PLEASE REVIEW THIS NOTICE CAREFULLY AND ACKNOWLEDGE RECEIPT.

Effective Date:
This Notice is effective April 14, 2003

You have the right to receive a paper copy of this or any revised Notice and/or an electronic copy by email upon request to the Privacy Officer.

If you have any questions about this Notice, please contact the Gulf Coast Glaucoma Clinic Privacy Officer.

How to Complain About Our Privacy Practices.

If you believe that we may have violated your privacy rights, or you disagree with a decision we make about access to your PHI, you may file a complaint with the Privacy Officer listed below. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, SW, Washington D.C. 20201 or call 1-877-696-6775. There will be no retaliation for filing a complaint.

Contact: Lawrence M. Hurvitz, MD, Privacy Officer

If you have questions about this Notice or any complaints about our privacy practices, please contact:

Lawrence M. Hurvitz, MD
Bldg F, Suite B
3920 Bee Ridge Road
Sarasota, FL 34233

The Gulf Coast Glaucoma Clinic (the Clinic) is required by law to maintain the privacy of protected health information (PHI) and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. We reserve the right to change our privacy practices and the terms of this Notice at any time. This Notice describes how the Clinic has extended certain protections to your PHI and how, when, and why we may use and disclosure your PHI. With certain exceptions, the Clinic will use or disclose your PHI in the minimum necessary manner to accomplish the intended purpose of the use or disclosure. The Clinic will share PHI as is necessary to provide quality health care and receive reimbursement for those services as permitted by law. The terms of this Notice of Privacy Practices are effective April 14, 2003.

You may view this Notice or any new notices on our website at www.glaucomaclinic.com.

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

The Clinic is committed to maintaining the confidentiality of your health information. Your health information may be used and disclosed for purposes of treatment, payment, and health care operations. Outside of these permitted uses, we must have your written and signed authorization unless the law permits or requires the use or disclosure without your authorization. You have the right to revoke that authorization in writing except to the extent any action has been taken in reliance on the authorization.

Treatment, Payment, and Health Care Operations. Except as otherwise provided, the Clinic may use and disclose your health information for purposes of treatment, payment, and as otherwise necessary and permitted by law, for our health care operations. This may include disclosure to another health care provider who, at the request of your physician, becomes involved in your treatment, for purposes of approval of reimbursement from your health plan, or for audit purposes, we may disclose to our accountant or attorney.

Business Associates. It may be necessary for us to provide your health information to certain outside persons or entities that assist us with our health care operations, such as auditing, accreditation, legal services, etc. These business associates are required to properly safeguard the privacy of your health information.

Appointments and Services. We may contact you to provide appointment reminder, information about treatment alternatives, or other health-related benefits and services that may be of interest to you. You have the right to request, and we will accommodate your reasonable requests, to receive communications regarding your health information from us by alternative means or at alternative locations. You may request such confidential communication by sending your written request to the Clinic Privacy Officer.

USE AND DISCLOSURES REQUIRING YOU TO HAVE AN OPPORTUNITY TO OBJECT.

Family and Friends. With your approval and using our professional judgment, your health information may be disclosed to designated family, friends, and others who are directly involved in your care or in the payment for your care. If you are unavailable, incapacitated, or in an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited health information with such individuals without your approval.

Patient Directories. Your name, location, and general condition may be put into our patient directory for disclosure to callers or visitors who ask for you by name. Your religious affiliation may be shared with clergy.

USES AND DISCLOSURES OF PHI

The following uses and disclosure of PHI may be made without your prior consent or authorization.

1. Required by Law. If we suspect child abuse or neglect, we may also release health information as required by law, or related to suspected criminal activity, or in response to a court order.

2. To Avert Threat to Health or Safety.

3. For Health Oversight Activities.

4. Relating to Decedents. We may release health information to coroners and/or funeral directors consistent with law.

5. For Research Purposes. In certain circumstances and with your prior authorization, we may use or disclose health information for research purposes.

6. For Public Health Activities. Such as required reporting of disease, injury, and birth and death, and for required public health investigations.

7. For Specific Government Functions. If you are a member of the military as required by armed forces services. We may also release your individual health information if necessary for national security or intelligence activities. Also, to workers' compensation agencies.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

1. Restrictions on Use and Disclosure of Individual Health Information. You have the right to request that we restrict how we use and disclose your health information. These restrictions must be made in writing and signed by you or your representative. The Clinic is not required to agree to your restrictions. We cannot agree to limit uses/disclosures that are required by law. In the event of a termination of an agreed-to restriction by us, we will notify you of such termination. You may terminate, in writing or orally, any agreed-to restriction by sending such termination notice to the Privacy Officer.

2. Access to Individual Health Information. You have the right to inspect and copy your health information. All such requests must be made in writing and signed by you or your representative. A fee set by the Florida Dept. of Health will be assessed if you request a copy of the information. There will also be a charge for postage if you request a mailed copy and, if requested, for preparation of a summary of the requested information. You may obtain a Request for Access form from the Privacy Officer. We will respond within 30 days unless an extension is taken. In certain circumstances, you may not be permitted access. Depending on the circumstances, you may request a review of the decision to deny access. If we deny your request, you will be given written notice that will explain the basis and your right to appeal.

3. Amendments to Individual Health Information. You have the right to request that your health information be amended or corrected. We will respond within 60 days unless an extension is taken. In certain cases, we may deny your request for amendment and you will be given written notice that will explain the basis and your right to appeal, which will be appended to your health information. You may also submit a statement of disagreement and we may prepare a rebuttal that will be provided to you. All amendment requests must be in writing, signed by you or your representative, and must state the reasons for the amendment. If we make an amendment, we may notify others who work with us and have copies of the un-amended record if we believe that such notification is necessary. You may obtain a Request for Amendment form from the Privacy Officer.

4. Accounting for Disclosures of Individual Health Information. You have the right to receive an accounting of certain disclosures of your health information made by us after April 14, 2003. Requests must be made in writing and signed by you or your representative. Request for Accounting forms are available from the Privacy Officer. The first accounting in any 12-month period is free; you will be charged a fee of $10 for each subsequent accounting within the same twelve-month period. The right to receive this information is subject to certain exceptions, restrictions, and limitations.