SOUTH FLORIDA KIDNEY DISEASE & HYPERTENSION SPECIALISTS, PA (SFKDHS)
NOTICEOF PRIVACY PRACTICES
Effective Date: March 26, 2013
THISNOTICEDESCRIBESHOWMEDICALINFORMATIONABOUTYOUMAYBE USEDANDDISCLOSEDANDHOWYOUMAYOBTAINACCESSTOSUCHINFORMATION. PLEASE REVIEWTHIS NOTICE CAREFULLY.
Eachtimeyouvisitahospital,physician,orotherhealthcareproviderarecord ofyourvisitismade.Theserecordstypicallycontaininformationregardingyoursymptoms, examinationandtestresults,diagnoses,treatmentandcareplan.Thisinformation,whichmaybe referredtoasyourprotectedhealthinformationorPHI,maybeusedand/ordisclosedasfollowswithout your specific authorization:
1.Forthepurposeoftreatment,payment,orhealthcareoperations.Examplesofthese types of disclosures are provided below.
2.Toinformyouoftreatmentalternativesorabouthealthrelatedbenefitsandservicesthat may be of interest to you.
3.Toprocessinsuranceclaimsandtoallowthirdpartypayorstoverifythattheservices billedwereactuallyprovided.
4.WemaydiscloseyourPHIforthepurposeofresearch.WewillonlydiscloseyourPHI forresearchpurposeswithoutyourexpressauthorizationiftheresearchprotocolhasbeen approvedbyavalidinstitutional review board or privacy board.
5.We may disclose your PHI to public health officials.
6.We may disclose your PHI to law enforcement officials for law enforcement purposes.
7.WemaydiscloseyourPHItoanappropriategovernmentalauthorityifwereasonably believe that you may be a victimof abuse, neglect, or domestic violence.
8.Ifwebelieveitisnecessarytoavertaseriousthreattothehealthorsafetyofyourselfor thepublic,wemaydiscloseyourPHItoapersonorpersonswhowebelieveare reasonably able to preventorlessenthethreat.
9.We may disclose your PHI as a sourceofdataforbusinessplanning.
10.WemayuseyourPHIasatoolforqualityassuranceandcontinuousquality improvement.
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11.We may disclose your PHI as required byfederalandstatelawsandregulations.
12.WemaydiscloseyourPHItoahealthoversightagency,suchastheUnitedStates DepartmentofHealthandHumanServicesoranequivalentstateagency,forpurposes relatingtotheoversightofthehealthcaresystemandgovernmentbenefitprogramssuch as Medicare.
13.WemaydiscloseyourPHIinthecourseofajudicialoradministrativeproceedingin responsetoacourtorder,subpoena,discovery request or other lawful process.
14.WemaydiscloseyourPHItoacoronerormedicalexaminerforthepurposeof identifyingadeceasedperson,determiningacauseofdeath,orotherpurposesas authorizedbylaw.WemayalsodiscloseyourPHItofuneraldirectorsasnecessaryto carryouttheirduties.
15.WemaydisclosePHItoorganizationsinvolvedintheprocurement,banking,or transplantationofcadavericorgans,eyesortissue,forthepurposeoffacilitatingorgan andtissuedonation.
16.IfyouareamemberortheUnitedStatesorforeignArmedForces,wemaydiscloseyourPHIforactivitiesthataredeemednecessarybyappropriatemilitarycommandauthorities to assure the proper execution of a military mission.
17.WemaydiscloseyourPHItoauthorizedfederalofficialsfortheconductoflawful intelligence,counter-intelligenceandothernationalsecurityfunctionsauthorizedbylaw, orforthepurposeofprovidingprotectiveservicesto the President, foreign heads of state.
18.WemaydiscloseyourPHItoacorrectionalinstitutionoralawenforcementofficial having lawful custody of you.
19.Wemaydiscloseyourprotectedhealthinformationasauthorizedby,andincompliance with, lawsrelatingtoworkers’compensationandsimilarprogramsestablishedbylaw thatprovidebenefitsforwork-relatedillnessesandinjurieswithoutregardtofault.
20.Wemaydiscloseadecedent’sPHItofamily membersorotherswhowereinvolvedinthe careorpaymentforcareofthedecedentpriortodeathunlessdoingsoisinconsistent with any prior expressedpreference.
AnyuseordisclosureofyourPHIthatisnotlistedabovewillbemadeonlywithyourwritten authorization which may be revoked by you at any time.
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TheusesanddisclosuresofyourPHIthatmaybemadeonlywithyourauthorization include,butarenotlimited to, the following:
a.Those related to psychotherapy notes;
b.Usesanddisclosuresformarketingpurposes;and
c.DisclosuresthatconstitutethesaleofPHI.
YOUR HEALTH INFORMATION RIGHTS
Youhavetherightto:
1.RequestrestrictionsontheuseanddisclosureofyourPHI.However,SFKDHSisnot requiredtoagreetotherestrictionexceptasprovidedinItem8below.Ifyouwishto requestarestrictiononourusesanddisclosuresofyourPHI,pleaseprovideawritten requestdescribingyourrequestedrestrictiontothePrivacyOfficer.Wewillnotifyyou of our decision regarding the requested restriction.
2.Inspectandcopyalloranypartofyourmedicalorhealthrecord,asprovidedby45
C.F.R. §164.524.
3.Amendyourhealthrecord, as provided by 45 C.F.R. §164.526.
4.Requestandreceiveanaccountingof disclosures made of your PHI, except for disclosuresmadeforthepurposeoftreatment,payment, health care operations and certain other purposes, as setforthin45C.F.R.§164.528.
5.Obtain a paper copy of this Notice from South Florida Kidney Disease & Hypertension Specialists, PA Inc. upon request.
6.ReceivecommunicationsofyourPHIbyalternativemeansoratalternativelocations.For example,atyourrequest,wewillmailitemstoapostofficeboxinsteadofyour residence.
7.Ifyouexecuteanyauthorization(s)fortheuseanddisclosureofyourPHI,youare entitledtorevokesuchauthorization(s),excepttotheextentthatactionhasalreadybeen takeninreliancethereon.
8.RestrictdisclosureofPHItoahealthplanifthedisclosureisforpaymentorhealthcare operationsandpertainstoahealthcareitemorserviceforwhichthisindividualhaspaid outofpocketinfull.
SFKDHS’S RESPONSIBILITIES
1.Maintain the privacy of your PHI.
2.ProvideyouwiththisNoticeastoourlegaldutiesandprivacypracticeswithrespectto
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the information we maintainandcollectaboutyou.
3.Abide by the terms ofthis Notice, which may be amended fromtime to time.
4.Notify you if we are unable to agreetoarequested restriction.
5.Postnotice,inaclearandprominentlocation,thatarevisedcopyofthisNoticeis availableuponrequestifit isalteredoramended.
6.ProvideyouwithtimelynotificationfollowingabreachofyourunsecuredPHI.
SFKDHSreservestherighttochangeitsprivacypracticesforallPHIthatwemaintain.Ifour privacypracticesmateriallychange,SFKDHS will revise thisNotice andprovideyouwithnoticethatacopy of the revised Notice is available upon requestassetforthin45 C.F.R. §164.520.
SFKDHSwillnotuseordiscloseyourPHIinamannerinconsistentwiththisNoticewithoutyour authorization.
EXAMPLESOFDISCLOSURESFORPAYMENT,TREATMENTANDHEALTHCARE OPERATIONS
We will use your health information for treatment.
Forexample:Informationobtainedbyyournephrologist,byanurse,orbyanothermemberofyour healthcareteamwillberecordedinyourhealthrecordandusedtodevelopatreatmentplanforyou. Yourphysicianwilldocument information related to your office visits and treatment plan.Membersofyourhealthcareteam, includingnursesandmedical assistants,willrecorddetailsofyourtreatment plan,alongwithany observationsaboutyourhealthstatus,before,duringandafteryour office visits.Thisinformation willbereviewedbyyourphysicianandothermembers of your health care teamas needed.
We will use your health information for payment.
Forexample:Abillmaybesenttoyouortoathirdpartypayor.Theinformationonthebillor accompanyingthebillmayincludeinformationthatidentifiesyou,yourdiagnosis,thetreatments renderedtoyou,andthemedications,suppliesandequipment used to performthe treatments.
Wewilluseyourhealthinformationfor regular health care operations.
Forexample:EmployeesofSFKDHSanditsmedicalstaffmayuseinformationinyourhealthrecordto assessthequalityofthecareandtreatmentyoureceivehere,andoutcomesinyourcaseandotherslike it.Theinformationwillthenbeusedinanefforttocontinuallyimprovethequalityandeffectivenessof the health care and services that we providetoallofourpatients.
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EXAMPLES OF OTHER PERMISSIBLEOR REQUIRED DISCLOSURES
Businessassociates:Therearesomeservicesprovidedatthisoffice oronbehalfofSFKDHSthrough contractswithbusinessassociates.Examplesinclude external billing and collection services and other legal andconsultingservicesprovidedinresponsetobillingandreimbursementissueswhichmayarisefrom timetotime.Whenweenterintocontractstoobtaintheseservices,wemayneedtodiscloseyourPHI toourbusinessassociatesothatsuchbusinessassociatemayperformthejobwhichwehaverequested. To protect your PHI, we requireourbusinessassociatetoappropriately safeguard your information.
Notification:WemayuseordisclosePHItonotifyorassistinnotifyingafamilymember,personal representative,closepersonalfriend,orotherpersonresponsibleforyourcareofyourlocationand generalcondition.SFKDHSwillnotdiscloseyourPHItoyourfamilymembers,personal representativeorclosepersonalfriendsasdescribedinthisparagraphifyouobjecttosuch disclosures.Please notify the Privacy Officerifyouobjectto suchdisclosures.
Communicationwithfamilymembers:Healthprofessionals,includingthoseemployedbyorunder contractwithSFKDHS,maydisclosetoafamilymember,otherrelative,closepersonalfriendoranyother personyouidentify,yourPHIrelativetothatperson’sinvolvementinyourcareorpaymentrelatedto yourcare,unlessyouobjecttosuch disclosures.PleasenotifySFKDHSifyouobjectto such disclosures.
Research:WemaydiscloseyourPHItoresearcherswithoutavalidauthorizationfromtheapplicable individualonlywhentherequirementtoobtainanauthorizationiswaivedbyaninstitutionalreview board.
Marketing:Wemaycontactyoutoprovideappointmentremindersorinformationabouttreatment alternatives or other health-related benefits and services thatmay beof interest to you.
PublicHealth:Asrequiredbylaw,wemaydiscloseyourPHItopublichealthorlegalauthorities charged with preventing or controllingdisease,injuryordisability.
LawEnforcement:WemaydiscloseyourPHIforlawenforcementpurposesasrequiredbylaworin responsetoavalidsubpoena.
FederallawmakesprovisionforyourPHItobereleasedtoanappropriatehealthoversightagency, publichealthauthorityorattorney,providedthataworkforcememberorbusinessassociatebelievesin goodfaiththatwehaveengagedinunlawfulconductorotherwiseviolatedprofessionalorclinical standards and are potentiallyendangeringoneormorepatients, workers or the public.
FOR MORE INFORMATION ORTO REPORTAPROBLEM
Ifyoubelieveyourprivacyrightshavebeenviolated,youmayfileacomplaintwiththePrivacyOfficer. Additionally,youmayfileacomplaintwiththeSecretaryoftheDepartmentofHealthandHuman Services,OfficeofCivilRights(800-368-1019).Therewillbenoretaliationagainstyouforfilinga complaint.
Ifyouhavequestions,wouldlikeadditionalinformation,orifyouwishtofileacomplaintregardingouruseordisclosureofyourPHI,youmaycontactSFKDHS’sPrivacyOfficerat 561-989-9070.
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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Bysigningthisform,IacknowledgereceiptoftheNoticeofPrivacyPracticesofSouth Florida Kidney Disease & Hypertension Specialists, PA.TheNoticeofPrivacyPracticesprovidesinformationabouthowSouth Florida Kidney Disease & Hypertension Specialists, PAmayuseanddisclosemy protectedhealthinformation.
I acknowledge receipt of the Notice of Privacy Practices of South Florida Kidney Disease & Hypertension Specialists, PA.
Date: (patient/parent/conservator/guardian)
FOR SOUTH FLORIDA KIDNEY DISEASE & HYPERTENSION SPECIALISTS, PA USE ONLY
InabilitytoObtainAcknowledgement
Tobecompletedonlyifnosignatureisobtained.Ifitisnotpossibletoobtainthepatient’s acknowledgement, describe the good faith efforts made to obtain the patient’s acknowledgement, and the reasons why the acknowledgementwasnotobtained:
SignatureofSouth Florida Kidney Disease & Hypertension Specialists, PArepresentative:
Date:
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