Notice of Privacy Practices

Original Effective Date: August 1, 2012

Effective Date of Last Revision (if any) _______________________________

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.

A federal regulation, known as the “HIPAA Privacy Rule,” requires that we provide detailed notice in writing of our privacy practices. We know that this Notice is long. The HIPAA Privacy Rule requires us to address many specific things in this Notice.

I. Our Commitment to Protecting Health Information About You

In this Notice, we describe the ways that we may use and disclose health information about our patients. The HIPAA Privacy Rule requires that we protect the privacy of health information that identifies a patient, or where there is a reasonable basis to believe the information can be used to identify a patient. This information is called “protected health information” or “PHI”. We are required by law to:

.Maintain the privacy of PHI about you; · Give you this Notice of our legal duties and privacy practices with respect to PHI; and · Comply with the terms of our Notice of Privacy Practices that is currently in effect.

We reserve the right to make changes to this Notice and to make such changes effective for all PHI we may already have about you. If and when this Notice is changed, we will post a copy in our office in a prominent location and on our Web site at www.health.com. We will also provide you with a copy of the revised Notice upon your request made to our Administrative Office.

II. How We May Use and Disclose Protected Health Information About You

Uses and Disclosures for Treatment, Payment, and Health Care Operations

The following categories describe the different ways we may use and disclose PHI for treatment, payment, or health care operations. The examples included with each category do not list every type of use or disclosure that may fall within that category.

Treatment: We may use and disclose PHI about you to provide, coordinate or manage your health care and related services. We may consult with other health care providers regarding your treatment and coordinate and manage your health care with others. For example, we may use and disclose PHI when you need a prescription, lab work, and x-ray, or other health care services. In addition, we may use and disclose PHI about you when referring you to another health care provider. For example, if you are referred to another physician, we may disclose PHI to your new physician regarding whether you are allergic to any medications.

We may also disclose PHI about you for the treatment activities of another health care provider. For example, we may send a report about your care from us to a physician that we refer you to so that the other physician may treat you.

Payment: We may use and disclose PHI so that we can bill and collect payment for the treatment and services provided to you. Before providing treatment or services, we may share details with you health plan concerning the services you are scheduled to receive. For example, we may ask for payment approval from your health plan before we provide care or services. We may use and disclose PHI to find out if your health plan will cover the cost of care and services we provide. We may use and disclose PHI to confirm you are receiving the appropriate amount of care to obtain payment for services. We may use and disclose PHI for billing, claims management, and collection activities. We may disclose PHI to insurance companies providing you with additional coverage. We may disclose limited PHI to consumer reporting agencies relating to collection of payments owed to us.

We may also disclose PHI to another health care provider or to a company or health plan required to comply with the HIPAA Privacy Rule for the payment activities of that health care provider, company, or health plan. For example, we may allow a health insurance company to review PHI for the insurance company’s activities to determine the insurance benefits to be paid for your care. Health Care

Operations: We may use and disclose PHI in performing business activities, which are called health care operations. Health care operations include doing things that allow us to improve the quality of care we provide and to reduce health care things that allow us to improve the quality of care we provide and to reduce health care costs. We may use and disclose PHI about you in the following health care operations:

Reviewing and improving the quality, efficiency and cost of care that we provide to our patients. For example, we may use PHI about you to develop ways to assist our physicians and staff in deciding how we can improve the medical treatment we provided to others. ·

Providing training programs for students, trainees, health care providers, or non-health care professionals (for example, billing personnel) to help them practice or improve their skills. ·

Cooperating with various people who review our activities. For example, PHI may be seen by doctors reviewing the services provided to you, and by accountants, lawyers, and others who assist us in complying with the law and managing our business. ·

Assisting us in making plans for our practice’s future operations. ·

Resolving grievances within our practice. · Business management and general administrative activities of our practice, including managing our activities related to complying with the HIPAA Privacy Rule and other legal requirements. ·

Creating “de-Identified” information that is not identifiable to any individual.

If another health care provider, company, or health plan that is required to comply with the HIPAA Privacy Rule has or once had a relationship with you, we may disclose PHI about you for certain health care operations of that health care provider or company.

We may also disclose PHI for the health care operations of an “organized health care management” (HMO) in which we participate. An example of an “organized health care arrangement” is the joint care provided by a hospital and the doctors who see patients in the hospital.

Communication From Our Office: We may contact you to remind you of appointments and to provide you with information about treatment alternatives or other health related benefits and services that may be of interest to you.

Other Uses and Disclosures we can make without your Written Authorization

Uses and Disclosures For Which You Have The Opportunity To Agree or Object We may use and disclose PHI about you in some situations where you have the opportunity to agree or object to certain uses and disclosures of PHI about you. If you do not object, then we may make these types of uses and disclosures of PHI.

· Individuals Involved in Your Care or Payment for Your Care: We may Disclose PHI about you to your family member, close friend, or any other person identified by you if that information is directly relevant to the person’s involvement in your care or payment for your care. If you are present and able to consent or object (or if you are available in advance), then we may only use or disclose PHI if you do not object after you have been informed of your opportunity to object. If you are not present or you are unable to consent or object, we may exercise professional judgment in determining whether the use or disclosure of PHI is in your best interests. For example, if you are brought into this office and are unable to communicate normally with your physician for some reason, we may find it is in your best interest to give your prescription and other medical supplies to the friend or relative who brought you in for treatment. We may also use and disclose PHI to notify such persons of your location, general condition, or death. We also may coordinate with disaster relief agencies to make this type of notification. We also may use professional judgment and our experience with common practice to make reasonable decisions about your best interests in allowing a person to act on your behalf to pick up filled prescriptions, medical supplies, x-rays, or other things that contain PHI about you.

OTHER USES AND DISCLOSURES WE CAN MAKE WITHOUT YOUR WRITTEN AUTHORIZATION OR OPPORTUNITY TO AGREE OR OBJECT We may use and disclose PHI about you in the following circumstances without your authorization or opportunity to agree or object, provided that we comply with certain conditions that may apply.

Required by Law: We may use and disclose PHI as required by federal, state, or local law. Any disclosure complies with the law and is limited to the requirements of the law.

Public Health Activities: We may use or disclose PHI to public health authorities or other authorized persons to carry out certain activities related to public health, including the following activities:

To prevent or control disease, injury, or disability;

To report disease, injury, birth, or death; · To report child abuse or neglect;

To report reactions to medications or problems with products or devices regulated by the federal Food and Drug Administration or other activities related to qualify, safety, or effectiveness of FDA-regulated products or activities; ·

To locate and notify persons of recalls of products they may be using; ·

To notify a person who may have been exposed to a communicable disease in order to control who may be at risk of contracting or spreading the disease; or ·

To report to your employer, under limited circumstances, information related primarily to workplace injuries or illness, or workplace medical surveillance.

Abuse, Neglect, or Domestic Violence: We may disclose PHI in certain cases to proper government authorities if we reasonably believe that a patient has been a victim of domestic violence, abuse, or neglect.

Health Oversight Activities: We may disclose PHI to a health oversight agency for oversight activities including, for example, audits, investigations, inspections, licensure and disciplinary activities and other activities conducted by health oversight agencies to monitor the health care system, government health care programs, and compliance with certain laws.

Lawsuits and Other Legal Proceedings: We may use or disclose PHI when required by a court or administrative tribunal order. We may also disclose PHI in response to subpoenas, discovery requests, or other required legal process when efforts have been made to advise you of the request or to obtain an order protecting the information requested.

Law Enforcement: Under certain conditions, we may disclose PHI to law enforcement officials for the following purposes where the disclosure is:

About a suspected crime victim if, under certain limited circumstances we are unable to obtain a person’s agreement because of incapacity or emergency; ·

To alert law enforcement of a death that we suspect was the result of criminal conduct; ·

Required by law’ · In response to a court order, warrant, subpoena, summons, administrative agency request, or other authorized process’ ·

To identify or locate a suspect, fugitive, material witness, or missing person’ ·

About a crime or suspected crime committed at our office; or ·

In response to a medical emergency not occurring at the office, if necessary to report a crime, including the nature of the crime, the location of the crime or the victim, and the identity of the person who committed the crime.

Coroners, Medical Examiners, Funeral Directors: We may disclose PHI to a coroner or medical examiner to identify a deceased person and determine the cause of death. In addition, we may disclose PHI to funeral directors, as authorized by law, so that they may carry out their jobs.

Organ and Tissue Donation: If you are an organ donor, we may use or disclose PHI to organizations that help procure, locate, and transplant organs in order to facilitate an organ, eye, or tissue donation and transplantation.

Research: We may use and disclose PHI about you for research purposes under certain limited circumstances. We must obtain a written authorization to use and disclose PHI about you for research purposes except in situations where a research project meets specific, detailed criteria established by the HIPAA Privacy Rule to ensure the privacy of PHI.

To Avert a Serious Threat to Health or Safety: We may use or disclose PHI about you in limited circumstances when necessary to prevent a threat to the health or safety of a person or to the public. This disclosure can only be made to person who is able to help prevent the threat.

Specialized Government Functions: Under certain circumstances we may disclose PHI:

For certain military and veteran activities, including determination of eligibility for veterans for veterans benefits and where deemed necessary by military command authorities; ·

For national security and intelligence activities; ·

To help provide protective services for the president and others; ·

For the health or safety of inmates and others at correctional institutions or other law enforcement custodial situations for the general safety and health related to corrections facilities.

Disclosures required by HIPAA Privacy Rule: We are required to disclose PHI to the Secretary of the United States Department of Health and Human Services when requested by the Secretary to review our compliance with the HIPAA Privacy Rule. We are also required in certain cases to disclose PHI to you upon your request to access PHI or for an accounting of certain disclosures of PHI about you (those requests are described in Section III of this Notice).

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION REQUIRE YOUR AUTHORIZATION

Workers’ Compensation: We may disclose PHI as authorized by workers’ compensation laws or other similar programs that provide benefits for work-related injuries or illness.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION REQUIRE YOUR AUTHORIZATION

All other uses and disclosures of PHI about you will only be made with your written authorization. If you have authorized us to use or disclose PHI about you, you may revoke your authorization at any time, except to the extent we have taken action based on the authorization.

III. Your Rights Regarding Protected Health Information (PHI) About You

Under federal law, you have the following rights regarding PHI about you:

Right to Request Restrictions: You have the right to request additional restrictions on the PHI that we may use for treatment, payment and health care operations. You may also request additional restrictions on our disclosure of PHI to certain individuals involved in your care that otherwise are permitted by the Privacy Rule.

We are not required to agree to your request. If we do agree to your request, we are required to comply with our agreement except in certain cases, including where the information is needed to treat you in the case of an emergency. To request restrictions, you must make your request in writing to our Administration Office. In your request, please include (1) the information that you want to restrict; (2) how you want to restrict the information (for example, restricting use to this office, only restricting disclosure to persons outside this office, or restricting both); and (3) to whom you want those restrictions to apply.

Right to Receive Confidential Communications: You have the right to request that you receive communications regarding PHI in a certain manner or at a certain location. For example, you may request that we contact you at home, rather than at work. You must make your request in writing to our Administration Office. You must specify how you would like to be contacted (for example, by regular mail to your post office box and not your home). We are required to accommodate reasonable requests.

Right to Inspect and Copy: You have the right to request the opportunity to inspect and receive a copy of PHI about you in certain records that we maintain. This includes your medical and billing records but does not include psychotherapy notes or information gathered or prepared for a civil, criminal, or administrative proceeding. We may deny your request to inspect and copy PHI only in limited circumstances. To inspect and copy PHI please contact our Administrative Offices. If you request a copy of PHI about you, we will charge you a reasonable fee for the copying, postage, labor and supplies used in meeting your request. The minimal charge will be $30.00 payable prior to the inspection of the PHI.

Right to Amend: You have the right to request that we amend PHI about you as long as such information is kept by or for our office. To make this type of request you must submit your request in writing to our Administrative Office. You must also give us a reason for your request. We may deny your request in certain cases, including if it is not in writing or if you do not give us a reason for the request.

Right to Receive an Accounting of Disclosures: You have the right to request an “accounting” of certain disclosures that we have made of PHI about you. This is a list of disclosures made by us during a specified period of up to six years other than disclosures made: for treatment, payment, and health care operations; to family members or friends involved in your care; to you directly; pursuant to an authorization of you or your personal representative, or for certain notification purposes (including national security, intelligence, correctional, and law enforcement purposes) and disclosures made before April 14, 2003. If you wish to make such a request, please contact our Administrative Office identified on the last page of this Notice. The first list that you request in a 12-month period will be free, but we will charge you for our reasonable costs of providing additional lists in the same 12-month period. We will tell you about these costs, and you may choose to cancel your request at any time before costs are incurred.

Right to a Paper Copy of this Notice: You have a right to receive a paper copy of this Notice at any time. You are entitled to a paper copy of this Notice even if you have previously agreed to receive this Notice electronically.

A paper copy can be obtained at: ·

Our Web-site  www.mmghealth.com
The Habana Office at 4700 N. Habana Ave. Suite 201·
The North Tampa Office at 13801 Bruce B Downs Blvd., Suite 406

IV. Complaints

If you believe your privacy rights have been violated, you may file a complaint with us, or the Secretary of the United States Department of Health and Human Services. To file a complaint with our office, please contact, Anne Wilson, our Office Manager at the address and number listed below. We will not retaliate or take action against you for filing a complaint.

V. Questions

If you have any questions about this Notice, please contact our Administrative Office at the address and telephone number listed below.

VI. Administrative Office’s Contact Information

You may contact our Administrative Office at the following address and phone numbers:

For Information and Requests contact:

Rosie Flanders, Assistant Administrator
13801 Bruce B. Downs Blvd. Suite 406
Tampa, Fl 33614
(813) 345.2380

For Billing Related Questions contact:

Sheri Niego
13801 Bruce B. Downs Blvd. Suite 406
Tampa, Fl 33613-3946
(813) 345.2380

For Complaints in regards to Privacy Rights please contact:

Beverly Fernandez, Assistant Administrator
4700 N. Habana Ave. Suite 201
Tampa, Fl 33614
(813) 354.2380

For Research related Complaints Please contact:

Plessie DeForest, Regulatory Coordinator
4700 N. Habana Ave. Suite 303
Tampa, Fl 33614
(813) 354.2401

This notice was published and first became effective on August 1, 2012