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.
NOTICE OF PRIVACY PRACTICES
Important: This notice describes your rights as a patient and how your medical information may be used and disclosed.
Please review this notice carefully:
The terms of this Notice of Privacy Practices apply to JOSE A. GAUDIER, M.D., P.A. and are effective April 14, 2003. We will share individual patient health information as is necessary to provide quality health care and receive reimbursement for those services as permitted by law. This office is required by law to maintain the privacy of your individual health information and to provide you with a notice of privacy practices with respect to your individual health information. We reserve the right to change the terms of this Notice of Privacy Practices as necessary. A copy of any revised notice will be available in this office.
USES AND DISCLOSURES OF YOUR HEALTH INFORMATION. Except as described below, we will maintain the confidentiality of your individual health information. Your individual health information may be used and disclosed as customary and reasonable for purposes of treatment, payment, and health care operations and if you have signed an authorization form permitting the use or disclosure. You have the right to revoke that authorization in writing on any action not already taken while relying on that authorization. However, to do so may jeopardize the service we are able to provide to you.
Because you have signed this acknowledgment, we will be able to use and disclose your individual health information as necessary in the course of your treatment or to receive payment, or if necessary and permitted by law, in our health care operations which include clinical improvement, professional peer review, business management, accreditation, licensing, etc.
With your approval and using our best judgment, your individual health information may be disclosed to designated family, friends, or others who are involved in your care or in payment of your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share some of your health information with some of these people without your approval.
At times, it may be necessary for us to provide your individual health information to certain outside persons or organizations that assist us with our health care operations, such as auditing, accreditation, legal services, etc. These business associates are required to sign an agreement with us that they will properly safeguard the privacy of your information.
AMENDMENTS. You have the right to request in writing that individual health information we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. In any case, we will NOT amend the original document but will make your amendment request part of your record. All amendment requests must be in writing on our amendment form, signed by you or your designated representative, and must state the reasons for the amendment/correction. If an amendment or correction you request is made by us, we may also notify others who work with us, your referring doctor, or an authorized interested agency or company who may already have copies of the uncorrected record, if we believe such a notification is necessary. You may obtain an amendment request from our Medical Records Department or our Office Manager and give the request to any of our staff.
ACCOUNTABILITY FOR DISCLOSURE OF YOUR INFORMATION. You have the right to receive an accounting of certain disclosures made by us of your individual health information after April 14, 2003. Requests must be made in writing and signed by you or your designated representative and given or mailed to our Medical Records Department or Office Manager. We will not charge for the first accounting, but you will be charged a fee for each additional accounting you request in the same 12 month period.
RESTRICTIONS ON USE AND DISCLOSURE OF YOUR INDIVIDUAL HEALTH INFORMATION. You have the right to request restrictions on certain of our uses and disclosures of your information. We are not required to agree to your restriction request, but will attempt to accommodate reasonable requests when appropriate and we keep the right to terminate a restriction we have agreed to if we believe such termination is appropriate. You also have the right to terminate your restriction request by writing to us at:
JOSE A. GAUDIER, M.D., P.A., P.O. Box 5277, Ocala, FL 34478
COMPLAINTS OF PRIVACY VIOLATION. If you believe your privacy rights have been violated, you can file a written complaint within 180 days of the violation, detailing specifically how your privacy rights have been violated, including your name, date of birth and social security number. You may send this to us at.
JOSE A. GAUDIER, M.D., P.A., P.O. Box 5277, Ocala, FL 34478.
You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. There will be no retaliation for filing a complaint either with us or with the government.
ADDITIONAL INFORMATION. If you have questions or need additional assistance regarding this notice, you may contact our Compliance Officer at JOSE A. GAUDIER, M.D., P.A., P.O. Box 5277, Ocala, FL 34478, Tel 352-732-8630.