Halifax Medical
Center
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.
Our Pledge Regarding Your Health Information
We understand that medical information about you and your
health is personal.
We create a record
of the care and services you receive from us. We need this record to provide
you with quality care, obtain payment for the services we provide, and to
comply with legal requirements. This Notice applies to all of the records of
your care generated by us, whether made by your personal doctor, other Practice
doctors, or Practice staff.
We are
required by law to 1) make sure that medical information that identifies you is
kept private; 2) give you this Notice of our legal duties and privacy
practices; and 3) follow the terms of the Notice that is currently in
effect.
The professional and
non-professional staff at each of our Practice sites will follow the terms of
this Notice. Each of our Practice sites may share medical information with each
other for treatment, payment or practice operations purposes described in this
Notice.
How We May Use And Disclose Medical Information
About You
The following categories and examples describe the
different ways that we use and disclose medical information. Not every use or disclosure in a category
will be listed. However, all of the ways
we are permitted to use and disclose information will fall within one of the
categories.
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Category:
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Description and
Examples:
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Treatment
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We may share medical information about you with another
physician, a hospital, nurse, technician, medical student or other personnel
involved in your care. For example, a
hospital may need to see a part of your medical record before you have
surgery.
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For payment
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We may share medical information with Medicare or other
health plan to obtain payment for services provided to you, to verify
insurance coverage, or to obtain authorization for further treatment. For example, an insurance company may need
to see part of your medical record before they will pay for the services.
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For Practice operations
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We may share medical information as necessary to manage
the medical, legal and financial affairs of the Practice and to monitor the
quality of services provided to our patients.
For example, our billing service company may need patient information
in order to process claims. Any business
associate with whom we share medical information will agree in writing to
protect your privacy.
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Telephone Communications
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We may disclose medical information pertaining to
prescriptions, diagnostic tests and appointment reminders when calling your residence
or other location you designate.
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Family members and friends
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We will share medical information to a friend or family
member that is involved in your care or payment of your bill. We will give you an opportunity to agree or
object to these disclosures unless it is clear from the circumstances that
you do not object.
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Worker compensation
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We may report a work-related injury to a worker
compensation carrier or to advise your employer about a work-related injury.
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To meet legal requirements and for public
health activities
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We may disclose medical information to a government agency
that oversees medical practice in the State such as the Florida Agency for
Health Care Administration or the Board of Medicine. We are also required to report certain
diseases and conditions to the local unit of the Department of Health for its
public health activities.
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Law enforcement, lawsuits, disputes and
reports of abuse or neglect
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We may disclose medical information to an attorney or a
law enforcement official to comply with a court order, subpoena, discovery
request or other legal mandate. We may
also disclose medical information to assist law enforcement with
investigating crime. For example we
are required to report wounds resulting from violence and incidents of abuse
or neglect.
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To avert a serious threat to health or
safety
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We may use and disclose medical information about you when
necessary to prevent a serious threat to your health and safety or that of
the public or another person. Any disclosure, however, would only be to
someone able to respond to the threat.
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For special government functions
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We may be required to disclose medical information to a
government agency for national security purposes, a correctional facility in
which you may be incarcerated, or to a military authority if you are in the
service or a veteran.
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Organ and tissue donation
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We may disclose medical information to an organization
that handles organ, eye or tissue transplantation.
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Medical Examiners and Funeral Directors
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We may release medical information to a coroner or medical
examiner to identify a deceased person or determine the cause of death. We
may also release medical information about individuals to funeral directors
as necessary to carry out their duties.
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Other Uses of Medical Information
Other uses and disclosures of medical information not
covered by this Notice or the laws that apply to us will be made only with your
written permission. If you provide us
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 authorization. You understand that we are unable to take
back any disclosures we have already made with your permission, and that we are
required to retain our records of the care that we provided to you.
Your Rights Regarding Medical Information
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You may access your medical information
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To access your medical information, you must submit your
request to us at the address listed at the end of this Notice. If you request
copies, we may charge a fee allowed by law.
We may deny your request in certain very limited circumstances. For example we might deny access to
psychotherapy notes that might be a part of your record.
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You may amend or correct your medical
Information
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You may ask us to amend or correct your medical
information. Please make your request in writing and submit it to the address
listed at the end of this Notice. You
must provide a reason that supports your request.
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You may request an "accounting of
disclosures"
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You may request a list of the disclosures we made of
medical information about you, other than for treatment, payment or Practice
operations as described above, and without your written authorization.
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You may request restrictions on the use or
disclosure of your medical information
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You may request a restriction or limitation on the medical
information we use or disclose about you for treatment, payment or practice
operations. For example, you could ask
that we not share information about a surgery you had with a family member or
friend. We are not required to agree
to your request. If we do agree, we
will comply with your request unless the information is needed to provide you
emergency treatment.
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You may request confidential
communications
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You have the right to request that we communicate with you
about medical matters in a certain way or at a certain location. For example,
you can ask that we only contact you at work or by mail. We will try to accommodate all reasonable
requests.
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You may have a paper copy of this Notice
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You have the right to a paper copy of this Notice. You may
ask us to give you a paper copy of this Notice at any time, even if you obtained
a copy electronically.
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Changes to This Notice
We reserve the right to change this Notice. We reserve the
right to make the changed 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 prominent locations at our Practice sites.
The Notice will contain the effective date.
Exercise of Privacy Rights and Complaints
To exercise your privacy rights or to file a complaint,
contact us at our address below. A
complaint may also be filed with the Secretary of the U.S. Department of Health
and Human Services. You will not be penalized for filing a complaint.
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Family Practice Residency Program
Family Health Center
Sports Medicine Center
303 N. Clyde Morris Blvd.
Daytona Beach, FL 32114
(386) 254-4165
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Office for Civil Rights
U.S. Department of Health and Human
Services
200
Independence Avenue, S.W.
Room 509F, HHH
Building
Washington, D.C. 20201
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Effective Date: April 1, 2003