Effective date: December 1, 2006

NOTICE OF PRIVACY PRACTICES

This notice describes how Personal Health Information (PHI) about you may be used, disclosed and how you can get access to this information. 

If you have any questions regarding this notice please contact: Faith E. Holt, Flagler Acupuncture and Pain Clinic, 102 Flagler Plaza Drive, Palm Coast, FL 32137.

WHO WILL FOLLOW THIS NOTICE

This notice describes Flagler Acupuncture and Pain Clinic practices and that of any healthcare professional authorized to enter information into your patient chart. 

OUR PLEDGE REGARDING PERSONAL HEALTH INFORMATION (PHI)
Your health information is personal. We are committed to protecting your PERSONAL HEALTH INFORMATION (PHI). We create a record of care and services you receive here at Flagler Acupuncture and Pain Clinic. We need this record to provide you with quality care and to comply with certain legal requirements. We are required by law to make sure that medical information that identifies you is kept private and to give you this notice of our legal duties and privacy practices with respect to medical information about you.

HOW WE MAY USE AND DISCLOSE YOUR PHI: we will use your PHI as described in the following categories.

For Treatment: We may use your PHI to provide you with medical treatment or services.  

For Payment: We may use and disclose your PHI so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. 

Treatment Alternatives: We may use and disclose your PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services: We may use and disclose your PHI to tell you about health-related benefits or services that may interest you.

Individuals Involved in Your Care or Payment for Your Care:  We may release your PHI to a friend or family member who is involved in your medical care. We may also release PHI to someone who helps pay for your care.

As Required by Law: We will disclose your PHI when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. 

SPECIAL SITUATIONS

Organ and Tissue Donation: If you are an organ donor we may release PHI about organ, tissue, and eye donors and recipients to organizations that manage organ, tissue, and eye donation and transplantation.

AUTHORIZATIONS FOR OTHER USES AND DISCLOSURES

As described above, Flagler Acupuncture and Pain Clinic will use your PHI and disclose it outside Flagler Acupuncture and Pain Clinic for treatment, payment, health care operations, and when permitted or required by law.  We will not use or disclose your PHI for other reasons without your written authorization. You may revoke the authorization, in writing, at any time, but we cannot take back any uses or disclosures of your health information already made with your authorization. 

YOUR RIGHTS REGARDING PHI

Right to Accounting: You may request an accounting, which is a listing of the entities or persons (other then yourself) to whom FBAH has disclosed your PHI without your written authorization.  Your request must be in writing, signed, dated and you must specify the records you wish to amend, and give the reason for your request. You must address the request to Faith E. Holt, Flagler Acupuncture and Pain Clinic, 102 Flagler Plaza Drive, Palm Coast, FL 32137. We will respond to you within 60 days.

Right to Amend: If you feel that PHI we have about you is incorrect or incomplete, you have the right to ask us to amend your medical records. Your request must be in writing, signed, dated and you must specify the records you wish to amend, and give the reason for your request. You must address the request to Faith E. Holt, Flagler Acupuncture and Pain Clinic, 102 Flagler Plaza Drive, Palm Coast, FL 32137.. We will respond to you within 60 days. We may deny your request, if we do; we will tell you why and explain your options.

Right to Inspect and Obtain Copy: You have the right to inspect and obtain a copy of your completed medical records unless the physician believes that disclosure of that information could harm you. You may not see or get a copy of information gathered for a legal proceeding or certain research records while the research is going on. Your request must be in writing, signed, dated and you must specify the records you wish to inspect, and give the reason for your request. You must address the request to Faith E. Holt, Flagler Acupuncture and Pain Clinic, 102 Flagler Plaza Drive, Palm Coast, FL 32137. We will respond to you within 60 days.

Right to Restrict Restrictions: You have the right to ask us to restrict the uses or disclosures we make of your PHI for treatment, payment, or health care operations, but we do not have to agree. You may also ask us to limit the PHI we use or disclose about you to someone who is involved in your care or the payment for your care. Again, we do not have to agree. The request should describe the information you want, say whether you want to limit the use or disclosure of the information or both and tell us who should not receive this restricted information.  Your request must be in writing, signed, dated and you must specify the records you wish to restrict. You must address the request to Faith E. Holt, Flagler Acupuncture and Pain Clinic, 102 Flagler Plaza Drive, Palm Coast, FL 32137. We will respond to you within 60 days.

Right to Request Confidential Communications: You have the right to request that we communicate with you about your health in a certain way or at a certain location. Your request for confidential communications must be in writing. You need not tell us the reason for the request. Your request must be in writing, signed, dated and you must specify your communication preference, and give the reason for your request. You must address the request to Faith E. Holt, Flagler Acupuncture and Pain Clinic, 102 Flagler Plaza Drive, Palm Coast, FL 32137. We will respond to you within 60 days. We will accommodate all reasonable requests. 

Right to a Paper Copy of This Notice: You have a 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 agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may request a copy of Notice to Faith E. Holt, Flagler Acupuncture and Pain Clinic, 102 Flagler Plaza Drive, Palm Coast, FL 32137. We will respond to you within 60 days.

Changes to This Notice: FBAH may change this Notice at any time. Any change in this Notice could apply to PHI we already have about you, as well as any information we receive in the future. We will post of copy of this Notice in our office at office at : Flagler Acupuncture and Pain Clinic, 102 Flagler Plaza Drive, Palm Coast, FL 32137.