904-739-0050

Bahri Orthopaedics

Privacy

Bahri Orthopedics and Sports Medicine Clinic, P.L.

6100 Kennerly Road, Suite 101, Jacksonville, Fl 32216
1045 Riverside Avenue, Suite 110, Jacksonville, Fl 32204
3316 3rd St , Suite 201, Jacksonville Beach, Fl 32250

HIPAA NOTICE OF PRIVACY PRACTICES

Effective Date: April 1, 2003

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW IT CAREFULLY


If you have any questions about this notice, please contact our Practice Administrator at (904) 739-0050.

OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you.

  • make sure that health information that identifies you is kept private;
  • give you this notice of our legal duties and privacy practices with respect to health information about you; and
  • follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose health information.

For Treatment: We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices, at the hospital if you are hospitalized under our supervision, or at another doctor's office, lab, pharmacy, or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes.

For Payment: We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or a third party.

For Health Care Operations: We may use and disclose health information about you for operations of our health care practice. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care.

Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an appointment. Please let us know if you do not wish to have us contact you by telephone voice mail concerning your appointment, or if you wish to have us use a different telephone number to contact you for this purpose.

As Required By Law. We will disclose health information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Military and Veterans: If you are a member of the armed forces or separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities

Workers Compensation: We may release health information about you for Workers Compensation or similar programs.

Public Health Risks: We may disclose health information about you for public health activities. These activities generally include the following:

  • to prevent or control disease, injury or disability;
  • to report births and deaths;
  • to report child abuse or neglect;
  • to report reactions to medications or problems with products;
  • to notify people of recalls of products they may be using;
  • to notify person or organization required to receive information on FDA-regulated products;
  • 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;
  • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release health information if asked to do so by a law enforcement official:

  • in reporting certain injuries, as required by law, gunshot wounds, burns, injuries to perpetrators of crime;
  • in response to a court order, subpoena, warrant, summons or similar process;
  • to identify or locate a suspect, fugitive, material witness, or missing person:
  • about the victim of a crime, if the victim agrees to disclosure or under certain limited circumstances, we are unable to obtain the person's agreement;
  • about a death we believe may be the result of criminal conduct;
  • about criminal conduct at our facility; and
  • in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.

Coroners, Health Examiners and Funeral Directors: We may release health information to a coroner or health examiner. We may also release health information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates: If you are an inmate of a correctional institution or under the custody of a law.

Enforcement official, we may release health information about you to the correctional institution or law enforcement official.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billing records. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to Practice Administrator, Bahri Orthopedics and Sports Medicine Clinic, P.L. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing, submitted to Practice Administrator, Bahri Orthopedics and Sports Medicine Clinic, P.L., and must be contained on one page of paper legibly handwritten or typed in at least 10 point font size. In addition, you must provide a reason that supports your request for an amendment. 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 health information kept by or for our practice;
  • is not part of the information which you would be permitted to inspect and copy; or
  • is accurate and complete.

Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures: You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described.

To request this list of disclosures, you must submit your request in writing to Practice Administrator, Bahri Orthopedics and Sports Medicine Clinic, P.L. Your request must state a time period which may not be longer than six years and may not include dates before April 1, 2003. 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 will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.

Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend.

We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to Practice Administrator, Bahri Orthopedics and Sports Medicine Clinic, P.L. In your request, you must tell us what information you want to limit and to whom you want the limits to apply.

Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location.

To request confidential communications, you must make your request in writing to Practice Administrator, Bahri Orthopedics and Sports Medicine Clinic, P.L. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from Practice Administrator, Bahri Orthopedics and Sports Medicine Clinic, P.L. You may also obtain a copy of this notice from our website, www.BahriOrthopedics.com.

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 health 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 in our facility. The notice will contain on the first page, in the top right-hand corner, the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact Practice Administrator, Bahri Orthopedics and Sports Medicine Clinic, P.L. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. 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.

Acknowledgement of Receipt of this Notice

We will request that you sign a separate form or notice acknowledging you have received a copy of this notice. If you choose, or are not able to sign, a staff member will sign their name, date. This acknowledgement will be filed with your records.

 

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Acknowledgement of Receipt of Notice of Privacy Practices


I, _______________________________________, have received the Notice of Privacy

Practices from Bahri Orthopedics and Sports Medicine Clinic, P.L..


X Date: ________________


In lieu of patient signature, I, _______________________________________, a staff member of Bahri Orthopedics and Sports Medicine Clinic, P.L., state that _______________________________________ has been given our current Notice of Privacy Practices.


X Date: ________________

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