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Notice of Privacy Practices

Effective Date: January 10, 2014

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, HOW YOU CAN ACCESS THIS INFORMATION, AND YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are committed to protecting the privacy and security of your health information. This notice explains your rights, our responsibilities, and the circumstances in which your health information may be used or disclosed.

1. Your Rights

When it comes to your health information, you have certain rights. This section explains those rights and how you can exercise them.

Access your medical records

You may ask to see or receive an electronic or paper copy of your medical record and other health information we maintain about you. Contact our Privacy Officer for instructions.

We will generally provide a copy or summary of your health information within 30 days of receiving your written request. A reasonable, cost-based fee may apply.

Request corrections to your medical records

If you believe that information in your medical record is incorrect or incomplete, you may request a correction in writing. Contact our Privacy Officer for instructions.

We may deny your request, but if we do, we will explain the reason in writing within 60 days.

Request confidential communications

You may ask us in writing to contact you in a particular way, such as by calling your home or office phone, or to send mail to a different address.

We will accommodate all reasonable requests. Contact our Privacy Officer to make your request.

Ask us to limit the use or disclosure of your information

You may ask us in writing not to use or disclose certain health information for treatment, payment, or health care operations. We are not required to agree to every request, and we may decline if the restriction could affect your care.

Special rule for services paid for in full: If you pay for a health care service or item entirely out of pocket, you may ask us in writing not to disclose information about that service or item to your health insurer for payment or health care operations. We will honor that request unless a law requires us to disclose the information.

Contact our Privacy Officer for instructions on submitting either type of request.

Request an accounting of disclosures

You may request a list of certain disclosures of your health information made during the six years preceding your request. The list will identify to whom the information was disclosed and why.

This accounting does not include disclosures for treatment, payment, or health care operations, or certain other disclosures, such as those you specifically asked us to make.

We will provide one accounting per year at no charge. A reasonable, cost-based fee may apply if you request another accounting within a 12-month period.

Contact our Privacy Officer to request an accounting.

Obtain a copy of this notice

You may request a paper copy of this notice at any time, even if you have agreed to receive it electronically. We will provide a paper copy promptly.

Choose someone to act on your behalf

If you have granted someone medical power of attorney or someone is legally authorized to act as your guardian, that person may exercise your rights and make choices about your health information on your behalf.

Before acting on a request, we will verify that the person has the appropriate authority.

File a complaint

If you believe that your privacy rights have been violated, you may file a complaint with our Privacy Officer.

You may also submit a complaint to the U.S. Department of Health and Human Services, Office for Civil Rights, by:

We will not retaliate against you for filing a complaint.

2. Your Choices

For certain uses and disclosures of your health information, you may tell us how you would like your information shared. If you have a preference in any of the situations described below, please tell us what you want us to do. We will follow your instructions as applicable.

You may direct us to:

  • Share information with family members, close friends, or other people involved in your care.
  • Share information in a disaster-relief situation.
  • Include information about you in a hospital directory.

If you are unable to communicate your preference—for example, because you are unconscious—we may share information when we believe doing so is in your best interest. We may also disclose information when necessary to lessen a serious and imminent threat to health or safety.

Uses and disclosures requiring your written permission

We will not use or disclose your information for the following purposes without your written permission:

  • Marketing purposes.
  • Sale of your information.
  • Most disclosures of psychotherapy notes.

Fundraising

We may contact you about fundraising activities. You have the right to opt out of receiving fundraising communications, and we will honor your request if you tell us you do not wish to receive them.

3. How We Use and Disclose Your Health Information

We may use and disclose your health information for treatment, payment, and health care operations, as described below. We may also use or disclose it in certain other circumstances permitted or required by law.

Treatment

We may use your health information and share it with other health care professionals involved in your treatment.

Example: A physician treating you for an injury may consult another physician about your overall health.

Payment

We may use and disclose your health information to bill for services and obtain payment from health plans or other entities.

Example: Information may be provided to a health insurance plan so that it can pay for services.

Health care operations

We may use and disclose your health information to operate our practice, improve care, manage treatment and services, and contact you when necessary.

Public health and safety

We may disclose your health information in certain situations involving public health or safety, including:

  • Preventing disease.
  • Helping with product recalls.
  • Reporting adverse reactions to medications.
  • Reporting suspected abuse, neglect, or domestic violence.
  • Preventing or reducing a serious threat to the health or safety of any person.

Research

We may use or disclose your health information for health research when the required documentation establishes that an alteration to or waiver of individual authorization has been approved by an Institutional Review Board (IRB) or privacy board.

Compliance with the law

We will disclose your information when required by state or federal law. This includes disclosures to the U.S. Department of Health and Human Services when it seeks to verify compliance with federal privacy law.

Organ and tissue donation

We may disclose your health information to organ procurement organizations when appropriate.

Medical examiners, coroners, and funeral directors

When an individual dies, we may disclose health information to a coroner, medical examiner, or funeral director as permitted by law.

Workers’ compensation, law enforcement, and government requests

We may use or disclose your health information:

  • For workers’ compensation claims.
  • For law enforcement purposes or to law enforcement officials.
  • To health oversight agencies for activities authorized by law.
  • For special government functions, including military, national security, and presidential protective services.

Lawsuits and legal proceedings

We may disclose your health information in response to a court or administrative order or a subpoena, as permitted by law.

Additional information

Certain disclosures are subject to specific legal requirements and conditions. For more information about federal health information privacy protections, visit:

https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

4. Our Responsibilities

We are required by law to:

  • Maintain the privacy and security of your protected health information.
  • Notify you promptly if a breach occurs that may have compromised the privacy or security of your information.
  • Follow the duties and privacy practices described in this notice.
  • Provide you with a copy of this notice.

We will not use or disclose your health information for purposes other than those described in this notice unless you give us written permission, except as otherwise permitted or required by law.

If you authorize a use or disclosure in writing, you may change your mind at any time. Please notify us in writing if you wish to withdraw your permission.

For additional information about HIPAA privacy notices, visit:

https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

5. Changes to This Notice

We may change the terms of this notice. Any changes will apply to all health information we maintain about you.

The revised notice will be available upon request, in our office, and on our website.

6. Privacy Officer and Contact Information

If you have questions about this notice, would like more information about our privacy practices, or wish to file a complaint, please contact:

Pat Kirsner, Privacy Officer

Ronald M. Kirsner, M.D., P.A.

9822 Tapestry Park Circle, Unit 206
Jacksonville, Florida 32246

Phone: (904) 564-2232
Fax: (904) 207-7897

7. Additional Protections Under Florida Law

Under Florida law, we will not disclose treatment records relating to the following areas without your written permission unless a legal exception applies:

  • Alcohol and substance abuse.
  • Genetic testing.
  • HIV/AIDS.
  • Mental health.

These additional protections apply subject to the exceptions provided by applicable law.

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