Jacksonville Beaches Medical Imaging
Southside Medical Imaging
Jacksonville Medical Imaging
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.
If you have any questions about this notice, please contact our Privacy Officer
Cathy Blaese
904.241.7772
This Notice
of Privacy Practices describes how we may use and disclose your protected health
information to carryout treatment, payment or healthcare operations and for
other purposes that are permitted or required by law.
It also describes your rights to access and control you protected health
information. “Protected health
information” is information about you, including demographic information, that
may identify you and that relates to your past, present or future physical or
metal health condition and related healthcare services.
We are required by law to give
you this notice. It will tell you about the ways in which we may use and
disclose health information about you and describes your rights and our
obligations regarding the use and disclosure of that information.
You will be asked to sign a
consent form giving Jacksonville Beaches Medical Imaging, Southside Medical
Imaging and Jacksonville Medical Imaging
permission to use and disclose your protected health information for treatment,
payment and healthcare operations.
Following are examples of the types of uses and disclosures of your protected
healthcare information that we are permitted to make once you have signed the
consent form. Any other use or
disclosure of your protected health information will be made only upon your
written authorization unless otherwise permitted or required by law (see Other
Uses and Disclosures below).
We will use health information about you to provide you with medical treatment
or services. We may disclose health information about you to doctors, nurses,
technicians, office staff or other personnel who are involved in taking care of
you and who have already obtained your permission to have access to your
protected health information. For
example, we will disclose your protected health information, as necessary, to
the physician that referred you to our facility.
We will also disclose protected health information to other physicians or
healthcare providers (e.g., a specialist or hospital) who, at the request of
your physician, becomes involved in your healthcare.
We may use and disclose health information about
you so that the treatment and services you receive at this office may be billed
to and payment may be collected from you, an insurance company or a third party.
For example, we may need to give your health plan information about a service
you received here so your health plan will pay us or reimburse you for the
service. We may also tell your health plan about a treatment you are going to
receive to obtain prior approval, or to determine whether your plan will cover
the treatment.
For
Healthcare Operations
We may use and disclose health information about
you in order to run our office and make sure that you and our other patients
receive quality care. For example, we may use your health information to
evaluate the performance of our staff in caring for you. We may also use health
information about all or many of our patients to help us decide what additional
services we should offer or how we can become more efficient.
We may use or disclose health information about you
without your permission for the following purposes, subject to all applicable
legal requirements and limitations:
Required By Law –
We will disclose health
information about you when required to do so by federal, state or local law.
Workers' Compensation –
We may release health
information about you for workers' compensation or similar programs. These
programs provide benefits for work‑related injuries or illness.
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. Subject to all applicable legal
requirements, we may also disclose health information about you in response to a
subpoena.
Information Not Personally
Identifiable –
We may use or disclose health information about you in a way that does not
personally identify you or reveal who you are.
Family and Friends –
We may disclose health
information about you to your family members or friends if we obtain your verbal
agreement to do so or if we give you an opportunity to object to such a
disclosure and you do not raise an objection. We may also disclose health
information to your family or friends if we can infer from the circumstances,
based on our professional judgment, that you would not object. For example, we
may assume you agree to our disclosure of your personal health information to
your spouse when you bring your spouse with you into the exam room during your
examination or while your examination is discussed. In situations where you are
not capable of giving consent (because you are not present or due to your
incapacity or medical emergency) we may also use our professional judgment and
experience to make reasonable inferences that it is in your best interest to
allow another person to act on your behalf, for example, to pick up your medical
records or x‑rays.
Health Oversight Activities –
We may disclose health
information to a health oversight agency for audits, investigations,
inspections, or licensing purposes. These disclosures may be necessary for
certain state and federal agencies to monitor the health care system, government
programs, and compliance with civil rights laws.
Military, Veterans, National Security and Intelligence
–
If you are or were a member of the
armed forces, or part of the national security or intelligence communities, we
may be required by military command or other government authorities to release
health information about you. We may also release information about foreign
military personnel to the appropriate foreign military authority.
We will not use or disclose your health information for any purpose other than
those identified in the previous section without your specific, written
Authorization. We must obtain your
Authorization separate from any
Consent we may have obtained from you.
If you give us Authorization to use or
disclose health information about you, you may revoke that
Authorization, in writing, at any
time. If you revoke your Authorization,
we will no longer use or disclose information about you for the reasons
covered by your written Authorization,
but we cannot take back any uses or disclosures already made with your
permission.
You have the following rights regarding health information we maintain about
you:
You have the right to inspect and obtain a copy of your health
information, such as medical and billing records, that is in your medical record
chart maintained at our office. You must submit a written request to a member of
our staff in order to inspect and/or receive a copy of your health information.
We are required to comply with your request within 30 days.
If you request a copy of the information, we may charge a fee for the
costs of copying, mailing or other associated supplies. We may deny your request
to inspect and/or copy in certain limited circumstances. If you are denied
access to your health information, you may ask that the denial be reviewed.
Please contact our Privacy Officer if you have questions about access
to your medical record.
Right to Amend
If you believe 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 our office keeps the information.
To request an amendment, complete and submit a
Medical Record Amendment/Correction Form to our Privacy Officer. 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:
a) We did not create, unless the person or entity that created the information is no longer available to make the amendment.
b) Is not part of the health
information that we keep as a part of your medical record.
c) You would not be permitted to
inspect and copy.
You have the right to request an "accounting of disclosures." This
is a list of the disclosures we made of medical information about you for
purposes other than treatment, payment and health care operations. To
obtain this list, you must submit your request in writing to
our Privacy Officer. It must
state a time period, which may not be longer than six years and may not include
dates before April 14, 2003. Your request should indicate in what form you want
the list (for example, on paper, electronically). 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.
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. For example, you could ask that we not
disclose information about an examination you had to a specific physician or
insurance company. You also have the right to request that any part of your
protected health information not be disclosed to family members or friends who
are involved in your care. We are
not required to agree to your request if there is reason to believe it is in
your best interest to permit use and disclosure of your protected health
information. If we do agree to the
requested restriction, we will comply with your request unless the information
is needed to provide you emergency treatment.
To request restrictions, you must complete and submit
a
Request For Restricting Uses and Disclosures of Protected Health Information
form
to our Privacy Officer.
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.
To request confidential communications, you must complete and submit
the
Requests For Restricting Confidential Communications
to
our Privacy Officer.
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.
You have the right to a paper copy of this notice. You may ask us
to give you a copy of this notice at any time. Even if you have agreed to
receive it electronically, you are still entitled to a paper copy. To obtain
such a copy, contact any member of our staff or our Privacy Officer.
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and 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 in the office with its effective date in the top right hand
corner. You are entitled to a copy of the notice currently in effect.
COMPLAINTS
If you believe your
privacy rights have been violated, you may file a complaint with our office or
with the Secretary of the Department of Health and Human Services. To file a
complaint, contact Cathy Blaese, Privacy
Officer, 904.241.7772 or request a
How to File a Health Information Privacy Complaint
guide from a staff member. You
will not be penalized for filing a complaint.