Notice of Privacy Practices

Effective Date: May 1, 2013
Revised Date: August 2, 2021

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.

Uses and Disclosures: We may use or share your health information in the following ways:

Without Your Signed Authorization:

• For treatment, payment and health care operations

• • Example for treatment: Your physician refers you to a specialty doctor for continuing treatment. Your physician may send your medical records to the referring physician to help in the treatment plan for your condition. Your information may also be shared with other healthcare providers or facilities utilizing an interface known as the healthcare exchange. Another way your information may be shared is through your pharmacy benefits to help better manage your medications and prevent adverse reactions.
  • Example for payment: A bill may be sent to a third-party payer. The information on the bill may include information that identifies you, as well as your diagnosis, the procedures and supplies used.
  • Example for healthcare operations: Members of the medical staff, the Risk Manager, Quality Improvement Manager, or other quality improvement team member may use your health information to assess the care and outcome in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare services that we provide. Another way we may use your health information is to conduct or arrange for a medical review, legal services or for an audit for compliance training.
• When a release is required by law, including judicial proceedings, health oversight regulatory agencies and law enforcement. This may also include sharing your information with Health and Human Services for compliance purposes.
• To medical examiners, coroners, funeral directors and research.
• In an emergency situation or to avert a serious threat to health or safety.
• To organ, tissue or other donation organizations if there is no indication in your record on how to harvest your organs.
• Under certain circumstances, we may use and disclose limited medical information about you for research or quality improvement purposes within our organization. For example, clinicians may request our clinical research staff to review your medical information to see if you would be eligible for a study.
• To worker’s compensation and other programs providing benefits for work-related injuries or illnesses.
• For public health and safety issues: to help with product recall; to report suspected cases of abuse, neglect or domestic violence; to prevent or reduce a serious threat to anyone’s health or safety; and for preventing disease.
• For special government functions such as military, national security and presidential protective services.
• For response to court or administrative order, or in response to a subpoena.

Special Cases:

• Appointment Reminders: We may contact you by paper, phone, email or leave a message to remind you of an upcoming appointment or that you’re due for a preventative service, or request that you call the office.
• Treatment Alternatives: We may use or disclose your medical information to tell you about or recommend treatment options or alternatives.
• Health Related Benefits and Services: We may use your medical information to contact you and offer other health-related services or medical education that may be of interest to you.

Your Rights:  You have the following rights concerning your protected health information (PHI):

• Request restricted access to all or part of your information:
  • You can ask us not to use or share certain health information for treatment, payment or healthcare operations.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or operations with your health insurer.
• To receive correspondence of confidential information by alternate means or location (Example: records to be mailed to a work address instead of the home address).
• To receive copies of your health information. A processing fee for copies may apply. Fees determined by state regulations.
• To request changes to be made to your health information.
• To receive a report (accounting of disclosures) that shows who we’ve shared your information with the six years prior to your request. Exceptions of disclosures may include those disclosures for treatment, payment and healthcare operations.
• To request access to your information.
• To get updates or reissue of this notice, at your request.
• You may give a personal representative, such as a medical power of attorney or legal guardian, authorization to exercise your rights and make choices about your health information.
• To file a complaint against our practice if you feel we have violated your rights or privacy.
• The individual will submit all requests in writing to the health care organization to the address listed below.
• We will respond to your requests:
  • 30 days: for request to access or receive copies of health information on paper; for request to make changes to your information; and request for a disclosure report.
  • 10 days: for request to access or receive copies of your health information electronically.

Healthcare Organization:  This organization is required to:

• Maintain the privacy of your protected health information.
• Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
• Abide by the terms of the notice currently in effect.
• Notify you if we are unable to agree to a requested restriction.
• Accommodate reasonable requests you may have to communicate health information by alternative means.
• Notify you of a breach involving your unsecured protected health information (PHI).

Intercoastal Medical Group, Inc. reserves the right to change practices and to make the new provisions effective for all protected health information maintained. Should the information change, Intercoastal will provide you the revised notice.

Any other use or disclosure of protected health information not listed above will be made only with the individual’s written authorization, this includes: use or disclosure for marketing purposes; selling of your information; sharing your information with your family, friends or others involved in your care; sharing your information for disaster relief situation; and including your information in a hospital directory. The individual has the right to revoke such authorization at any time by sending the request in writing to the address below.

To File a Complaint or Contact a Company Representative: If you have questions or feel that your privacy rights have been violated, you can contact the Privacy Officer or the Office for Civil Rights. The law forbids us from taking retaliatory action against you if you complain.

Company Representative: Privacy Officer
Address: 943 South Beneva Road, Suite 306, Sarasota, FL 34232
Phone: (941) 955-1108 ext. 1011

The Office for Civil Rights (OCR)
U.S. Department of Health and Human Services
200 Independence Avenue S.W.
Washington D.C. 20201
Phone: (877) 696-6775
https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf