Appointment Request

Notice of Privacy Practices
NOTICE OF PRIVACY PRACTICES (HIPAA INFORMATION)

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.

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USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov Protected health information includes demographic and medical information that concerns the past, present, or future physical or mental health of an individual. Demographic information could include your name, address, telephone number, social security number, and any other means of identifying you as a specific person. Protected health information contains specific information that identifies a person or can be used to identify a person.



Protected health information is health information created or received by a health care provider, health plan, employer, or health care clearinghouse. This medical information is used by the practice in many ways while performing normal business activities.



Your protected health information may be used or disclosed by the practice for purposes of treatment, payment, and health care operations. Healthcare professionals use medical information in the clinics or hospitals to take care of you. Your protected health information may be shared, with or without your consent, with another healthcare provider for purposes of your treatment. Some protected health information can be disclosed without your written authorization, as allowed by law. Those circumstances include:

Reporting abuse of children, adults, or disabled persons.
Investigations related to a missing child.
Internal investigations and audits by the Department’s divisions, bureaus, and offices.
Investigations and audits by the state’s Inspector General and Auditor General, and the
Legislature’s Office of Program Policy Analysis and Government Accountability.

Public health purposes, including vital statistics, disease reporting, public health
Surveillance, investigations, interventions, and regulation of health professionals.

District medical examiner investigations;
Court orders, warrants, or subpoenas;
Law enforcement purposes, administrative investigations, and judicial and administrative proceedings


INDIVIDUAL RIGHTS

You have the right to request the practice to restrict the use and disclosure of your protected health information to carry out treatment, payment, or health care operations. You may also limit disclosures to individuals involved with your care. The practice is not required to agree to any restriction.

You have the right to be assured that your information will be kept confidential. The practice will make contact with you in the manner and at the address or phone number you select. You may be asked to put your request in writing. If you are responsible to pay for services, you may provide an address other than your residence where you can receive mail and

where we may contact you.

You have the right to inspect and receive a copy of your protected health information that is maintained by the practice within 30 days of the practice’s receipt of your request to obtain a copy of your protected health information. You must complete the practice’s Authorization to Disclosure Confidential Information form and submit the request to the county health department or Children’s Medical Services office. If there are delays in getting you the information, you will be told the reason for the delay and the anticipated date when you will receive your information.

Your inspection of information will be supervised at an appointed time and place. You may be denied access as specified by law.

If you choose to receive a copy of your protected health information, you have the right to receive the information in the form or format you request. If the Department cannot produce it in that form or format, it will give you the information in a readable hard copy form or another form or format that you and the practice agree to.

The practice cannot give you access to psychotherapy notes or certain information being used in a legal proceeding. Records are maintained for specified periods of time in accordance with the law. If your request covers information beyond that time the Department is required to

keep the record, the information may no longer be available.



DH8006-SSG-09/2017

If access is denied, you have the right to request a review by a licensed healthcare professional who was not involved in the decision to deny access. This licensed healthcare professional will be designated by the Practice. You have the right to correct your protected health information. Your request to correct your protected health information must be in writing and provide a reason to support your requested correction. The Practice may deny your request, in whole or part, if it finds the protected health information:

Was not created by the practice.
It is not protected health information.
It is by law not available for your inspection.
It is accurate and complete.
If your correction is accepted, the practice will make the correction and tell you and others

who need to know about the correction.

Summary of HIPAA PRIVACY POLICIES:

Patient information will be kept confidential except as necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, US Mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
The practice utilizes several vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
Your confidential information will not be used for the purposes of marketing or advertising of products, goods, or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.
You have the right to request restrictions in the use of your PHI and to request changes in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA Information Form and any subsequent changes. I understand that the consent shall remain in force from this time forward.



Additional uses of information

Appointment Reminders:
Your health information will be used by our staff to send you appointment reminders.
Information about treatments:
Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you.
Individual Rights:
You have certain rights under the federal privacy standards.
These include:

 The right to request restrictions on the use and disclosure of your protected health information.
 The right to receive confidential communications concerning your medical condition and treatment.
 The right to inspect and copy your protected health information.
 The right to amend or submit corrections to your protected health information.
 The right to receive an accounting of how and to whom your protected health information has been disclosed.
 The right to receive a printed copy of this notice.
Weight and Body Solutions:
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices
We are also required to abide by the privacy policies and practices that are outlined in this notice.
Right to Revise Privacy Practices:
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.
Request to Inspect Protected Health Information:
As permitted by federal regulations, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the front office receptionist or the office manager.
Complaints:
If you would like to submit a comment or complaint about our privacy practices, or to request further information concerning our privacy practices, you can do so by sending a letter outlining your concerns or questions to our Privacy Officer at :

The Privacy Officer
Weight and Body Solutions
5414 Town n Country BLVD
Tampa, FL 33615
813-886-4395
Fax: 813-886-6959

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address above. You will not be penalized or otherwise retaliated against for filing a complaint.