HIPAA Privacy Notice

NOTICE OF PRIVACY PRACTICES

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.

I. Who We Are

This Notice describes the privacy practices of your medical billing company.

II. Our Privacy Obligations

We are required by law to maintain the privacy of your health information ("Protected Health Information" or "PHI") and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

III. Permissible Uses and Disclosures Without Your Written Authorization

In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:

A. Uses and Disclosures for Medical Billing Operations. We may use and disclose PHI, but not your "Highly Confidential Information" (defined in Section IV. C below), in order to treat you, obtain payment for equipment and services provided to you and conduct our "healthcare operations" as detailed below:

ยท         Payment. We may use and disclose your PHI to obtain payment for equipment and services that we provide to you -- for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your healthcare (Your Payor") to verify that Your Payor will pay for healthcare.

B. Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure. If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person?s involvement with your healthcare or payment related to your healthcare. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.

C. Public Health Activities. We may disclose your PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U. S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work- related illnesses and injuries or workplace medical surveillance.

D. Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.

E. Health Oversight Activities. We may disclose your PHI to a health oversight agency that oversees the healthcare system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

F. Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

G. Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.

H. Decedents. We may disclose your PHI to a coroner or medical examiner as authorized by law.

I. Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

J. Research. We may use or disclose your PHI without your consent or authorization if an Institutional Review Board or Privacy Board approves a waiver of authorization for disclosure.

K. Health or Safety. We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person?s or the public?s health or safety.

L. Specialized Government Functions. We may use and disclose your PHI to units of the government with special functions, such as the U. S. military or the U. S. Department of State under certain circumstances.

M. Workers' Compensation. We may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers compensation or other similar programs.

N. As Required by Law. We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.

IV. Uses and Disclosures Requiring Your Written Authorization

A. Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III, we only may use or disclose your PHI when you grant us your written authorization ("Your Authorization"). For instance, you will need to execute an authorization before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved.

B. Marketing. We must also obtain your written authorization ("Your Marketing Authorization") prior to using your PHI to send you any marketing materials. In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.

C. Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law require special privacy protections for certain highly confidential information about you ("Highly Confidential Information"). We will comply with such special privacy protections which may cover the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment and referral; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult with a disability; (9) is about sexual assault; or (10) is about abortion.

V. Your Rights Regarding Your Protected Health Information

A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Physician and Patient Relations Department. You may also file written complaints with the Director, Office for Civil Rights of the U. S. Department of Health and Human Services. Upon request, the Physician and Patient Relations Department will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.

B. Right to Request Restrictions. You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and healthcare operations; (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care; or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for restrictions carefully, we are not required to agree to a requested restriction. If you wish to request restrictions, please submit a written request to our Physician and Patient Relations Department. A form to request restrictions is available upon request from the Physician and Patient Relations Department.

C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.

D. Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Physician and Patient Relations Department identified below. A form of written revocation is available upon request from the Physician and Patient Relations Department.

E. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please submit a written request to the Physician and Patient Relations Department. You may obtain a record request form from the Physician and Patient Relations Department and submit the completed form to the Physician and Patient Relations Department. Requests for a copy of a limited amount of your medical or billing records (e. g., a prescription) maintained by us on- site may be made orally to our local facility. We may, however, require that you submit a written request to the Physician and Patient Relations Department.

F. Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please send a written request for the amendment, including the reason for the amendment, to the Physician and Patient Relations Department. You may obtain a form to request an amendment from the Physician and Patient Relations Department. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

G. Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.

H. Right to Receive Paper Copy of This Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.

VI. Effective Date and Duration of This Notice

A. Effective Date. This Notice is effective as of September 1, 2005.

B. Right to Change Terms of This Notice. We reserve the right to, meaning we may, change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice on our Internet site. You also may obtain any new notice by contacting the Physician Online Inc via the Contact Us page.

VII. Physicians Online Inc.

You may contact the Physicians Online Inc:

Physician Online Inc
6820 Southpoint Pkwy. Suite 6
Jacksonville, FL 32216
Telephone Numbers:
(800) 721-9545
(904) 281-0944

ACKNOWLEDGMENT

 

Please acknowledge your receipt of this Notice of Privacy Practices by filling in the requested information below, signing it and returning it to:

Physician Online Inc
6820 Southpoint Pkwy. Suite 6
Jacksonville, FL 32216

Printed Name:  __________________________________________________
Street Address: __________________________________________________
City:_____________________________________ State: _______ Zip: _______
Signature: ______________________________________________________