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Copyright 2010, Westchase Sports Medicine Orthopaedics, All Rights Reserved.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.
1. OUR PLEDGE REGARDING MEDICAL INFORMATION.
The privacy of your medical information is important to us. We understand that your medical information is personal and we
are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record
to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may
use and share medical information about you. This also describes your rights and duties we have regarding the use and
disclosure of medical information.
2. OUR LEGAL DUTY
The law requires us to:
1. Keep your medical information private.
2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
3. Follow the terms of the current notice.
We have the right to:
1. Change our privacy practices and the new terms of this notice at any time, provided that the changes are permitted by law.
2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep,
including information previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available
3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways that we use and disclose medical information. Not every use or disclosure will
be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will
not use or disclose your medical information for any purpose not listed herein without your specific written authorization. Any
specific written authorization you provide may be revoked at any time by writing to us.
FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may
disclose medical information about you to doctors, nurses, technicians, medical students, or other health care providers to
assist them in treating you.
FOR PAYMENT: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a
third-party payor. The information on or accompanying the bill may include your medical information.
FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care operations. This
might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and
getting the accreditation, certificates, licenses, and credentials we need to serve you.
ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment,
and health care operations, we may use and disclose medical information for the following purposes:
Facility Directory: Unless you notify us that you object, the following medical information about you will be placed in our facility
directories: name, location, condition described in general terms, and your religious affiliation, if any. We may disclose this
information to members of the clergy, or, except for your religious affiliation, to others who contact us and ask for information
about you by name.
Notification: We may use and disclose medical information to notify or help to notify a family member, your personal
representative, or another person responsible for your care. We will share information about your location, general condition,
or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse
permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health
information that is directly necessary for our health care, according to our professional judgment. We will also use your
professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies,
xray, or medical information for you.
Disaster Relief: We may share medical information with a public or private organization or person who can legally assist in
disaster relief efforts.
Funeral Director, Coroner, Medical Examiner: To help them carry out their duties, we may share the medical information of a
person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military
personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for
medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial
situations, and for government programs providing public health benefits.
Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to a court or
administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited
circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law
enforcement officials. We may share limited information with a law enforcement official concerning the medical information of
a suspect, fugitive, material witness, crime victim, or missing person. We may share the medical information of an inmate or
other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.
Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities
charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your
medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse
events associated with product defects or problems, to enable product recalls, repairs, or replacements, to track products, or to
conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a
person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease
Victims of Abuse, Neglect, or Domestic Violence: We may use and disclose medical information to appropriate authorities if
we reasonably believe you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.
We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or
safety of others. We may share medical information when necessary to help law enforcement officials capture a person who
has admitted to being part of a crime or has escaped from legal custody.
Workers Compensation: We may disclose health information when authorized or necessary to comply with laws relating to
workers compensation or other similar programs.
Health Oversight Activities: We may disclose medical information to an agency providing health oversight for oversight
activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections,
licensure or disciplinary actions, or other authorized activities.
Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These
circumstances include reporting required by certain laws (i.e. reporting some types of wounds), pursuant to certain subpoenas
or court orders, reporting limited information concerning identification and location at the request of a law enforcement official,
reporting death, crimes on our premises, and crimes in emergencies.
Appointment Reminders: We may use and disclose medical information for purposes of sending you appointment postcards
or otherwise reminding you of your appointments.
Alternative and Additional Medical Services: We may use and disclose medical information to furnish you with information
about health-related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives.
4. YOUR INDIVIDUAL RIGHTS
You have a right to:
1. Look at or get copies of certain parts of your medical information. You may request that we provide copies in a format other
than photocopies. We will use the format you request unless it is not practical for us to do so. You must make your request in
writing. You may get the form to request access by using the contact information listed at the end of this notice. You may also
request access by sending a letter to the contact person listed. If you request copies, we will charge you $1.00 per page for the
first 25 pages, then .50 per page thereafter, plus postage if you want the copies mailed to you. Contact us for a full explanation
of our fee schedule. (Rule 64B8-10.003, Florida Administrative Code)
2. Receive a list of all the times we or our business associates shared your medical information for purposes other than
treatment, payment, and health care operations and other specified exceptions.
3. Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to
agree to these additional restrictions, but if we do, we will abide by our agreement, except in the case of an emergency.
4. Request that we communicate with you about our medical information by different means or to different locations. Your
request that we communicate your medical information to you by a different means or at different locations must be made in
writing to the contact person listed at the end of this notice.
5. Request that we change certain parts of your medical information. We may deny your request if we did not create the
information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation.
You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept
your request to change the information, we will make reasonable efforts to tell others, including people you name, of the
change and to include the changes in any future sharing of that information.
6. If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain same by making
a request in writing to the contact person listed at the end of this notice.
QUESTIONS AND COMPLAINTS
If you have any questions about this notice, or if you think that we may have violated your privacy rights, please contact us. You
may also submit a written complaint to the US Department of Health and Human Services. You may contact us to submit a
complaint or submit requests involving any of your rights in Section 4 of this notice by writing to:
WESTCHASE SPORTS MEDICINE ORTHOPAEDICS
11301 Countryway Blvd.
Tampa, FL. 33626
Attn: Lisa Borrego
We will provide you with the address to file your complaint to the US Department of Health and Human Services and will not
retaliate in any way if you choose to file a complaint.
You may download and print this form by clicking here. The downloadable form requires a pdf reader such
as adobe reader. If you do not have adobe reader, you may click here to download the free version.