FAMILY ALLERGY & ASTHMA CONSULTANTS
4123 University Blvd. S., Suite B, Jacksonville, FL 32216
NOTICE OF PRIVACY RIGHTS AND PRACTICES
CONFIDENTIALITY OF YOUR HEALTH CARE INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE READ IT CAREFULLY.
This notice is required by law to tell you how Family Allergy & Asthma Consultants, P.A. (FAAC) protects the confidentiality of your health care information in our possession. Protected Health Information (PHI) is defined as any individually identifiable information regarding a patient's medical history, mental or physical condition, or treatment. Some examples of PHI include your name, address, telephone and/or fax number, electronic mail address, social security number or other identification number, date of birth, date of treatment, treatment records, x‑rays, statement of financial responsibility, and patient history. FAAC receives, uses, and discloses your PHI for treatment, payment, and health care operations. Any other disclosure of your PHI is prohibited.
We must follow the privacy practices that are described in this notice. However, we may change this notice and make the new notice effective for your entire PHI that we maintain. If we make any substantive changes to our privacy practices, we will promptly change this notice and redistribute to you within 60 days of the change to our practices. You may also request a copy of this notice from the office manager at the practice that provides your care/treatment. You should receive a copy of this notice at the time of enrollment in the FAAC practice.
Permitted Uses and Disclosures of Your PHI
We are permitted to use or disclose your PHI without your prior authorization for the following purposes. These permitted uses and/or disclosures include disclosures to you, uses and/or disclosures for purposes of health care treatment, payment of claims, and other health care operations.
We are also permitted to use and/or disclose your PHI to comply with a valid authorization, to notify or assist in notifying a family member, another person, or a personal representative of your condition, to assist in disaster relief efforts, and to report victims of abuse, neglect, or domestic violence. Other permitted uses and/or disclosures are for purposes of health oversight by government agencies, judicial, administrative, or other law enforcement purposes, information about decedents to coroners, medical examiners and funeral directors, for research purposes, for organ donation purposes, to avert a serious threat to health or safety, for specialized government functions such as military and veterans activities, for workers compensation purposes, and for use in creating summary information that can no longer be traced to you.
Additionally, we are permitted to incidentally use and/or disclose your PHI during the course of a permitted use and/or disclosure, but we must attempt to keep incidental uses and/or disclosures to a minimum. We use administrative, technical, and physical safeguards to maintain the privacy of your PHI, and we must limit the use and/or disclosure of your PHI to the minimum amount necessary to accomplish the purpose of the use and/or disclosure.
Examples of Uses and Disclosures of Your PHI for Treatment, Payment or Healthcare Operations
Such activities may include but are not limited to: processing your claims, collecting enrollment information and copays, reviewing the quality of health care you receive, providing customer service, resolving your grievances, and sharing payment information with other insurers. Additional examples include the following:
Uses and/or disclosures of PHI in facilitating treatment.
For example, FAAC may use or disclose your PHI to determine eligibility for services requested by your doctor.
Uses and/or disclosures of PHI for payment.
For example, FAAC may use and disclose your PHI to bill you or your plan sponsor.
Uses and/or disclosures of PHI for health care operations
For example, FAAC may use and disclose your PHI to review the quality of care provided by our physicians.
Disclosures FAAC Must Make Without an Authorization
We are required to disclose your PHI to you or your authorized personal representative (with certain exceptions), when required by the U. S. Secretary of Health and Human Services to investigate or determine our compliance with law, and when otherwise required by Law. FAAC must disclose your PHI without your prior authorization in response to the following:
- Court order;
- Order of a board, commission, or administrative agency for purposes of adjudication pursuant to its lawful authority;
- Subpoena in civil action;
- Investigative subpoena of a government board, commission, or agency;
- Subpoena in an arbitration;
- Law enforcement search warrant; or
- Coroner's request during investigations
Disclosures FAAC Makes With Your Authorization
FAAC will not use or disclose your PHI without your prior authorization if the law requires your authorization. You can later revoke that authorization in writing to stop any future use and disclosure. The authorization will be obtained from you by FAAC or by a person requesting your PHI from FAAC.
Your Rights Regarding PHI
You have the right to request an inspection of and obtain a copy of your PHI. You may access your PHI by contacting FAAC at the address listed below. You must include (1) your name, address, telephone number and account number and (2) the PHI you are requesting. FAAC may charge a reasonable fee for providing you copies of your PHI. FAAC will only maintain that PHI that we obtain or utilize in providing your health care.
You may not inspect or copy PHI compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, or PHI that is otherwise not subject to disclosure under federal or state law. In some circumstances, you may have a right to have this decision reviewed. Please contact FAAC at the address listed below if you have questions about access to your PHI
You have the right to request a restriction of your PHI. You have the right to ask that we limit how we use and disclose your PHI. We will consider your request but are not legally required to accept it. If we accept your request, we will put any limits in writing and abide by them except in an emergency situation. You may not limit the uses and disclosure that we are legally required or allowed to make.
You have the right to correct or update your PHI. This means that you may request an amendment of PHI about you for as long as we maintain this information. 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 any such rebuttal. Please contact FAAC at the address listed below if you have questions about amending your PHI.
You have the right to request or receive confidential communication from us by alternative means or at a different address. We will agree to a reasonable request if you tell us that disclosure of your PHI could endanger you. You may be required to provide us with a statement of possible danger, a different address, or method of contact or information as to how payment will be handled. Please make this request in writing to FAAC at the address listed below.
You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. This right does not apply to disclosures for purposes of treatment, payment, or health care operations or for information we disclosed after we received a valid authorization from you. Additionally, we do not need to account for disclosures made to you, to family members or friends involved in your care, or for notification purposes. We do not need to account for disclosures made for national security reasons or certain law enforcement purposes, disclosures made as part of a limited data set, incidental disclosures, or disclosures made prior to April 14, 2003. Please contact FAAC at the address listed below if you would like to receive an accounting of disclosures or if you have questions about this right.
You may complain to us or to the U. S. Secretary of Health and Human Services if you believe that FAAC has violated your privacy rights. You may file a complaint with us by notifying FAAC at the address listed below.
You may contact FAAC at the address and telephone number listed below for further information about the complaint process or any of the information contained in this notice.
Family Allergy & Asthma Consultants
Attn: Business Manager
4123 University Blvd. S., Suite B
Jacksonville, FL 32216
Phone (904) 636-9100
This notice is effective on and after April 14, 2003.