Fuad Afzal, MD
P.O.Box 952951
Lake Mary, FL 32795
Phone: 407-896-1789 Fax: 407-896-1735
www.midfloridakidney.com

Patient Privacy Information (HIPPA)

NOTICE OF PRIVACY PRACTICES
Basically, except for discloser of information required by law or for billing purposes or patient management nothing can be disclosed without the signature of the patient as well as the signature of the attending physician.Information transfer will take at least 1 day to complete and transferred by mail unless you request in writing an alternative method. Signatures must be in writing on regular paper and electronic options including faxes and e-mail are not acceptable. For release of your information by our office, paper copies of a signature are as valid as the original.

The notice below will explain how we may use and disclose your medical information, our obligations related to the use and disclosure of your medical information, and your rights related to any medical information that we have about you. This notice applies to the medical records that are generated in or by our office.

With a few exceptions, we are required to obtain your authorization for the use or disclosure of the information. We have listed some of the reasons why we might use or disclose your medical information and some examples of the types of uses and disclosures below. Not every use or disclosure is covered.

In addition to the office, the following persons will also follow the practices described in this Notice of Privacy Practices: Any health care professional who is authorized to enter information in your medical records. In addition, they may share medical information for treatment, payment or healthcare operations as they are described in this Notice of Privacy Practices.

USE AND DISCLOSURE OF MEDICAL INFORMATION
We can use or disclose medical information about you regarding your treatment, payment for services, or for healthcare operations. We may also disclose your protected health care information for the treatment activities of another provider, the payment activities of another provider or covered entity, and certain limited healthcare operations of another covered entity.

FOR TREATMENT: To provide you with medical treatment and services, we may need to use or disclose information about you to doctors, nurses, technicians, or other healthcare personnel who are involved in your treatment. For example, a doctor may need to know what drugs you are allergic to before prescribing medications. We may also disclose medical information about you to people who may be involved in your medical care after you leave the office such as home health agencies, your family, a friend, Hospice employees, long term care facilities, and, if you request, your clergy member.

FOR PAYMENT: We may use and disclose your medical information to bill and receive payment for the treatment that you receive here. We may also ask your insurance company for prior approval for a service to determine whether the insurance company will pay for the service.

USES AND DISCLOSURES OF MEDICAL INFORMATION THAT DO NOT REQUIRE YOUR AUTHORIZATION: We can use or disclose health information about you without your authorization when there is a potential emergency, when we are required by law or statue, or when there are substantial communication barriers to obtaining authorization from you. Further, we may disclose your health information without your authorization in any of the following circumstances:
When necessary to contact you to provide: appointment notices, simple messages left noting test results OK, simple generic or routine management instructions delivered by email or voicemail as a reply to your email or voicemail or recent health management, when it is required by law, or required by regulations or statutes for public health activities, such as mandated disease reporting, etc. When reporting information about victims of abuse, neglect or domestic violence; when disclosing information for the purpose of health oversight activities, such as audits, investigations, licensures or actions or legal proceedings or actions and activity with a pharmacy relating to your potential medication. When disclosing information for law enforcement purposes, for instance, to locate or identify a suspect, fugitive, witness or missing person or regarding a victim of a crime who cannot give authorization because of incapacity; when disclosing information about deceased persons to medical examiners, coroners and funeral directors; when disclosing or using information for organ and tissue donation purposes; when we believe in good faith that the disclosure is necessary to avert a serious health or safety threat to you or to the public safety;

Disclosure or to which you may object:
We will use or disclose your health information for any of the purposes described in the above section unless you affirmatively object or otherwise restrict a particular release. You must direct your written objections or restrictions to the Privacy Site Coordinator who is ___________________ at our office address.

Other uses and Disclosures:
We will not use or disclose your health information without your written authorization except as described in this Notice of Privacy Practices. If you provide us with written authorization to use or disclose information, you can change your mind and revoke your authorization at any time, as long as it is in writing. If you revoke your authorization, we will no longer use or disclose the information. However, we will not be able to take back any disclosures that we have made pursuant to your previous authorization.

Your Health Information Rights:
Although your health record is the property of our office, you have the right to:
Request Restrictions: You have the right to request that we restrict any use or disclosure of your health information. We are not required to agree to any restriction that you request. If we do agree to adhere to your restrictions, we will comply with your request unless the information is needed to provide your treatment. Any request to restrict uses or disclosures must be made in writing to the Privacy Site Coordinator or the Our Office Corporate Privacy Officer. Your request must indicate: (1) what information you want limited; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.

Receive information in certain form and location: You have the right to receive information about your health in a certain form and location. For instance, you can request that we contact you at work. To request confidential communications, you must make your request in writing to the privacy Site Coordinator. The request must tell us how and/or where you want to receive information. We will attempt to accommodate reasonable requests.

Inspect and copy your protected health information: You have the right to inspect and request a copy of your protected health information that may be used to make decisions about your care, with the exception of psychotherapy notes. If you want to see or copy your medical information, you must submit your request in writing to the office Privacy Officer. If you request copies of information, we may charge the standard fee for any costs associated with your request, including the cost of copies, mailing, or other supplies as set by Missouri statues and regs.

*** NOTE: We can deny your request if it is not in writing and if it does not include why the information should be changed. We can also deny your request for the following reasons: (1) the information was not created by our office or unless the person or entity that did create the information is no longer available; (2) the information is not part of the medical record kept by or for our office, or (3) the information is not part of the medical record that you would be permitted to inspect and copy; or (4) we believe the information is accurate and complete.

Complaints: If you believe that we have violated any of your privacy rights or to have not adhered to the information contained in this Notice of Privacy Practices, you can file a complaint by putting it in writing and sending it to the Office or Privacy Site Coordinator. You may also file a complaint with Secretary of the US Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, DC 20201. To acquire a copy of the complaint form from the Office of Civil Rights please call 1-800-368-1019.

Changes to this Notice of privacy Practices: We reserve the right to change or modify the information contained in this Notice of Privacy Practices. Any changes that we can make can be effective for any health information that we can have about you and any information that we might obtain. The most recent version of our Notice of practices will be with the office receptionist or can be obtained from our office.

If you have any questions about the content of this Notice of privacy Practices, or if you need to contact someone at this site about any of the information contained in this Notice of Privacy Practices, please contact:
Privacy Site Coordinator is _______________________, via our office phone or address.