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.
For purposes of this Notice “us” “we” and “our” refers to (Mukesh Patel, MD) and
“you” or “your” refers to our patients (or their legal representatives as
determined by us in accordance with Florida informed consent law). When you
receive health-care services from us, we will obtain access to your medical
information (e.g., your health history). We are committed to maintaining the
privacy of your health information and we have implemented numerous procedures
to ensure that we do so.
Florida law and the Health Insurance Portability & Accountability Act of 1996 (HIPAA)
require us to maintain the confidentiality of all your health-care records and
other individually identifiable health information used by or disclosed to us in
any form, whether electronically, on paper, or orally(“PHI” or Protected Health
Information). HIPAA is a federal law that gives you significant new rights to
understand and control how your health information is used. HIPAA and Florida
law provide penalties for covered entities and records owners, respectively,
that misuse or improperly disclose PHI.
Starting April 14, 2003, HIPAA requires us to provide you with this Notice of
our legal duties and the privacy practices we are required to follow when you
first come into our office for health-care services. If you have any questions
about this Notice, please ask to speak to our privacy officer, Rashmi Patel at
(727) 863-7487.
Our doctors, clinical staff, Business Associates (outside contractors we hire),
employees and other office personnel follow the policies and procedures set
forth in this notice. If your regular doctor is unavailable to assist you (e.g.
illness, on-call coverage, vacation, etc.), we may provide you with the name of
another health-care provider outside our practice for you to consult with by
telephone. If we do so, that provider will follow the policies and procedures
set forth in this notice or those established for his or her practice, so long
as they substantially conform to those for our practice.
Under the law (§456.074, Fla. Stats., and HIPAA), we must have your signature
on a written, dated Consent form and / or an Authorization form (not an
Acknowledgment form) before we will use and disclose your PHI for certain
purposes as detailed in the rules below.
Documentation You will be asked to sign a Consent form and/or an
Authorization form when you receive this Notice of Privacy Practices. If you did
not sign such a form or need a copy of the one you signed, please contact our
privacy officer. You may take back or revoke your Consent or Authorization at
any time (unless we already have acted based on it) by submitting our Revocation
form in writing to us at our address listed above. Your revocation will take
effect when we actually receive it. We cannot give it retroactive effect, so it
will not affect any use or disclosure that occurred in our reliance on your
Consent or Authorization prior to revocation (e.g., if after we provide services
to you, you revoke your Authorization or Consent in order to prevent us billing
or collecting for those services, your revocation will have no effect because we
relied on your Authorization or Consent to provide services before you revoked
it).
General Rule If you do not sign our Consent form or if you revoke it, as
a general rule (subject to exceptions described below under “Healthcare
Treatment, Payment and Operations Rule” and “Special Rules”), we cannot in any
manner use or disclose to anyone (excluding you, but including payers and
Business Associates) your PHI or any other information in your medical record.
Under Florida law, we are unable to submit claims to payers under assignment of
benefits without your signature on our Consent form. We will not condition
treatment on your signing an Authorization, but we may be forced to decline you
as a new patient or discontinue you as an active patient if you choose not to
sign the Consent or revoke it.
Health-care Treatment, Payment and Operations Rule With your signed
Consent, we may use or disclose your PHI in order:
Special Rules Notwithstanding anything else contained in this Notice,
only in accordance with applicable law, and under strictly limited
circumstances, we may use or disclose your PHI without your permission, Consent
or Authorization for the following purposes:
Minimum Necessary Rule Our staff will not use or access your PHI unless
it is necessary to do their jobs (e.g., doctors uninvolved in your care will not
access your PHI; ancillary clinical staff caring for you will not access your
billing information; billing staff will not access your PHI except as needed to
complete the claim form for the latest visit; janitorial staff will not access
your PHI). Also, we disclose to others outside our staff only as much of your
PHI as is necessary to accomplish the recipient’s lawful purposes. For example,
we may use and disclose the entire contents of your medical record:
If we believe that a request from others for disclosure of your entire
medical record is unnecessary, we will ask the requester to document why
this is needed, retain that documentation and make it available to you upon
request.
Incidental Disclosure Rule We will take reasonable administrative, technical
and security safeguards to ensure the privacy of your PHI when we use or
disclose it (e.g., we require employees to talk softly when discussing PHI
with you, we use computer passwords and change them periodically [e.g., when
an employee leaves us], we allow access to areas where PHI is stored or
filed only when we are present to supervise and prevent unauthorized
access).
Business Associate Rule Business Associates and other third parties (if any)
that receive your PHI from us will be prohibited from re-disclosing it
unless required to do so by law or you give prior express written consent to
the re-disclosure. Nothing in our Business Associate agreement will allow
our Business Associate to violate this re-disclosure prohibition.
Super-confidential Information Rule If we have PHI about you regarding HIV
testing, alcohol or substance abuse diagnosis and treatment, or
psychotherapy and mental health records (super-confidential information
under the law), we will not disclose it under the General or Health-care
Treatment, Payment and Operations Rules (see above) without you first
signing and properly completing our Consent form (i.e., you specifically
must initial the type of super-confidential information we are allowed to
disclose). If you do not specifically authorize disclosure by initialing the
super-confidential information, we will not disclose it unless authorized
under the Special Rules (see above) (e.g., we are required by law to
disclose it). If we disclose super-confidential information (either because
you have initialed the Consent form or the Special Rules authorize us to do
so), we will comply with state and federal law that requires us to warn the
recipient in writing that re-disclosure is prohibited.
Changes to Privacy Policies Rule We reserve the right to change our privacy
practices (by changing the terms of this Notice) at any time as authorized
by law. The changes will be effective immediately upon us making them. They
will apply to all PHI we create or receive in the future, as well as to all
PHI created or received by us in the past (i.e., to PHI about you that we
had before the changes took effect). If we make changes, we will post the
changed Notice, along with its effective date, in our office. Also, upon
request, you will be given a copy of our current Notice.
Authorization Rule We will not use or disclose your PHI for any purpose or
to any person other than as stated in the rules above without your signature
on a specifically worded, written Authorization form (not a Consent or an
Acknowledgement). If we need your Authorization, we must obtain it on our
Authorization form, which is separate from any Consent or Acknowledgment we
may have obtained from you. We will not condition treatment on whether you
sign the Authorization (or not).
If you got this Notice via e-mail or web-site, you have the right to get, at
any time, a paper copy by asking our privacy officer. Also, you have the
following additional rights regarding PHI we maintain about you:
To Inspect and Copy You have the right to see and get a copy of your PHI
including, but not limited to, medical and billing records by submitting a
written request to our privacy officer on our Request to Inspect, Copy or
Summarize form. Original records will not leave the premises, will be
available for inspection only during our regular business hours, and only if
our privacy officer is present at all times. You may ask us to give you the
copies in a format other than photocopies (and we will do so unless we
determine that it is impracticable) or ask us to prepare a summary in lieu
of the copies. We may charge you a fee not to exceed Florida law to recover
our costs (including postage, supplies and staff time as applicable, but
excluding staff time for search and retrieval ) to duplicate or summarize
your PHI. We will not condition release of the copies or summary on payment
of your outstanding balance for professional services (if you have one), but
we may condition release of the copies or summary on payment of the copying
fees. We will respond to requests in a timely manner, without delay for
legal review, in less than thirty days if submitted in writing on our form
or otherwise, and in ten business days or less if malpractice litigation or
pre-suit production is involved. We may deny your request in certain limited
circumstances (e.g., we do not have the PHI, it came from a confidential
source, etc). If we deny your request, you may ask for a review of that
decision. If required by law, we will select a licensed health-care
professional (other than the person who denied your request initially) to
review the denial and we will follow his or her decision. If we select a
licensed health-care professional who is not affiliated with us, we will
ensure a Business Associate agreement is executed that prevents
re-disclosure of your PHI without your consent by the outside professional.
To Request Amendment / Correction If another doctor involved in your care
tells us in writing to change your PHI, we will do so as expeditiously as
possible upon receipt of the changes and will send you written confirmation
that we have made the changes. If you think PHI we have about you is
incorrect, or that something important is missing from your records, you may
ask us to amend or correct it (so long as we have it) by submitting a
Request for Amendment / Correction form to our privacy officer. We normally
will act on your request within 60 days from receipt, but we may extend our
response time (within the 60-day period) no more than once and by no more
than 30 days, in which case we will notify you in writing why and when we
will be able to respond. If we grant your request, we will let you know
within five business days, make the changes by noting (not deleting) what is
incorrect or incomplete and adding to it the changed language, and send the
changes within 5 business days to persons you ask us to and persons we know
may rely on incorrect or incomplete PHI to your detriment (or already have).
We may deny your request under certain circumstances (e.g., it is not in
writing, it does not give a reason why you want the change, we did not
create the PHI you want changed (and the entity that did can be contacted),
it was compiled for use in litigation, or we determine it is accurate and
complete). If we deny your request, we will (in writing within 5 business
days) tell you: why and how to file a complaint with us if you disagree,
that you may submit a written disagreement with our denial (and we may
submit a written rebuttal and give you a copy of it), that you may ask us to
disclose your initial request and our denial when we make future disclosures
of PHI pertaining to your request, and that you may complain to us and the
U.S. Department of Health and Human Services.
To an Accounting of Disclosures You may ask us for a list of those who got
your PHI from us by submitting a Request for Accounting of Disclosures form
to us. The list will not cover some disclosures (e.g. PHI given to you,
given to your legal representative, given to others for treatment, payment
or health-care-operations purposes). Your request must state in what form
you want the list (e.g., paper or electronically) and the time period you
want us to cover, which may be up to but no more than the last six years
(excluding dates before April 14, 2003). If you ask us for this list more
than once in a 12-month period, we may charge you a reasonable, cost-based
fee to respond, in which case we will tell you the cost before we incur it
and let you choose if you want to withdraw or modify your request to avoid
the cost.
To Request Restrictions You may ask us to limit how your PHI is used and
disclosed (i.e. in addition to our rules as set forth in this Notice) by
submitting a written Request for Restrictions on Use / Disclosure form to us
(e.g., you may not want us to disclose your surgery to family members or
friends involved in paying for our services or providing your home care). If
we agree to these additional limitations, we will follow them except in an
emergency where we will not have time to check for limitations. Also, in
some circumstances we may be unable to grant your request (e.g., we are
required by law to use or disclose your PHI in a manner that you want
restricted; you signed an Authorization form, which you may revoke, that
allows us to use or disclose your PHI in the manner you want restricted; in
an emergency).
To Request Alternative Communications You may ask us to communicate with you
in a different way or at a different place by submitting a written Request
for Alternative Communication form to us. We will not ask you why and we
will accommodate all reasonable requests (including, e.g., to send
appointment reminders in closed envelopes rather than by postcards, to send
your PHI to a post office box instead of your home address, to communicate
with you at a telephone number other than your home number). You must tell
us the alternative means or location you want us to use and explain to our
satisfaction how payments to us will be made if we communicate with you as
you request.
To Complain or Get More Information We will follow our rules as set forth in
this Notice. If you want more information or if you believe your privacy
rights have been violated (e.g., you disagree with a decision of ours about
inspection / copying, amendment / correction, accounting of disclosures,
restrictions or alternative communications), we want to make it right. We
never will penalize you for filing a complaint. To do so, please file a
formal, written complaint within 180 days with:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Ave., S.W.
Washington, D.C. 20201
(877) 696-6775 (toll free)
Or, submit a written Complaint form to us at the following address:
Rashmi Patel
13740 Office Park Court
Suite A
Hudson, FL 34667
(727) 863-7487 Voice
(727) 861-7504 Fax
mukeshpatelmd@yahoo.com
You may get your complaint form by calling our privacy officer.
These privacy practices will be effective April 14, 2003, and will remain in
effect until we replace them as specified above.