Notice of Privacy









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.


The Practice may 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

payers, 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.

• (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

1. The Practice may use and/or disclose your PHI, without a written Consent from you, in the

following additional 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 Consent 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 Consent and the Practice

determines, in the exercise of its professional judgment, that your Consent to receive

treatment is clearly inferred from the circumstances.

(f) Public Health Activities – Such activities include, for example, information collected

by a public health authority, as authorized by law, to prevent or control disease and that

does not identify you and, even without your name, cannot be used to identify you.

(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

(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 and that does not identify you and, even without your name, cannot

be used to identify you.

(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) 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.

(p) Disclosure of immunizations to schools required for admission upon your informal


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 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.


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.

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 unless you direct the Practice to the contrary.  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.

Uses and/or disclosures, other than those described above, will be made only with your

(a) Revoke any Authorization and/or Consent, 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 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 obtain a copy your PHI as provided by 45 CFR 164.524.  To inspect and

copy your PHI, you are requested to 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

(e) Amend your PHI as provided by 45 CFR 164.528.  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 45 CFR 164.528.

The request should indicate in what form you want the list (such as a paper or electronic copy)

(g) Receive a paper copy of this Privacy Notice from the Practice upon request to the

Practice’s Privacy Officer.

(h) Receive notice of any breach of confidentiality of your PHI by the Practice.

(i) Prohibit report of any test, examination or treatment to your health plan or anyone else

for which you pay in cash or by credit card.

(j) Complain to the Practice or to the Office of Civil Rights, U.S. Department of Health

and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building,

Washington, D.C. 20201, 202 619-0257, email: or to the Florida Attorney

General, Office of the Attorney General, PL-01 The Capitol, Tallahassee, FL 32399-1050, 850

414-3300 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.

(k) Request copies of your PHI in electronic format.

To obtain more information on, or have your questions about your rights answered, you

may contact the Practice’s Privacy Officer, Lindsie Parker, at 850-433-1111 or via email



• (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 your entire 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.


You may obtain additional information about our privacy practices or express concerns

or complaints to the person identified below whom is the Privacy Officer and Contact person

appointed for this practice. The Privacy Officer is Lindsie Parker.

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

This Notice is in effect as of 9/23/2013.