Patient Notice of Privacy Practice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice or if you need more information, please contact:
Physician Partners of America
Attn: Rekha Rajan-Wilson, Compliance Privacy Officer
813-549-2134 ext 4379 or Email Compliance
4730 N. Habana Ave, Suite 204
Tampa, FL 33614

WHAT IS PROTECTED HEALTH INFORMATION (PHI)?

PHI is information that individually identifies you. We create a record or receive information from you or from another health care provider, health plan, your employer, or a health care clearinghouse that relates to:

• Your past, present or future physical or mental health conditions,
• The provision of health care to you, or
• The past, present, or future payment for your health care.

HOW WE MAY USE AND DISCLOSE YOUR PHI

• We may use your PHI to provide you medical treatment or services and to manage or coordinate your medical care. For example, your PHI may be provided to another health care provider (e.g. physician, laboratory, pharmacy) to whom you have been referred to ensure that the necessary information to provide you with a service

• We may use and disclose your PHI so that we can bill for the treatment and services that you receive from us and can collect payment from you, a health plan, or a third party. For example, we may need to give your health plan information about your treatment in order for your health plan to agree to pay for that treatment.

• Health Care Operations. We may use and disclose PHI for our health care operations. For example, we may use your PHI to internally review the quality of the treatment and services you receive; to evaluate the performance of our team members and for education.

• Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services. We may use and disclose PHI to remind you that you have an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health-related benefits and services that may be of interest to you.

• We may disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.

• Research: We may use and disclose your PHI for research purposes, but we will only do so if the research has been specially approved by an authorized institutional review board or a privacy board which has reviewed the research proposal and has set up protocols to ensure the privacy of your PHI. Even without the special approval, we may permit researchers to look at the PHI to help them prepare for research.

• As Required By Law: We will disclose PHI about you when required to do so by international, federal, state, and local law.

• To Avert a Serious Threat to Health or Safety. We may use and disclose PHI when necessary to prevent a serious threat to your health or safety or to the health and safety of others. But we will only disclose the information to someone who may be able to help prevent the threat.

• Abuse, Neglect, or Domestic Violence. We may disclose PHI to the appropriate government authority if we believe a patient has been a victim of abuse, neglect, or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure.

• Business Associates. We may disclose PHI to our business associates who perform functions on our behalf or provide us with services. For example, we may use another company to do our billing or to provide transcription or consulting services to us. All of our business associates are obligated, under a contract with us, to protect the privacy and ensure the security of your PHI.

• Organ and Tissue Donation. If you are an organ or tissue donor, we may use or disclose your PHI to organizations that handle organ procurement or transplantation — such as an organ donation bank – as necessary to facilitate organ or tissue donation and transplantation.

• Specialized Government Functions: We may disclose PHI to the military about its members or veterans, for national security and protectives for the President or other heads of state, to the government for security clearance reviews, and to a jail or prison about its inmates.

• Workers Compensation. We may use and disclose PHI for workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses.

• Public Health Risks. We may disclose PHI for public health activities. This includes disclosures to: (1) a person subject to the jurisdiction of the Food an Drug Administration (“FDA”) for purposes related to the quality, safety and effectiveness of an FDA regulated product or activity;  (2) prevent or control disease, injury or disability; (3) report births and deaths; (4) report child abuse or neglect; (5) report reactions to medications or problems with products; (6) notify people of recalls of products they may be using; and (7) a person who may have been exposed to a disease or may be at risk for contacting or spreading a disease or condition.

• Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

• Data Breach Notification Purposes. We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information.

• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or administrative order. We also may disclose PHI in response to a subpoena, discovery request, or other legal processes from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your PHI to defend ourselves in the event of a lawsuit.

• Law Enforcement. We may disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes.

• Coroners, Medical Examiners, and Funeral Directors. We may disclose PHI to a coroner, medical examiner, or funeral director so they can carry out their duties.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT OUT

• Individuals Involved in Your Care. Unless you object in writing, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

• Payment for Your Care. Unless you object in writing, you can exercise your rights under HIPAA that your healthcare provider not disclose information about the services received when you pay in full out of pocket for the service and refuse to file a claim with your health plan.

• Disaster Relief. We may disclose your PHI to disaster relief organizations that seek your PHI to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree to object to such a disclosure whenever we practicably can do so.

YOUR RIGHTS REGARDING YOUR PHI You have the following rights, subject to certain limitations, regarding your PHI:

• Your Written Authorization IS Required for Other Uses and Disclosures

The following uses and disclosures of your PHI will be made only with your written authorization:

• Most uses and disclosure of psychotherapy notes;
• Uses and disclosures of PHI for marketing purposes; and
• Disclosures that constitute a sale of your PHI.

• Other Uses and Disclosures. Other uses and Disclosures of PHI not covered by this Notice or the laws that apply to use will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose PHI under the authorization. But the disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

• Inspect and Copy. You have the right to inspect and receive a copy of PHI that may be used to make decisions about your care or payment for your care. We have up to 30 days to make your PHI available to you and we may charge you a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. You can only direct us in writing to submit your PHI to a third party not covered in this notice. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request and we will comply with the outcome of the review.

• Summary or Explanation. We can also provide you with a summary of your PHI, rather the entire record, or we can provide you with an explanation of the PHI which has been provided to you, so long as you agree to this alternative form and pays the associated fees.

• Electronic Copy of Electronic Medical Records. If your PHI is maintained in an electronic format (known as the electronic medical record or electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. If the PHI is not readily producible in the form or format you request, your record will be provided in a readable hard copy form.

• Notice of Breach. You have the right to be notified of a breach of any of your unsecured PHI.

• Request Amendments. If you feel that the PHI we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by us. A request for amendment must be made in writing to the Privacy Officer at the address provided at the beginning of the Notice and it must tell us the reason for your request. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal.

• Accounting Disclosures. You have the right to ask for an “accounting disclosures,” which is a list of the disclosure we made of your PHI. To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer. The first accounting of disclosures you request within any 12- month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the list. We will tell you what the costs are, and you may choose to withdraw or modify your request before the costs are incurred.

• Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or healthcare operations. We are not required by federal regulations to agree to your request. If we do agree with your request, we will comply unless the information is needed to provide emergency treatment. To request restrictions, you must make your request in writing to the Privacy Officer. Your request must state the specific restriction requested, whether you want to limit our use and/or disclosure; and to whom you want the restrictions to apply.

• Request Confidential Communications. You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you only at work number. You must make any such request in writing and you must specify how or where we are to contact you.

• Paper Copy of This Notice. You have the right to a paper copy of this Notice, even if you have agreed to receive this notice electronically. Please contact the Physician Partners of America office that you are receiving services from to obtain a copy.

• Change to This Notice. We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for PHI we already have as well as for any PHI we create or receive in the future. A copy of our current Notice is posted in our office and a paper copy can be provided to you at the office you receive services from.

• Special Protections for HIV, Alcohol, and Substance Abuse, Mental Health and Genetic Information. Certain Federal and State Laws may require special privacy protection that restricts the use and disclosure of certain health information, including HIV-related information, alcohol, and substance abuse information, mental health information, and genetic information. Some parts of this HIPAA Notice of Privacy Practice may not apply to this type of information.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Physician Partners of America Privacy Officer, at the address listed at the beginning of this Notice or with the Secretary of the U.S Department of Health and Human Services. To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services 200 Independence Ave., S.W., Washington D.C. 20201. Call (202)619-0257 or toll-free (877) 696-6775 or go to the website of the Office of Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. You will not be penalized for filing a complaint.