this notice descr旧es how medical information abojt … · 2019-06-20 · this notice descr旧es...
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Notice of P「ivacy P「actices
Pa巾e「s in Women’s Health of Jupiter, LLC
THIS NOTICE DESCR旧ES HOW MEDICAL INFORMATION ABOJT YOJ MAY BE 〕SED AND DISCLOSED AND IOW YOU CAN GET ACCESS
TO THIS INFORMAT10N. PLEASE REVIEW IT CAREFJLLY.
HOWWE肌AY USE AND DISCLQSE H臥町H
INFOR肌叩ON: Described as fo=o鵬are the ways we
may use and disc10Se hea肌informatio[仇at identifies
y閃く白開瓶面fo州a同い).軸加鵬酬ow巾
PurPOSeS, We wi= use and disc10Se Hea肌lnfomato[
Only with yoll「 Written pemlission. You may revoke such
Pemissio[ at any time by両肌g to our practice.
摘朋e〃尊
We may use and disclose Health lnfomaton fo「 yo間
軸ta雨的叩V柑ey関w軸闘he郡h c訓e serviees, Fo「 examp心We may disc10Se
J]ea臨lnfoma的n to doctoiS,剛rSeS, teChnieians, or
Other persomeL剛ing people ou朗e our office, Who
are invoived i[ yOur medieal ca記and need the
infomafron to provide you w肌mediea血別e.
Pay朋e〃寄
We may use and disdose Hea冊Infomaton so thatwe
O「 Oth師may b… and 「eceive paymentfrom you, an
insuran∞ ∞mPany, or a th潤party for the廿eatment and
Serviees you 「eceived. For examp時We may give you「
hea剛p加infomation so that they刷pay for your
什eat爪印し
H開聞∽鳩Ope館的膿
We may use and discIose Iea皿lnfo町滑的m fo「 heam
care oper翻on purposes. These uses and disctosures are
necessary to make sure that訓of oIIr Patents 「eCeive
qua時care and to operate and manage our o範e. For
example, We may use andl discIose infor隔個on to make
SUre the ob§tetricahor gyne∞kyJical care you receive is
Of the hishest qua時We aiso may share infoma的n
W臨othe「 entities that have a 「e闘onsh巾W胸you 〈for
example' yOur heaIth pfan〉 for thei「 hea肌cgre operation
ac館∨摘es.
Appo加納)en〔 Rem加ders, nlca(mentA/(ematives and
Hea筋Reね!ed βene舶and ServIbes. We may use
and disdose IeaIt出nfom軸to ∞ntact yOll and to
remind you that yo両ave an appointment w軸us. We
aiso may use and discIose Hea間冊omaton to te" you
about廿eatme∩t aItematives o「 heaIth寸e胤ed benefits
andふ肌府es that may be of interest to you.
加脇du細面面ve伽n Ybur Care oI Paymen筋子
YouI C訓e, When appr。P南te, We may Share Hea伽
Informatio[ With a person who is invoived in your medieal
care or payment foryour care, Such as you「 fam時o「 a
CIose friend. We also may notry your fam時about your
bca的[ O「 general co[ditio[ O「 disc10se Such infomafro[
to a[ enfty assis僧ng in a disaste「 「eifef effch
Research. Jnder cehain cfroumstances, We may uSe
and discIose Hea臨lnfoma償m fo「 「esearch. For
examp時a reseaI℃h p「o軸may invoive ∞mPa血g the
heaIth of patents who rec宙ved one treatment to those
who 「eceived anotheL for庇same cond柑on. Before ue
use or disclose Hea聞lnfomaton fo「 「esea「くれ小e
project wi= go伽「ough a special approvaI process. Even
Without specfaI app「oval, We may Pemit researchers to
hok at records to help the両dentry patients who may be
included in their research project or for other s刷ar
恥やOS玲弱め的aS小印的not「emo鳴0南船a oopyof any HeaIth Infoma on,
Fmd帽扇ig Ac脇飲獅・ We may llSe O「 disclose yo]「
Protected Hea剛nfomation, as [eceSSary, in order to
contact you for fundraising activ楓es. You have the right
め叩く〇両が記∞廟的軸両面g ∞m皿n軸s.
(Optonal) If you de rot w飢t tO reCeive these materials,
PIease submit a writt飢「equeSt tO the Privacy OffroeL
SPECIAL S町UATIQl埠
As Requ存ed OyLaw. We wi" discIose Hea胸
囲Oma的n wh飢reqU圃to de so by internatio帽L
federal, State Or id faw,
7b Averfa Se面ous m朋t t州ea仰OISafefy, We may use
a[d disclose Ieam lnfomatio[ Whe…eCeSSary tO PreVe[t a
Serious冊eatto you「 heaIth and safety o川e hea伽and safety
Of the public or anothe「 person. DiscIosures, howeve「, W紺be
made onIy to someone who may be able to heip prevent the
小幅at.
Business Associates. We may discIose HeaI帥nfomaton to
Oll「 business associates that perform func鱈ons on ou「 behaIf o「
PrOVide us w柵services if the infomaton is necessa「y for such
functio[S Or Servi∝rs. Fo「 example, We may uSe a[Other
COmPany tO Perfom b冊g services on oll「 behalf. All of ou「
business associates a「e o胡gated to p「otect the privaey of you「
infomaton and are not a=owed to use o「 discIose arly
infomation other than as spec胸ed in o]r ∞[tract.
O細B朋ch M朋c∂的n Pu坤oses. We may use your
contact infomation to provide legalIy-required notices of
unaし他orized acquis胸on, aCCeSS, Or disc10Su「e Of your heaIth
informa6o[. We may send notice di「ectly to you o「 p「ovide
no晦to肌e sponso「 ofyou「 pIa[ through which you 「eceive
cOVerag e.
O岬紬and T樽sue Do朋的n. 1fyou are an organ donori We
may use or 「elease Hea伽l[fomafro[ to O喝a[iza的ns that
handIe organ叩C]rement O「 Othe「 e嗣es engaged in
PrOCurement; ba[king o「 transportato[ Of o喝an§, eyes, 0「
tissues to facii触e organ, eye O「tissue donation; a[d
鳴nspIan刷On.
M据わry and l佃や周"S. Ifyou are a membe「 ofthe amed
fo鵬s, We may 「eIease HeaIth lnfomaton as required by
m胸ry ∞mmand authorities. We also may 「eiease HeaIth
infoma的[ to the app「op南te foreign m蝿ry aし個orty if you
a「e a member of a foreign m冊tary.
胸筋ers’Compensa(jon. We may reiease HeaIth lnfomation
for workersi ∞mPenSation or simiiar p「ograms. These
P「OgramS Provide be[efits fo「 work-related injuries or冊ess.
Pub侮Hea聞朋sks. We may discIose Iealt=nfomation for
PubIic hea凪activities. These ac帥ties generally incIude
discIosu「es to preve[t O「 COntrOI disease,岬ry or disabi時
「eport b柵S and deaths; rePOrt Ch胸abuse o「 negIec臣eport
「eactions to medications o「 p「obiems w瓶products; nOfty
PeOPIe of reca‖s of products they may be using; a Pe「SO[ Who
may have bee[ eXPOSed to a disease o「 may be at risk for
contrac師g o「 SPreading a disease o「 condition; and the
approp南te govemme[t aJthorty if we be"eve a patient has
been the v融m of abuse, neglect o「 domestic vioience. We wi=
Only make榔S discIosure ifyou ag「ee orwhen requi「ed o「
authorized by iaw. 立
YOJR RiGHTS:
You have the following rights 「egarding Hea剛nfomaton we
have about you:
Access to e/ecfro扉c ′ecO′ds. The Hea皿Infoma的n
TechnoIogy for Economic and C嗣cal Iea肌Ac川lTECI Act
訓ows people to ask for eIectronic ∞Pies of thei「 PHI contained
in electronic heath re∞「ds o「 to request in w軸g or
electronha=y that another pe「son receive an electronic copy of
these re∞「ds. The final o面bus rules expa[d an脚viduai,s
right to access electronic reco「ds or to di「ect tha川ey be sent
to another pe「son to incIude not oniy eIecfronic hea肌「e∞「ds
but aIso a=y re∞「ds in one o「 more designated 「eco「d sets. 1f
the individuaI requests a[ elect「onic copy言t must be provided
in the fomat 「equested or in a mufually ag「eed-uPO[ fomat.
Covered en帥es may charge individuaIs for the cost of any
elecfronic media (SuCh as a JSB [ash drive) used to provide a
COPy Ofthe eIecf面c PHI.
R馴れo hspect and CopyL You have a right to inspect and
∞Py HeaIth l[fomaton that may be used to make decisions
about yo]「Care O「 Payment foryou「 ca「e. This includes
medical and b冊g 「ecords, Othe「 than psychotherapy notes.
To inspeot a〔d copy榔s Iea刷nfomation, yOu muSt make
your request両W嗣g.
的航o Am帥掴you fee冊rat Hea刷nformatio11 We
have is in(摘O「 incomplete, you may aSk us to
amend the infomaton. You have伽e right to 「equest
an amendmentfo「as tong as伽e infom(舶[ is kept by
or for our o冊冷To request an amendment, you muSt
make you「 「equest, in w珊ng.
Rjg伽fo an Accom伽g ofDischsWes, Yo両ave
the right to 「equest a略et of cehe血disdosures we
ma鳴面白舗剛的帆的両o「甲やOS総0小針伽an
treatment, Payment and hea個care operatio[S or for
whieh you provided writt飢authorizafro[. To request an
a∝則[個ng of discIesures, you must make your
「印u銃口[ W相即
榊のRe押勝洞es伽c海00. Yo両a博聞e噂的request a 「estictio[ O「柵itaton on the HeaIth
Infoma同いWe use O「 discIose for treatment payment
or hea胸care operattons. You aiso have the巾ghtto
request a linlit or¥ the HeaIth lnformaUon we discIose to
SomeOne鵬in you「 ca「e o川e paymentforyour
Ca「e,臨e a fam母memberor制. Forexample, you
∞u旧ask thatwe [Ot Share information about a
Partjcu胤dfagnosis or treatm飢t W柵your spouse. To
request a restriction, yOu muSt make yo冊requeSt, in
W朋的.
We訓e no requ新od to ayIee to yOuI鳩queS口fwe
ag「ee. we刷comply w肌you「 「equest unless the
infomlafron is needed to p「ovide you w輸emergeney
龍田同園蘭
Rjg励to Request Con刷bn細/ commun細a!ion. You
have the right to request that we cormunieate with you
about med同matters i[ a ce南面way orata cen緬
脚on. Fo「example, you ca[ aSk仙atwe orty
contact you by ma用or at work. To request confidential
communication, you muSt make yoll=equeSt, in
W爪ing. Yo]r requeSt muSt SPegiv how or where you
Wish to be ∞[tacted. We w用accommodate
峨褐o[ab虚説qu鎧庭.
Rfgh偉o a P叩e/ Cny o門部s Nof汚e, Yo両ave個e
right to a papercopy ofthis notice. You may ask us to
give you a ∞Py ofthis [O鵬at any time.
CHANGES TO THIS NOTiCE:
We reserve the right to change輔S nOtice and make
the new no船e app時to Hea肌infomaton we aIready
have as we" as any infoma的n we receive ln the
future. We w時OSt a COPy of ou「 ourrent no鵬at 。ur
Office. The [O的e W冊CO[tain伽e effec甘ve date on the
first page言n the top right-hand comer.
CO MPしAINTS :
If you be=eve you「 privacy rights have been vto時y
yo] may file a ∞mPfaintw瓶ou「 o惰ce o「with the
Secrctary of the Depa巾nent of Heam and Human
Serviees. A" ∞mP眺must be made in w柵ng.
Yoow用博t鵬pe山繭短軸g a oo叩廟帆
Please sigrl the accompanying“Acknowledgement” fo m
C輔y Lewis
600 Heritage Drive/Suife 21 0
J岬的「,乱3糾粥0価c蟻〈紡1) 3塊-1515
戸種x: (稀1) 3軸・1516
2013
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