Notice of Privacy Practices




We are required by applicable federal and state law to maintain the privacy of protected health information. We are also required to give you this Notice of our privacy practices our legal duties, and your rights concerning your health information. We are required to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 10/01/2013, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this notice.


We use and disclose health information about you for treatment, payment, and healthcare operations. Some information, such as HIV-related information, genetic information, alcohol and substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal laws. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. Payment activities involve billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in affect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Persons Involved in Care: We may use or disclose health information to notify or assist in the notification (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use and disclosure of your health information, we will provide you with an opportunity to object to such uses and disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Public Health Activities: We may disclose your health information for public health activities including disclosures to prevent or control disease, injury, or disability, report child abuse or neglect, or to report reactions to medications or problems with products/ devices. We may disclose your health information to notify a person of a recall, repair, or replacement of products or devices, to notify a person who may have been exposed to a disease or condition or to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information of inmates or patients under certain circumstances.

Worker’s Compensation: We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Law Enforcement: We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.                          

Health Oversight Activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose your health information 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 instituted by someone else involved in the dispute, but only if it efforts have been made, either by requesting by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Research: We may disclose your health information to researchers when their research has been approved by an institution review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy or your information.

Coroners, Medical Examiners, and Funeral Directors: We may release your health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose your health information to funeral directors consistent with applicable law to enable them to carry out their duties.

Fundraising: We may contact you to provide you with information about our sponsored activities, including fundraising programs as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.

Appointment Reminders: We may use or disclose your health information or provide you with appointment reminders (such as voicemail messages, postcards, or letters).

Other Uses and Disclosures of Health Information: Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of health information for marketing, and for the sale of health information. We will also obtain your written authorization before using or disclosing your health information for purposes other than those provided for in this notice (or as otherwise permitted or required by law). You make revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your health information, except to the extent that we have already taken action in reliance on the authorization.


Access: You have the right to look at or get copies of your health information with limited exceptions. You must make the request in writing. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practically do so. If you request information that we maintain electronically, you have the right to an electronic copy. You may obtain a form to request access by using contact information listed at the end of this Notice. If you request copies, we will charge you $1.00 for each page. $10.00 per hour for staff time to locate and copy your health information, and postage if you want copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information, for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

Disclosing Accounting: With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations.  To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information by submitting a written request to the privacy official Your written request must include the information that you would like to limit, whether you would like to limit our use or disclosure or both, and finally to whom you would like the limits to apply. We are not required to agree to these additional restrictions, except in the case where the disclosure is to a health plan for carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan)( has paid our practice in full. But if we do agree to any limitations, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about you health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend you health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this notice in written form.


If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Human Health and Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the Department of Human Health and Services.

Our Privacy Official: Fonda Hammock

Telephone: (239) 561-2258

Fax: (239) 603-0459


Address: 14361 Metropolis Ave. Suite 1, Fort Myers, Fl, 33912

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