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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS
IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal and
state laws to maintain the privacy of your protected health information. We
are also required to give you this notice about our privacy practices, our
legal duties, and your rights concerning your protected health information. We
must follow the privacy practices that are described in this notice while it
is in effect. This notice takes effect April 14, 2003, and will remain in
effect until we replace it.
We reserve the right to change our
privacy practices and the terms of this notice at any time, provided that such
changes are permitted by applicable law. We reserve the right to make the
changes in our privacy practices and the new terms of our notice effective for
all protected healthin formation that we maintain, including medical
information we created or received before we made the changes.
You
may request a copy of our notice (or any subsequent revised notice) at any
time. For more information about our privacy practices, or for additional
copies of this notice, please contact us using the information listed at the
end of this notice.
Uses and Disclosures of Protected Health
Information
We will use and disclose your protected health information
about you for treatment, payment, and health care operations. Following are
examples of the types of uses and disclosures of your protected health care
information that may occur. These examples are not meant to be exhaustive, but
to describe the types of uses and disclosures that maybe made by our
office.
Treatment: We will use and disclose your protected health
information to provide, coordinate or manage your healthcare and any related
services. This includes the coordination or management of your health care
with a third party. For example, we would disclose your protected health
information, as necessary, to a home health agency that provides care to you.
We will also disclose protected health information to other physicians who may
be treating you. For example, your protected health information may be
provided to a physician to whom you have been referred to ensure that the
physician has the necessary information to diagnose or treat you.
In
addition, we may disclose your protected health information from time to time
to another physician or health care provider (e.g., a specialist or
laboratory)who, at the request of your physician, becomes involved in your
care by providing assistance with your health care diagnosis or treatment to
your physician.
Payment: Your protected health information will be
used, as needed, to obtain payment for your health care services. This may
include certain activities that your health insurance plan may undertake
before it approves or pays for the health care services we recommend for you,
such as: making a determination of eligibility or coverage for insurance
benefits, reviewing services provided to you for protected health necessity,
and undertaking utilization review activities. For example, obtaining approval
for a hospital stay may require that your relevant protected health
information be disclosed to the health plan to obtain approval for the
hospital admission.
Health Care Operations: We may use or disclose,
as needed, your protected health information in order to conduct certain
business and operational activities. These activities include, but are not
limited to, quality assessment activities, employee review activities,
training of students, licensing, and conducting or arranging for other
business activities.
For example, we may use a sign-in sheet at the
registration desk where you will be asked to sign your name. We may also call
you by name in the waiting room when your doctor is ready to see you. We may
use or disclose your protected health information, as necessary, to contact
you by telephone or mail to remind you of your appointment.
We will
share your protected health information with third party "business associates"
that perform various activities (e.g., billing, transcription services) for
the practice. Whenever an arrangement between our office and a business
associate involves the use or disclosure of your protected health information,
we will have a written contract that contains terms that will protect the
privacy of your protected health information.
We may use or
disclose your protected health information, as necessary, to provide you with
information about treatment alternatives or other health-related benefits and
services that may be of interest to you. We may also use and disclose your
protected health information for other marketing activities. For example, your
name and address may be used to send you a newsletter about our practice and
the services we offer. We may also send you information about products or
services that we believe may be beneficial to you. You may contact us to
request that these materials not be sent to you.
Uses and
Disclosures Based On Your Written Authorization:Other uses and disclosures of
your protected health information will be made only with your
authorization,unless otherwise permitted or required by law as described
below.
You may give us written authorization to use your protected
health information or to disclose it to anyone for any purpose. If you give us
an authorization, you may revoke it in writing at any time. Your revocation
will not affect any use or disclosures permitted by your authorization while
it was in effect. Without your written authorization, we will not disclose
your health care information except as described in this notice.
Others
Involved in Your Health Care: Unless you object, we may disclose to a member
of your family, a relative, a close friend or any other person you identify,
your protected health information that directly relates to that person's
involvement in your health care. If you are unable to agree or object to such
a disclosure, we may disclose such information as necessary if we determine
that it is in your best interest based on our professional judgment. We may
use or disclose protected health information to notify or assist in notifying
a family member, personal representative or any other person that is
responsible for your care of your location, general condition or death.
Marketing:
We may use your protected health information to contact you with information
about treatment alternatives that may be of interest to you. We may disclose
your protected health information to a business associate to assist us in
these activities. Unless the information is provided to you by a general
newsletter or in person or is for products or services of nominal value, you
may opt out of receiving further such information by telling us using the
contact information listed at the end of this notice.
Research;
Death; Organ Donation: We may use or disclose your protected health
information for research purposes in limited circumstances. We may disclose
the protected health information of a deceased person to a coroner, protected
health examiner, funeral director or organ procurement organization for
certain purposes.
Public Health and Safety: We may disclose your
protected health information to the extent necessary to avert a serious and
imminent threat to your health or safety, or the health or safety of others.
We may disclose your protected health information to a government agency
authorized to oversee the health care system or government programs or its
contractors, and to public health authorities for public health purposes.
Health
Oversight: We may disclose protected health information to a health oversight
agency for activities authorized by law, such as audits, investigations and
inspections. Oversight agencies seeking this information include government
agencies that oversee the health care system, government benefit programs,
other government regulatory programs and civil rights laws.
Abuse
or Neglect: We may disclose your protected health information to a public
health authority that is authorized by law to receive reports of child abuse
or neglect. In addition, we may disclose your protected health information if
we believe that you have been a victim of abuse, neglect or domestic violence
to the governmental entity or agency authorized to receive such information.
In this case, the disclosure will be made consistent with the requirements of
applicable federal and state laws.
Food and Drug Administration: We
may disclose your protected health information to a person or company required
by the Food and Drug Administration to report adverse events, product defects
or problems, biologic product deviations; to track products; to enable product
recalls; to make repairs or replacements; or to conduct post marketing
surveillance, as required.
Criminal Activity: Consistent with
applicable federal and state laws, we may disclose your protected health
information, if we believe that the use or disclosure is necessary to prevent
or lessen a serious and imminent threat to the health or safety of a person or
the public. We may also disclose protected health information if it is
necessary for law enforcement authorities to identify or apprehend an
individual.
Required by Law: We may use or disclose your protected
health information when we are required to do so by law. For example, we must
disclose your protected health information to the U.S. Department of Health
and Human Services upon request for purposes of determining whether we are in
compliance with federal privacy laws. We may disclose your protected health
information when authorized by workers' compensation or similar laws.
Process
and Proceedings: We may disclose your protected health 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, wemay disclose your
protected health information to law enforcement officials.
Law
Enforcement: We may disclose limited information to a law enforcement official
concerning the protected health information of a suspect, fugitive, material
witness, crime victim or missing person. We may disclose the protected health
information of an inmate or other person in lawful custody to a law
enforcement official or correctional institution under certain circumstances.
We may disclose protected health information where necessary to assist law
enforcement officials to capture an individual who has admitted to
participation in a crime or has escaped from lawful custody.
Patient
Rights
Access: You have the right to look at or get copies of your
protected health information, with limited exceptions. You must make a request
in writing to the contact person listed herein to obtain access to your
protected health information. You may also request access by sending us a
letter to the address at the end of this notice. If you request copies, we
will charge you $25.00 for each page or$10.00 per hour to locate and copy your
protected health information, and postage if you want the copies mailed to
you. If you prefer, we will prepare a summary or an explanation of your
protected health information for a fee. Contact us using the information
listed at the end of this notice for a full explanation of our fee
structure.
Accounting of Disclosures: You have the right to receive
a list of instances in which we or our business associates disclosed your
protected health information for purposes other than treatment, payment,
health care operations and certain other activities after April 14, 2003.
After April14, 2009, the accounting will be provided for the past six(6)
years. We will provide you with the date on which we made the disclosure, the
name of the person or entity to whom we disclosed your protected health
information, a description of the protected health information we disclosed,
the reason for the disclosure, and certain other information. If you request
this list more than once in a12-month period, we may charge you a reasonable,
cost-based fee for responding to these additional requests. Contact us using
the information listed at the end of this notice for a full explanation of our
fee structure.
Restriction Requests: You have the right to request
that we place additional restrictions on our use or disclosure of your
protected health information. We are not required to agree to these additional
restrictions, but if we do, wewill abide by our agreement (except in an
emergency). Any agreement we may make to a request for additional restrictions
must be in writing signed by a person authorized to make such an agreement on
our behalf. We will not be bound unless our agreement is so memorialized in
writing.
Confidential Communication: You have the right to request
that we communicate with you in confidence about your protected health
information by alternative means or to an alternative location. You must make
your request in writing. We must accommodate your request if it is reasonable,
specifies the alternative means or location,and continues to permit us to bill
and collect payment from you.
Amendment: You have the right to
request that we amend your protected health information. Your request must be
in writing, and it must explain why the information should be amended. We may
deny your request if we did not create the information you want amended 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 to be appended
to the information you wanted amended. If we accept your request to amend the
information, we will make reasonable efforts to inform others, including
people or entities you name, of the amendment and to include the changes in
any future disclosures of that information.
Electronic Notice: If
you receive this notice on our website or by electronic mail (e-mail), you are
entitled to receive this notice in written form. Please contact us using the
information listed at the end of this notice to obtain this notice in written
form.
Questions and Complaints
If you want more information
about our privacy practices or have questions or concerns, please contact us
using the information below. If you believe that we may have violated your
privacy rights, or you disagree with a decision we made about access to your
protected health information or in response to a request you made, you may
complain to us using the contact information below. You also may submit a
written complaint to the U.S. Department of Health and Human Services. We will
provide you with the address to file your complaint with the U.S. Department
of Health and Human Services upon request.
We support your right to
protect the privacy of your protected health information. We will not
retaliate in anyway if you choose to file a complaint with us or with the U.S.
Department of Health and Human Services
Name of Contact
Person: Dr. George Kollias
Telephone: 813-884-1457
Address: 10930
Sheldon Rd
Tampa, FL
33626