.

You also may access a copy of this Notice on our web site at www.doctorcalle.com.

 

 

NOTICE OF PRIVACY PRACTICES

Changes to This Notice

We reserve the right to change our privacy practices, policies and procedures and our Notice of

Privacy Practices. We also reserve the right to make the revised privacy policies, procedures and

Notice effective for 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 in WESTON MEDICAL CLINIC, INC, WESTON MEDICAL CLINIC & COSMETIC CENTER facilities and this Notice will contain the new effective date on the first page. In addition, each time you register at WESTON MEDICAL CLINIC, INC, and WESTON MEDICAL CLINIC & COSMETIC CENTER a copy of the current Notice will be available upon request.

Right to File A Complaint:

If you have any questions or would like to report a privacy concern, please contact the

appropriate contact person at WESTON MEDICAL CLINCIC INC, WESTON MEDICAL CLINIC & COSMETIC CENTER or PHANOR CALLE, MD (see below).

If you believe WESTON MEDICAL CLINIC, INC , WESTON MEDICAL CLINIC & COSMETIC CENTER and PHANOR CALLE, MD has violated your privacy rights, you may file a

complaint with our office: WESTON MEDICAL CLINIC , INC 17120 ROYAL PALM BLVD SUITE 4, WESTON FL 33326. or with the US Department of Health and Human Services Office for Civil Rights (“OCR”).

We will not retaliate against you if you file a complaint with us or with the OCR.