Notice of Privacy



This notice describes how personal and medical information about you may be used and disclosed, and how you can gain access to this information.

Please read it carefully

Protected Health Information (PHI) is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information that may identify you and relates to your past, present, or future physical or mental health condition and related healthcare services.

The health care providers and staff of Family Health Source are required to follow specific rules on maintaining the confidentiality of your PHI, using information and disclosure, or sharing this information with other healthcare professionals involved in your care and treatment. This notice describes your rights to access and control your PHI. This notice also acknowledges our responsibility and legal obligation to protect your personal and medical information and describes your rights concerning our use of that information.

Your Rights Under the HIPAA Privacy Rule
The following is a list of your rights, under the HIPAA Privacy Rule, in reference to your PHI.

  1. You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices. We are required to follow the terms of this Notice. We reserve the right to change the term of this Notice at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices. The Notice will be posted in a conspicuous location within the organization and posted on our website.
  2. You have the right to authorize other use and disclosures of your PHI that is not specified in this Notice. We would need your written authorization to use or disclose your PHI for marketing purposes, for most uses of disclosures of psychotherapy notes or if we intended to sell your PHI. You may revoke this authorization at any time, in writing.
  3. You have the right to request an alternate means of confidential communication. You have the right to ask us to contact you about your health information using an alternate method (email, phone) and to an alternate destination (cell phone, alternate address) designated by you. You must inform us of this request in writing on a form provided by our organization. We will follow all reasonable request.
  4. You have the right to inspect and receive a copy of your PHI. You may review and obtain a copy of your complete health record. We have the right to charge a fee for paper or electronic copies of health records as established by state or federal guidelines.
  5. You have the right to request an amendment to your PHI. You may request an amendment to your PHI as long as the health record is maintained by our organization. In certain cases, we may deny your request.
  6. You have the right to request a restriction to your PHI. You may request a restriction, in writing, not to use or disclose any part of your PHI for the purposes of treatment, payment, or healthcare operations. If accepted, we will enforce the restriction except in emergency situations when the information is needed for your treatment. In certain cases, we may deny your request. You may request, in writing, that we restrict communication with your health plan for treatment or services that have been paid for in full, out of pocket. We are not permitted to deny this type of requested restriction.
  7. You have the right to request disclosure accountability. You may request a list of disclosures that we have made of your PHI to persons or entities outside our organization.
  8. You have the right to receive a privacy breach notice. You have the right to receive written notification if our organization discovers a privacy breach of your PHI and determines through a risk assessment that notification is required.

How we may use or disclose your Protected Health Information (PHI)
The following is a list of ways we may use or disclose your PHI that does not require written authorization.

  1. Treatment. We may use or disclose your PHI to provide, coordinate or manage your healthcare and any related services. This includes the coordination and management of your healthcare with a third party that is involved in care and treatment. This would also include the pharmacy that would fill your prescriptions and any other healthcare providers that may be involved in your healthcare services.
  2. Payment. Your PHI will be used, as needed, to determine eligibility or coverage for insurance benefits and to obtain payments for your healthcare services.
  3. Healthcare Operations. We may use or disclose your PHI, as needed, to support the business activities of our organization. This may include, but not limited to, business planning and development, quality assessment and improvement, medical reviews, legal services auditing functions and patient safety activities.
  4. Special Notices. We may use your PHI, as necessary, to contact you by phone or other means, including our patient portal, to remind you of your appointments, to provide you with lab results or results of other diagnostic testing, or to provide information that describes or recommends treatment plans or alternatives regarding your care. We may also contact you to provide information about health-related benefits and services offered by our organization, fundraising activities or to disclose information regarding a group health plan. You have the right to opt-out of such special notices.
  5. Health Information Organization. The organization may choose to use a health information organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.
  6. To Others Involved in Your Healthcare. We may disclose your PHI to a family member, friend, or any other person that you identify that directly relates to that person’s involvement in your healthcare (Limited Patient Authorization for Disclosure of PHI to An Individual Form). If you are not present, unable to agree, or object to such a disclosure, we may disclose the necessary information we determine is in your best interest based on our professional judgment. We may use your PHI to notify or assist in notifying a family member, personal representative or other person that is responsible for your care of your general condition or death. Only PHI that is necessary will be disclosed.
  7. Other Permitted and required Users and Disclosers. We are also permitted to use or disclose your PHI without your written authorization for the following purposes:
    • As required by law (any information limited to the relevant requirements of the law)• For public health activities (disease control, vital statistics, public health)
    • Health oversight activities (adults, civil, criminal, or administrative investigations)
    • To report cases of abuse, neglect, or domestic violence
    • To comply with Food and Drug Administration requirements
    • Research purposes
    • Judicial and administrative proceedings (in response to a court order)
    • Law enforcement purposes
    • To coroners, medical examiners, and funeral directors (identifying disease process or cause of death)
    • For organ or tissue donation (with regards to military personnel, veterans, national security purposes, or when an inmate in a correction facility)
    • Worker’s compensation (to the extent necessary to comply with applicable laws)
    • To avert serious threats to health or safety
    • If requested by the Department of Health Services in order to investigate or determine our compliances with the requirement of the Privacy Rule.

Complaints/Grievance: If you feel we have violated your privacy of rights, or have questions concerning our Notice of Privacy Practices, you may contact or file a written complaint to the following address: Family Health Source Administration, 1205 S Woodland Blvd, DeLand, FL 32720 or with the federal agency in charge of enforcing patient’s privacy rights. That address is: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue S.W. Room 509F, HHS Building, Washington D.C. 20201.

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