THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THE INFORMATION. PLEASE REVIEW IT CAREFULLY.
OUR PLEDGE TO YOU
Justin Whisenant MD PA or Florida Neurointerventionalists (FNI or “we”) works cohesively with the hospitals and referring physicians to provide the highest level of radiology services for the health of the communities we serve. FNI is committed to protecting your confidential health information. We routinely perform internal quality, privacy, and security assessments because we understand that the quality of services you receive, along with the privacy and security of your medical information, is important to you.
WHO WILL FOLLOW THIS NOTICE
This notice applies to our patients. FNI will comply with this notice with respect to uses and disclosures of your medical information.
HOW WE MAY USE AND DISCLOSE YOUR INFORMATION
FNI uses and discloses your health information for treatment and diagnosis purposes, to obtain payment for your treatment, and for activities related to our routine business operations, and for certain other purposes, without being required to obtain your authorization. Below are examples of some of the ways we may use and disclose your health information. We do not list all the ways we are permitted by law to use or disclose your information, but a use or disclosure should fall in one of the following categories:
1. How we use and disclose your information for treatment purposes:
We use an electronic archive to store the digital images of your exams. We have put in place security procedures and safeguards to protect the confidentiality and integrity of your electronic health information. Our electronic archive enhances the quality of the healthcare you receive by providing the timely exchange of medical information needed for your treatment. Your personal physician, members of your treatment team, or a consulting physician may access your archived health information directly by computer. FNI also automatically sends copies of your radiological report to your doctors.
Please note that Florida law requires that we provide you with notice that your medical information may be subject to electronic disclosure. That is, we may use and disclose your medical information electronically. For example, if your medical information is contained electronically in an electronic medical record with our offices, and another provider who is involved in your treatment requests a copy of your medical records, we may forward such records electronically.
2. How we use and disclose your information to collect payment:
To obtain payment, FNI may submit a claim to your health insurance company, your workers compensation company, or to an authorized third party and may disclose information to a collection agency. We will send you a billing statement should there be any remaining balance for which you are responsible.
3. How we use and disclose your information for business operations:
We may call or leave a message for you about your appointment or to remind you of any special preparations you need to follow before your exam. We may also send you an appointment card reminding you when it is time to schedule a follow-up appointment. FNI may use your health information to evaluate the quality of medical care we provide in our offices. Quality assurance helps us improve the services we provide. We may contract with independent business associates, external auditors, or private consultants to help us assess the quality and effectiveness of our services. We may use or disclose your information for internal and external educational purposes. FNI takes very seriously its obligation to maintain the privacy and confidentiality of information regarding patients. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and various state laws, patient information (also known as protected health information, or PHI) will be kept private and secure. Any images used for educational purposes will be de-identified to maintain privacy.
4. Ways we are required by law to disclose your information:
We may disclose your health information without your authorization when required to do so by federal, state, or local law. As examples, we are required to do the following: report cases of suspected contagious disease and FNI Privacy Notice – English – suspected child, elder, and spousal abuse; respond to court orders; comply with laws relating to workers compensation or other similar programs established by law; report incidents related to adverse reactions to medication, medical devices, or products to the Food and Drug Administration; and comply by law with health oversight or law enforcement agencies.
5. Other ways we may use or disclose your information:
We may use or disclose your health information for other purposes as permitted by law, including to our business associates, to your personal representative or other parties involved in your care, to avert an imminent threat or for public safety or public health purposes, for organ donation or certain research purposes, for workers compensation programs, to coroners and medical examiners, for marketing and fundraising purposes in certain instances, and certain other purposes permitted by law.
6. De-identified information:
We may de-identify your information by removing certain identifiers as requried by law. Once your information has been de-identified, it will no longer be considered private information or subject to the terms hereof, and we will be free to use such de-identified information as we determine.
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YOUR INDIVIDUAL RIGHTS
You have the right to:
• Look at and ask for a copy of your health information as provided by law. FNI is allowed to charge a reasonable
fee for making copies.
• Make a reasonable request that FNI contact you by alternate means, address, or telephone number to protect
the privacy of confidential communications about your health care.
• Request that FNI amend your health record, if you believe that your information is not correct or that your
medical record is not complete. We will notify you if we are unable to honor your request.
• Request that FNI restrict certain uses and disclosures of your information, unless the use or disclosure is
otherwise permitted or required by law. FNI is not required to agree to your request unless you are asking FNI
to restrict the use and disclosure of your information to a health plan for payment or health care operation
purposes and the information you wish to restrict pertains solely to a health care item or service for which you
have paid FNI in full.
• Receive an accounting of certain disclosures of your health information as provided by law.
• Ask for a paper copy of this privacy notice.
• If you sign an authorization allowing FNI to disclose your health information for reasons other than a purpose
described herein, you can revoke your authorization at any time, except to the extent that FNI has taken action
in reliance on it. You must revoke your authorization in writing to stop any future uses and disclosures.
PLEASE SUBMIT YOUR REQUEST IN WRITING TO THE ADDRESS BELOW
FNI will consider your written request. However, we may not be able to honor your request if prevented by law. If a request cannot be honored, we will notify you in writing.
OUR RIGHT TO CHANGE OUR PRIVACY NOTICE
We may make changes to this notice at any time. Changes may result in additional uses or disclosures of your health information not previously authorized by you or mentioned in this notice. You may obtain a copy of the current FNI privacy notice by clicking on the link on the website, by requesting it at any of our locations, or by sending a written request to the FNI address provided at the end of this notice. This notice supersedes all previous privacy notices.
OUR LEGAL DUTY
We are required by state and federal law to protect the privacy of your health information, to provide you with a copy of this notice at your request, and to follow the terms stated in this notice. FNI is required to notify you of certain unauthorized access, acquisition, or use of your medical information. FNI maintains a website at www.JustinWhisenantMD.com that provides a link to a printable form of this notice and an email link to our Privacy Officer. Our website offers a range of patient information and online services for your convenience. Except as described in this notice or otherwise permitted by law, FNI will not use or disclose your health information without your written authorization. Independent healthcare providers who access our electronic archive and our external business associates are also required by law to protect the confidentiality of your health information.
HOW TO FILE COMPLAINTS
If you are concerned that FNI has violated your privacy rights, or if you have any privacy related questions, you may contact our Privacy Officer in writing, by phone, by email, or by regular mail. FNI will not retaliate against you in FNI Privacy Notice – English – any way for filing a complaint.
For privacy related questions or concerns,
please contact our Privacy Officer:
Florida Neurointerventionalists/ Attention: Privacy Officer
To file a complaint with the Office for Civil Rights:
Office for Civil Rights
U.S. Department of Health and Human Services
Sam Nunn Atlanta Federal Center, Suite 16T70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
Customer Response Center: (800) 368-1019
Fax: (202) 619-3818
TDD :(800) 537-7697
Email: oc*****@*hs.gov
SIGNATURE
If we deliver a copy of this Notice to you, we will request that you sign below to indicate your receipt of this Notice and
your consent to our uses and disclosures of your information as set forth herein.
Patient Name:
_____________________________________
(Please Print Name)
Patient Date of Birth: _______________________________
Patient/Legal Representative: Date:
If Legal Representative, relationship to Patient:
Witness (optional): Date:
The effective date of this notice is:
25740487v.2
FNI
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