Original Effective Date: January 1, 2003
Last Revised 05/28/2018
The materials on Mid Florida Dermatology & Plastic Surgery’s and The Mid Florida Institute of Plastic Surgery’s website are provided “as is”. Mid Florida Dermatology & Plastic Surgery and The Mid Florida Institute of Plastic Surgery makes no warranties, expressed or implied, and hereby disclaims and negates all other warranties, including without limitation, implied warranties or conditions of merchantability, fitness for a particular purpose, or non-infringement of intellectual property or other violation of rights. Mid Florida Dermatology & Plastic Surgery and The Mid Florida Institute of Plastic Surgery does not warrant or make any representations concerning the accuracy, likely results, or reliability of the use of the materials on its Internet web site or otherwise relating to such materials or on any sites linked to this site. A federal regulation, known as the “HIPAA Privacy Rule” requires that we provide a detailed notice in writing of our privacy practices. We know that this Notice is long. The HIPAA Privacy Rule requires us to address many specific things in this Notice.
In this Notice, we describe the ways that we may use and disclose health information about our patients. The HIPAA Privacy Rule requires that we protect the privacy of health information that identifies a patient, or where there is a reasonable basis to believe the information can be used to identify a patient. This information is called “protected health information” or “PHI”. This Notice describes your rights as our patient and our obligations regarding the use and disclosure of PHI. We are required by law to:
As permitted by the HIPAA Privacy Rule, we reserve the right to make changes to this Notice and to make such changes effective for all PHI we may already have about you. If and when this Notice is changed, we will post a copy in our office in a prominent location. We will also provide you with a copy of the revised Notice upon your request. You will be asked to sign a form to show that you received this Notice. Even if you do not sign this form, we will still provide you with treatment.
The following categories describe the different ways we may use and disclose PHI for treatment, payment, or health care operations, without your consent or authorization. The examples included in each category do not list every type of use or disclosure that may fall within that category.
We may use and disclose PHI about you to provide, coordinate, or manage your health care and related services. We may consult with other health care providers regarding your treatment and to coordinate and manage your healthcare. For example, we may use and disclose PHI when you need a prescription, lab work, an X-ray, or other healthcare services. In addition, we may use and disclose PHI about you when referring you to another health care provider. If you were referred to another physician, we may disclose PHI to your new physician regarding any medication allergies. In emergencies, we may use and disclose PHI to provide the treatment you need. Additionally, if we refer you to another physician, we may send your PHI to that physician.
We may use and disclose PHI so that we can bill and collect payment for the treatment and services provided to you. Before providing treatment or services, we may share details with your health plan concerning the services you are scheduled to receive. For example, we may ask for payment approval from your health plan before we provide care or services. We may use and disclose PHI to find out if your health plan will cover the cost of care and services we provide. We may use and disclose PHI to confirm you are receiving the appropriate amount of care to obtain payment for services. We may use and disclose PHI to insurance companies providing you with additional coverage. We may disclose limited PHI to consumer reporting agencies relating to collection of payments owed to us.
We may also disclose PHI to another health care provider or to a company or health plan required to comply with the HIPAA Privacy Rule for the payment activities of that healthcare provider, company, or health plan. We may allow a health insurance company to review PHI for the insurance company’s activities to determine the insurance benefits to be paid for your care.
We may use and disclose PHI in performing business activities that are called health care operations. Health care operations include doing things that allow us to improve the quality of care we provide and to reduce health care costs. We may use and disclose PHI about you in the following health care operations:
If another health care provider, company, or health plan that is required to comply with the HIPAA Privacy Rule also has or once had a relationship with you, we may disclose PHI about you for certain healthcare operations of that healthcare provider or company. Such health care operations may include-reviewing and improving the quality, efficiency, and cost of care provided to you; reviewing and evaluating the skills, qualifications, and performance of healthcare providers; providing training programs for students, trainees, healthcare providers, or non-healthcare professionals; cooperating with outside organizations that evaluate, certify, or license healthcare providers or staff in a particular field or specialty; and assisting with legal compliance activities of that healthcare provider or company.
We may also disclose PHI for the healthcare operations of any “organized health care arrangement” in which we participate. An example of an organized healthcare arrangement is the joint care provided by a hospital and the physicians who see patients at the hospital.
We may contact you to remind you of appointments and to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care: We may use and disclose PHI about you in some situations where you have the opportunity to agree or object to certain uses and disclosures of PHI about you. If you do not object, we may make these types of uses and disclosures of PHI.
We may use and disclose PHI about you in the following circumstances without your authorization or opportunity to agree or object, provided that we comply with certain conditions that may apply.
We may use and disclose PHI as required by federal, state, or local law to the extent that the use or disclosure complies with the law and is limited to the requirements of the law.
We may use and disclose PHI to public health authorities or other authorized persons to carry out certain activities related to public health, including the following activities:
We may disclose PHI in certain cases to proper government authorities if we reasonably believe that a patient has been a victim of domestic violence, abuse, or neglect.
Health Oversight Activities: We may disclose PHI to a health oversight agency for oversight activities including, for example, audits, investigations, inspections, licensure and disciplinary activities, and other activities conducted by health oversight agencies to monitor the health care system, government healthcare programs, and compliance with certain laws.
We may use or disclose PHI when required by a court or administrative tribunal order. We may also disclose PHI in response to subpoenas, discovery requests, or other required legal process when efforts have been made to advise you of the request or to obtain an order protecting the information requested.
Under certain conditions, we may disclose PHI to law enforcement officials, where the disclosure is:
We may disclose PHI to a coroner or medical examiner to identify a deceased person and determine the cause of death. In addition, we may disclose PHI to funeral directors, as authorized by law, so that they may carry out their jobs.
If you are an organ donor, we may use or disclose PHI to organizations that help procure, locate, and transplant organs in order to facilitate an organ, eye, or tissue donation and transplantation.
We may use and disclose PHI about you for research purposes, under certain limited circumstances. We must obtain a written authorization to use and disclose PHI about you for research purposes, except in situations where a research project meets specific, detailed criteria established by the HIPAA Privacy Rule to ensure the privacy of PHI.
We may use and disclose PHI about you in limited circumstances when necessary to prevent a threat to the health or safety of a person or to the public. This disclosure can only be made to a person who is able to help prevent the threat.
Under certain conditions, we may disclose PHI:
We may disclose PHI as authorized by workers’ compensation laws or other similar programs that provide benefits for work-related injuries or illness
We are required to disclose PHI to the Secretary of the United States Department of Health and Human Services when requested by the Secretary to review our compliance with the HIPAA Privacy Rule. We are also required in certain cases to disclose PHI to you upon your request, to access PHI or for an accounting of certain disclosures of PHI about you.
Incidental Disclosures: We may use or disclose PHI incident to a use or disclosure permitted by the HIPAA Privacy Rule, so long as we have reasonably safeguarded against such incidental uses and disclosures and have limited them to the minimum necessary information.
We may use or disclose a limited data set (PHI that has certain identifying information removed) for the purposes of research, public health, or health care operations. This information may only be disclosed for research, public health, and health care operations purposes. The person receiving the information must sign an agreement to protect the information.
All other uses and disclosures of PHI about you will only be made with your written authorization. If you have authorized us to use or disclose PHI about you, you may later revoke your authorization at any time, except to the extent we have taken action based on the authorization.
You have the right to request additional restrictions on the PHI that we may use or disclose for treatment, payment, and health care operations. You may also request additional restrictions on our disclosure of PHI to certain individuals involved in your care that otherwise are permitted by the Privacy Rule. We are not required to agree to your request. If we do agree to your request, we are required to comply with our agreement except in certain cases, including where the information is needed to treat you in the case of an emergency. To request restrictions, you must make your request in writing to your Privacy Official. In your request, please include (1) the information that you want to restrict; (2) how you want to restrict the information (for example, restricting use of this office, only restricting disclosure to persons outside this office, or restricting both); and (3) to whom you want those restrictions to apply.
You have the right to request that you receive communications regarding PHI in a certain manner or at a certain location. For example, you may request that we contact you at home, rather that at work. You must make your request in writing. You must specify how you would like to be contacted (for example, by regular mail to your post office box and not your home). We are required to accommodate only reasonable requests.
You have the right to request the opportunity to inspect and receive a copy of PHI about you in certain records that we maintain. This includes your medical and billing records but does not include psychotherapy notes or information gathered or prepared for a civil, criminal, or administrative proceeding. We may deny your request to inspect and copy PHI only in limited circumstances. To inspect and copy PHI, please contact our Privacy Official. If you request a copy of PHI about you, we may charge you a reasonable fee for the copying, postage, labor, and supplies used in meeting your request.
You have the right to request that we amend PHI about you as long as such information is kept by or for our office. To make this type of request, you must submit your request in writing to our Privacy Official. You must also give us a reason for your request. We may deny your request in certain cases, including if it is not in writing or if you do not give us a reason for the request.
You have the right to request an “accounting” of certain disclosures that we have made of PHI about you. This is a list of disclosures made by use during a specified period of up to 6 years, other than disclosures made: for treatment, payment, and health care operations; for use in or related to a facility directory; to family members or friends involved in your care; to you directly; pursuant to an authorization of you or your personal representative; for certain notification purposes (including national security, intelligence, correctional, and law enforcement purposes); as incidental disclosures that occur as a result of otherwise pertained disclosures; as part of a limited data set of information that does not directly identify you; and before January 01, 2003. If you wish to make such a request, please contact our Privacy Official. The first list that you request in a 12-month period will be free, but we may charge you for our reasonable costs of providing additional lists in the same 12-month period. We will tell you about these costs, and you may choose to cancel your request at any time before costs are incurred.
You have a right to receive a paper copy of this Notice at any time. You are entitled to a paper copy of this Notice even if you have previously agreed to receive this Notice electronically. To obtain a paper copy of this Notice, please contact our Privacy Official.
If you believe your privacy rights have been violated, you may file a complaint with us or the Secretary of the United States Department of Health and Human Services. To file a complaint with our office, please contact out Privacy Official at the address and number listed below. We will not retaliate or take action against you for filing a complaint.
If you have any questions about this Notice, please contact our Privacy Official at the address and telephone number listed below.
You may contact our Privacy Official at the following address and phone number:
Privacy Official: Michael Gutierrez, M.D.
Address: 7652 Ashley Park Court, Suite #305 Orlando, FL 32806
This Notice was published and first became effective on 01/01/03
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