Notice Of Privacy Practices
Your Information – Your Rights – Our Responsibilities
Please review this notice carefullyTHIS 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. If you have any questions about this notice, please contact Amy Charley, Compliance Officer, 100 SE Third Ave, Suite 1800 Ft Lauderdale 33394; by phone at: 754-300-3120 ext. 4019; or by email at firstname.lastname@example.org. Your Health Information As per 45 CFR 164.520, this Notice of Privacy Practices (the Notice) describes how medical information about you may be used or disclosed and how you can access this information. Your personal health record contains private and confidential information about you and your health. Both State and Federal laws protect the confidentiality of this information. Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes any individually identifiable health information. PHI relates to your past, present or future physical or mental health or condition and any related health care services.
How We May Use and Disclose Health Information About YouBelow are examples of the uses and disclosures that we may make of your Protected Health Information (PHI). These examples are not exhaustive but simply describe the uses and disclosures that may be made.
Uses and Disclosures of PHI for Treatment, Payment and Health Care OperationsTreatment – Your PHI may be used and disclosed by your physician, counselor, our program staff and others outside of our program that are involved in your care for the purpose of providing, coordinating or managing your health care treatment and any related services. Example: Your care while with us may require coordination or management from a third party, consultation with other health care providers, or referral to another provider for health care treatment. Additionally, we may disclose your protected health information to another physician or health care provider who becomes involved in your care. Payment – With your authorization, we may use and disclose PHI about you so that we can receive payment for the treatment and services provided to you from your insurance or other payor sources. Example: We give information about you to your health insurance so it will pay for your services. Healthcare Operations – We may use and share your health info to run our business, improve your care, and contact you when necessary. This may include quality assessment activities, employee review activities, licensing, and conducting other business activities. Examples: using a sign-in sheet where you will be asked to sign your name and indicate your physician, counselor or staff. We may share your PHI with third parties that perform various business activities for us, such as a billing company. Also, we may contact you by phone to remind you of your appointments or to provide you with additional information regarding your treatment or other health-related benefits. Special Rules Regarding Disclosure of Behavioral Health, Substance Abuse, and HIV- Related Information: For disclosures concerning protected health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment, special restrictions may apply.
- HIV Related Information: We may disclose HIV-related information as permitted or required by State law. For example, your HIV-related information, if any, may be disclosed without your authorization for treatment purposes, certain health oversight activities, pursuant to a court order, or in the event of certain exposures to HIV by personnel of the company, another person, or a known partner (if certain conditions are met).
- Minors: We will comply with State law when using or disclosing protected health information of minors. For example, if you are an un-emancipated minor consenting to a health care service related to HIV/AIDS, venereal disease, abortion, outpatient mental health treatment or alcohol/drug dependence, and you have not requested that another person be treated as a personal representative, you may have the authority to consent to the use and disclosure of your health information.
Uses and Disclosures of PHI That Require Your Written AuthorizationOther uses and disclosures of your PHI will be made only with your written authorization. You may revoke this authorization at any time, unless the program or its staff has taken an action in reliance on the authorization of the use or disclosure you permitted. If you revoke it, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization, unless required to do so by law. You should understand that we are unable to take back any disclosures we have already made with your authorization and that we are required to retain our records of the treatment and care that we have provided to you.
Your Rights Regarding your Protected Health InformationYour rights with respect to your protected health information are explained below. Any requests with respect to these rights must be in writing and made to the attention of the Privacy Officer. A brief description of how you may exercise these rights is included: You have the right to inspect and copy your PHI – You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the record. A “designated record set” contains medical and billing records and any other records that the program uses for making decisions about you. Your request must be in writing. We may charge you a reasonable cost-based fee for the copies. We can deny you access to your PHI in certain circumstances. In some of those cases, you will have a right to appeal the denial of access. You may have the right to amend your PHI – You may request, in writing, that we amend your PHI that has been included in a designated record set. 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. We may prepare a rebuttal to your statement and will provide you with a copy of it. You have the right to receive an accounting of some types of PHI disclosures. You may request an accounting of disclosures for a period of up to six years, excluding disclosures made to you, made for treatment purposes or made as a result of your authorization. We may charge you a reasonable fee if you request more than one accounting in any 12-month period. You have a right to receive a paper copy of this notice. You have the right to obtain a copy of this notice from us whether by paper or via email. You have the right to request added restrictions on disclosures and uses of your PHI – You have the right to ask us not to use or disclose any part of your PHI for treatment, payment or health care operations or to family members involved in your care. Your request for restrictions must be in writing and we are not required to agree to such restrictions. You have a right to request confidential communications. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable, written requests. We may also condition this accommodation by asking you for information regarding how payment will be handled or specification of an alternative address or other method of contact. We will not ask you why you are making the request. You have a right to receive notification of unauthorized disclosure of your PHI (Breach Notification). We are required to notify you upon a breach of any unsecured PHI. The notice must be made without unreasonable delay, but no later than 60 days from when we discover the breach. Changes to This Notice We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post the current notice at our location(s) with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.
ComplaintsYou may file a complaint if you feel your rights are violated.
- If you have questions regarding this notice, contact the Advanced Recovery Systems, LLC Privacy Officer by mail 100 SE Third Ave, Suite 1800, Ft Lauderdale 33394; by email at email@example.com.
- Florida Complaint and Abuse Information – To report a complaint regarding the services you receive, call toll-free 888-419-3456. To report abuse, neglect, or exploitation, call toll-free 800-96-ABUSE.
- The Joint Commission (JCAHO) accredits this entity. If you have a complaint about the quality of care you have received, you may contact the Joint Commission by email at firstname.lastname@example.org or by mail at Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 6018.
- You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights at 200 Independence Ave. S.W., Washington, D.C. 20201, or by calling 1-877-696-6775, or visiting the following website: www.hhs.gov/ocr/privacy/hipaa/complaints/
- We will not retaliate against you for filing a complaint.