PLEASE REVIEW IT CAREFULLY.

PLEASE NOTE:
State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect August 1, 2018 and will remain in effect until it is amended or replaced by us.

It is our right to change our privacy practices provided the law permits the changes. Before we make a significant change, this Notice will be amended to reflect the changes and we will make the new notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date the changes were made.

Please direct any questions about this Notice to our Privacy Officer at 407­581­9065.

Privacy Officer address:
PremierMED Ophthalmology
Attn: Privacy Officer
1291 Winter Garden Vineland Rd, Suite 130, Winter Garden, FL 34787

OUR COMMITMENT TO YOUR PRIVACY

We understand that information about you and your health care is personal. We create a record of the care and services you receive from PremierMED Family and Sports Medicine, LLC and are committed to protecting that information.

We are required by law to 1) Make sure health information that identifies you is kept private.
2) Give you this Notice of our privacy practices. 3) Follow the terms of the Notice that is
currently in effect.

ROUTINE USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION
(PHI) (Please note: for the purposes of this document the terms “you” will pertain to the patient and/or legal guardian if appropriate)

TREATMENT: Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests, and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you. Many of the people who work in our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment.

PAYMENT: Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with the details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use you PHI to bill you directly for services and items.

HEALTH CARE OPERATIONS: Our practice may use and disclose your PHI to operate our business. Examples of the ways in which we may do this include using your PHI to evaluate the quality of care you receive from us, or to conduct cost­management and business planning activities for our practice. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities.

APPOINTMENT REMINDERS: Our practice may use and disclose your PHI to contact you at the number and or email you have supplied to us and remind you of an appointment.

TREATMENT OPTIONS: Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives; or communicate with you regarding the scheduling, ordering or of results of tests.

HEALTH RELATED BENEFITS AND SERVICES: Most uses and disclosures of PHI for marketing purposes and disclosures that constitute sale of protected health information require authorization. Premier Family and Sports Medicine, LLC does maintain various social media sites; additionally it maintains a neutral presence on third­party online review sites such as, but not limited to Healthgrades.com, Google, and Yelp. If you elect to leave any feedback on these sites it is at your own discretion and you could potentially forfeit your right to privacy as a patient of our practice by doing so. However, we still follow guidelines outlined by HIPPA. Please contact our Privacy Officer if you have questions at 407­581­9065.

RELEASE OF INFORMATION TO FAMILY & FRIENDS: Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of your child, with written and signed consent from the patient and/or legal guardian. For example, a parent or guardian may ask that a babysitter or aunt take their child to the doctor for treatment. In this example, this person would have access to the child’s medical information; however this person must be listed on the consent for treatment form in the patient’s chart and be able to present valid picture ID at the time they present to our office. Additionally, a parent may not speak English fluently and may have an interpreter assist them at the appointment, this person would have access to the child’s medical information.

OTHER: Uses and disclosures not described in this NPP will be made only with authorization from you, the individual.

USE AND DISCLOSURE OF YOUR PHI IN SPECIAL CIRCUMSTANCES DISCLOSURES REQUIRED BY LAW: Our practice will use and disclose your PHI when we are required to do so by federal, state or local law; such as for law enforcement purposes, suspected abuse or neglect reporting, health oversights or audits, funeral arrangements, organ donation, public health purposes or in the case of a medical emergency.

PUBLIC HEALTH: Our practice may disclose your PHI to public health authorities that are
authorized by law to collect information for the purpose of:

• maintaining vital records, such as births and deaths
• reporting child abuse or neglect
•  preventing or controlling disease, injury or disability
• notifying a person regarding potential exposure to a communicable disease
• notifying a person regarding a potential risk for spreading or contracting a disease or condition
• reporting reactions to drugs or problems with products or devices
• notifying individuals if a product or device they may be using has been recalled

HEALTH OVERSIGHT ACTIVITIES: Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include but are not limited to investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

LAWSUIT OR SIMILAR PROCEEDING: Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute.

NATIONAL SECURITY: The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.

YOUR PRIVACY RIGHTS AS OUR PATIENT

You have the following rights regarding the PHI we maintain about you:

CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request specifying the requested method of contact, or the location where you wish to be contacted. At our discretion, we will accommodate all reasonable requests. You are not required to give a reason for your request.

ACCESS: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian). There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit the completed request form. You may contact our Privacy Officer for a copy of this form. Once approved an appointment can be made to review your records, during the process of review no records may be removed from the office. Copies, if requested, will be $1.00 per page for the first 25 pages and $0.25 per page for every page over 25. The individual office may choose to waive this fee at the discretion of the physician. We will try to accommodate all reasonable requests, however, if we deny your request to inspect and/or copy your record you may request a written reason for the denial. You have a right to obtain a copy of your health information within the designated record set maintained in electronic form in an electronic format. We will send the electronic form of your health information to you via unencrypted email if you acknowledge the risk of the sending of unencrypted emails in writing.

AMENDMENT: You may ask us to amend your health information if you believe it is inaccurate or incomplete, and you may request that the amendment be in effect for as long as it is maintained by our practice. Your request for an amendment, must be in writing (the appropriate form can be requested from office staff) and must include an explanation of why the information should be amended. We will deny your request if you fail to submit your request with supporting explanation in writing. Also, we may deny your request if you ask us to amend information that is not created by us, or is not part of the medical information maintained by us, or if we find that the information we possess is accurate and complete. If we deny your request you will receive the denial in writing; you have a right to appeal the decision – but it must be done in writing.

RESTRICTIONS: You have the right to request that we restrict the uses or disclosure of your health information for treatment, payment or healthcare operations purposes. We are not required to comply with any other requests for restrictions, but if we do, we will abide by the written agreement (except in the case of a medical emergency). Additionally, you have a right to request that we place additional restrictions on our use or disclosure of your health information to a health plan. Specifically you have the right to request that we restrict the use or disclosure of health information to a health plan (insurance company) for purposes of payment or operations, IF you pay for the service out­of­pocket IN FULL at the time the service is provided. This request MUST be made in writing (the appropriate form can be requested from office staff). This requirement does not apply to disclosures for treatment, such as disclosures to a referring physician for continuation of care. This office is required to comply with any requests that limit disclosures to a health plan when the service has been paid out­of pocket and in full by the patient. Such restrictions do not override disclosures that are otherwise required by law. Additionally, if initial payment for services that have a request for restriction applied to them, is returned or invalid our office will make a good faith attempt to collect payment – if this is unsuccessful we have the right to then submit a claim for these services to the health plan.

ACCOUNTING OF DISCLOSURES: All of our patients have the right to request an accounting of all disclosures made. All requests for an accounting of disclosures must be submitted in writing (the appropriate form can be requested from office staff) and include: a time period, that must not exceed 6 years prior to the date of the request and/or be dated prior to April 14, 2003 – as information prior to that date was not required to be tracked. The first list you request within a 12­month period is free of charge. We may charge you for any additional lists requested within the same 12­month period. We will notify you of the costs involved with any additional requests prior to their completion, allowing you to withdraw your request before you incur any costs.

BREACH NOTIFICATION REQUIREMENTS: In the event that unsecured protected information about you is “breached”, we will notify you of the situation and any steps you should take to protect yourself against harm due to the breach. We will inform The Department of Health and Human Services and take any other steps that are required by law.

RIGHT TO FILE A COMPLAINT: If you believe your privacy rights have been violated, you may file a complaint with our practice and/or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, please submit it in writing and to the attention of the Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the Department of Health and Human Services.

RIGHT TO A PAPER COPY OF THIS NOTICE: You are entitled to receive a paper copy of our Notice of Privacy Practices. To obtain a paper copy of this Notice, contact our Privacy Officer in writing.

MINORS AND PERSONS WITH LEGAL GUARDIANS:
Minors and certain disabled adults are entitled to the privacy protection of their health information. Because, by law, they cannot make health decisions for themselves, a parent or guardian can make medical decisions on their behalf. Therefore parents and guardians can authorize the use and release of PHI and also hold all rights listed in this notice or the behalf of the minor child or disabled adult.

Under certain situations defined by law, minors can make independent healthcare decisions without parent or guardian knowledge or consent. In those situations, the minor may hold all rights listed in this notice. If the minor chooses to inform the parent or guardian, then all privacy rights regarding PHI may transfer to the parent or guardian. There are also certain situations where access, use or release of a minor’s PHI may occur without the consent of the parent or guardian, i.e. when the health or safety of the minor is in danger and PHI is necessary to protect the minor.

We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that we have created or maintained in the past, and for any we may create or maintain in the future.

Our practice will post a copy of our current Notice in our offices in a visible location, and you may request a copy of our most current Notice at any time.