Privacy & Patient Rights

Your Information. Your Rights. Our Responsibilities.

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.

Effective Date:

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive from Family Physicians Group. We need this record to provide you with quality care and to comply with certain legal requirements.

This notice applies to all of the records of your care and billing for that care that are generated or maintained by Family Physicians Group, whether made by Family Physicians Group personnel or other health care providers. Other health care providers may have different policies or notices about confidentiality and disclosure that apply to your medical information that is created in their offices or at locations other than Family Physicians Group.

We are required by law to make sure that medical information that identifies you is kept private. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your medical information.

We will make a good faith effort to obtain a written acknowledgement that you received this Notice of Privacy Practice for Protected Health Information the first time we provide services to you after April 14,2003 or as soon as reasonably possible under the circumstances.

WHO WILL FOLLOW THIS NOTICE

This notice describes the practices of Family Physicians Group.

  • Any healthcare professional authorized to enter information into your medical record maintained by Family Physicians Group.
  • Any persons or companies with whom Family Physicians Group contracts for services to help operate our practice and who have access to your medical information.
  • All these persons, entities, sites, and locations follow the terms of this notice. In addition, these persons, entities, sites, and locations may share medical information with each other for treatment, payment, or health care operations purposes and other purposes described in this notice.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Note very use or disclosure in a category will be listed. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made in our office.

For Treatment

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, volunteers, or other personnel who are involved in taking care of you at Family Physicians Group. We also may disclose medical information about you to people outside Family PhysiciansGroup who may be involved in your medical care after you have been treated byFamily Physicians Group, such as friends, family members, or employees or medical staff members of any hospital or skilled nursing facility to which you are transferred or subsequently admitted.

For Payment

We may use and disclose medical information about you so that the treatment and services you receive from Family Physicians Group may be billed by FamilyPhysicians Group and payment may be collected from you, an insurance company,or a third party. We also may disclose information about you to another health care provider, such as a hospital or skilled nursing facility to which you are admitted, for their payment activities concerning you.

For Health Care Operations

We and our business associates may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run Family Physicians Group and make sure that all of our patients receive quality care. We may also combine medical information about many patients to decide what additional servicesFamily Physicians Group should offer, and what services are not needed. We may also disclose information to doctors,nurses, technicians, and other personnel affiliated with Family PhysiciansGroup for review and learning purposes.We may also combine the medical information we have with medical information from other health care providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study healthcare and health care delivery without learning the identities of specific patients. We also may disclose information about you to another healthcare provider for its healthcare operations purposes if you also have received care from that provider.

Treatment Alternatives

We may use and disclose medical information to tell you about or recommend different ways to treat you.

Research

Under certain circumstances, we may use and disclose medical information about you for research purposes. Medical information about you that has had identifying information removed may be used for research without your consent. We also may disclose medical information about you to people preparing to conduct a research project (for example, to help them look for patients with specific medical needs), as long as the medical information they review does not leave Family PhysiciansGroup. If the researcher will have information about your mental health treatment that reveals who you are, we will seek your consent before disclosing that information to there searcher. Unless we notify you in advance and you give us written permission, we will not receive any money or other thing of value in connection for using or disclosing your medical information for research purposes except for money to cover the costs of preparing and sending the medical information to the researcher.

Individuals Involved in Your Care or Payment for Your Care

We may release medical information about you to a friend or family member who is involved in your medical care.This would include persons named in any durable health care power of attorney or similar document provided to us.We may also give information to someone who helps pay for some or all of your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that someone who helps pay for some or all of your care. In addition,we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

You can object to these releases by telling us that you do not wish any or all individuals involved in your care to receive this information. If you are not present or cannot agree or object, we will use our professional judgement to decide whether it is in your best interest to release relevant information to someone who is involved in your care or to an entity assisting in a disaster relief effort.

As Required or Permitted By Law

We may disclose medical information about you when required or permitted to do so by Federal, State, or Local law.

To Avert a Serious Threat to Health or Safety.

We may use and disclose medical information about you when it appears necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.Any disclosure would be to someone who appears able to help prevent the threat and will be limited to the information needed.

DISCLOSURES ALLOWED IN SPECIALSITUATIONS

Organ and Tissue Donation.

If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation, or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

Military Activity and National Security

If you are an active duty member of the armed forces or Coast Guard,we must give certain information about you to your commanding officer or other command authority so that your fitness for duty or for a particular mission maybe determined. We may also release medical information about foreign military personnel to the appropriate foreign military authority. We may use and disclose to components of the Department ofVeterans Affairs medical information about you to determine whether you are eligible for certain benefits.

We may release without your consent medical information about you as required by applicable law to authorized Federal or State officials for intelligence, counter intelligence, or other governmental activities prescribed by law to protect our national security.

Worker's Compensation.

In accordance with state law, we may release without your consent medical information about your treatment for a work related injury or illness or for which you claim workers & compensation to your employer, insurer, or care manager paying for that treatment under a workers & compensation program that provides benefits for work related injuries or illness.

Inmates

We may use or disclose your health information if you are an inmate or a correctional facility and your physician created or received your information in the course of providing care for you.

Public Health Risks.

We may disclose without your consent medical information about you for public health activities. These activities generally include but are not limited to the following:

  • To report,prevent or control disease, injury, or disability;
  • To report birth sand deaths;
  • To report reactions to medications or problems with products;
  • To notify people of recalls of products they may be using;
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
  • To report suspected abuse or neglect as required by law.

Health Oversight Activities.

We may disclose without your consent medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licenser. The government uses these activities to monitor the health care system, government programs, and compliance with civil rights laws.

Food and Drug Administration.

We may disclose your protected health information to a person or company required by the FDA to report adverse events, product defects product recalls, or to make repairs or replacement.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, we must disclose medical information about you in response to a court or administrative order. We also may disclose medical information about you in response to a subpoena or other lawful process from someone involved in a civil dispute.

Law Enforcement

We may release without your consent medical information to a law enforcement official:

  • In response to a court order, warrant, summons, grand jury demand, or similar process;
  • To comply with mandatory reporting requirements for violent injuries, such as gunshot wounds,stab wounds, and poisonings;
  • In response to a request from law enforcement for certain information to help locate a fugitive,material witness, suspect, or missing person;
  • To report a death or injury we believe may be the result of criminal conduct; and
  • To report suspected criminal conduct committed at Family Physicians Group facilities.

Coroners and Medical Examiners

We may release without your consent medical information to a coroner or medical examiner. This may be done, for example, to identify a deceased person or determine the cause of death.We also may release medical information about deceased patients ofFamily Physicians Group to funeral directors to carry out their duties.

EXCEPTIONS TO ALLOWABLE DISCLOSURES

Regard less of the other parts of this Notice, psychotherapy notes will not be disclosed outside the Family Physicians Group except as authorized by you in writing or pursuant to a court order, or as required by law. Psychotherapy notes about you will not be disclosed to personnel working within Family Physicians Group, except for training purposes or to defend a legal action brought against Family PhysiciansGroup, unless you have properly authorized such disclosure in writing.

Federal and state law require special privacy protections for certain health information regarding drug and alcohol information, genetic testing information and HIV test results. We will abide by all applicable state and federal laws related to the protection of this information. In order for us to disclose any information that is entitled to special restrictions, we must obtain your separate, specific consent, unless we are otherwise permitted by law to make such disclosure.

YOUR RIGHTS REGARDING medical information ABOUT YOU

You have the following rights regarding medical information we maintain about you.

Right to Inspect and Copy

You have the right to inspect and receive a copy of your medical record unless your attending physician determines that information in that record,if disclosed to you, would be harmful to your mental or physical health. If we deny your request to inspect and receive a copy of your medical information on this basis, you may request that the denial be reviewed. Another licensed healthcare professional chosen by Family Physicians Group will review your request and the denial. The person conducting the review will not be the person who denied your request. We will do what this reviewer decides.

If we have all or any portion of your medical information in an electronic format, you may request an electronic copy of those records or request that we send an electronic copy to any person or entity you designate in writing.

Your medical information is contained in records that are the property of Family Physicians Group. To inspector receive a copy of medical information that may be used to make decisions about you, you must submit your request in writing to Family Physicians Group's Privacy Officer.

We may charge a fee.

For the costs of copying, mailing, or other supplies associated with your request, and we may collect the fee before providing the copy to you. If you agree, we may provide you with a summary of the information instead of providing you with access to it, or with an explanation of the information instead of a copy. Before providing you with such a summary or explanation, we first will obtain your agreement to pay and will collect the fees, if any, for preparing the summary or explanation.

Right to Amend

If you feel that medical information we have about you in your record is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Family Physicians Group.

To request an amendment, make your request in writing to Family Physicians Group&s Privacy Officer. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for Family Physicians Group;
  • Is not part of the information that you would be permitted to inspect and copy; or
  • Has been determined to be accurate and complete.
  • If we deny your request for an amendment, you may submit a written statement of disagreement and ask that it be included in your medical record.

We will notify you of the denial within 60 days of your request.

Right to an Accounting of Disclosures

You have the right to request a list of certain disclosures we have made of medical information about you during the past six years. To request this list or accounting of disclosures, submit your request in writing to Family Physicians Group's Privacy Officer and state whether you want the list on paper or electronically. Your request must state a time period that may not be longer than six years. The first list you request within a 12 month period will be free.For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We may collect the fee before providing the list to you.

Right to Request Restrictions

Except where we are required to disclose the information by law, you have the right to request a restriction or limitation on the medical information we use or disclose about you.For example, you could revoke any and all authorizations you previously gave us relating to disclosure of your medical information.

We are not required to agree to your request

With the exception of restrictions on disclosures to your health plan,as described below. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

To request restrictions, make your request in writing to FamilyPhysicians Group&s Privacy Officer. In your request, you must tell us

What information you want to limit;

Whether you want to limit our use, disclosure, or both

To whom you want the limits to apply, for example, disclosures to your spouse.

You may request that we not disclose your medical information to your health insurance plan for some or all of the services you receive during a visit to any Family PhysiciansGroup location. If you pay the charges for those services you do not want disclosed in full at the time of such service, we are required to agree to your request. In full means the amount we charge for the service, not your copay, coinsurance, or deductible responsibility when your insurer pays for your care. Please

note that once information about a service has been submitted to your health plan, we cannot agree to your request.If you think you may wish to restrict the disclosure of your medical information for a certain service, please let us know as early in your visit as possible.

Right to Request Confidential Communications.

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, or at another mailing address other than your home address. We will accommodate all reasonable requests. We will not ask you the reason for your request. To request confidential communications, make your request in writing to the Privacy Officer and specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this notice or any revised notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice,request a copy from Family Physicians Group&s Privacy Officer in writing.

CHANGES TO THIS NOTICE

We reserve the right to change this notice.We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at Family Physicians Group's office. The notice will contain the effective date on the first page, in the top right hand corner.If the notice changes, a copy will be available to you upon request.

INVESTIGATIONS OF BREACHES OFPRIVACY

We will investigate any discovered unauthorized use or disclosure of your medical information to determine if it constitutes a breach of the federal privacy or security regulations addressing such information. If we determine that such a breach has occurred, we will provide you with notice of the breach and advise you what we intend to do to mitigate the damage (if any) caused by the breach, and about the steps you should take to protect yourself from potential harm resulting from the breach.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Family Physicians Group or with the Secretary of the United StatesDepartment of Health and Human Services.

Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Ave. SW

HHH Building,Room 509H

Washington,DC 20201

To file a complaint with Family Physicians Group, contact our Privacy Officer by mail:

Family Physicians Group

Attn: Privacy Officer

6416 OldWinter Garden Rd.

Orlando, FL 32835

All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or as required by law may be made only with your written authorization or as required by law. If you authorize us to use or disclose medical information about you,you may revoke that authorization, in writing, at any time. Your revocation will be effective as of the end of the day on which you provide it in writing to Family Physicians Group&s Privacy Officer. If you revoke your permission, we will no longer use or disclose medical information about you for the purposes that you previously had authorized in writing. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

CONTACT INFORMATION

If you have any questions about this notice, please contact Family Physicians Group's Privacy Officer.

To request any of the above rights, or for further information about thisPrivacy Notice, please contact Family Physician Group&s Privacy Officer:

Family Physicians Group

Attn: Privacy Officer

6416 OldWinter Garden Rd.

Orlando, FL 32835

855-244-2345

privacy@fpg-florida.com