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Notice of P「ivacy P「actices Pa巾e「s in Women’s Health of Jupiter, L THIS NOTICE DESCR旧ES HOW MEDICAL INFORMATION ABOJT YOJ MAY TO THIS INFORMAT10N. PLEASE REVIEW IT CAREFJLLY. HOWWE肌AY USE AND DISCLQSE H臥町H INFOR肌叩ON: Described as fo=o鵬are the ways we may use and disc10Se hea肌informatio[仇at identifies y閃く白開瓶面fo州a同い).軸加鵬酬ow巾 PurPOSeS, We wi= use and disc10Se Hea肌lnfomato[ Only with yoll「 Written pemlission. You may revoke such Pemissio[ at any time by両肌g to our practice. 摘朋e〃尊 We may use and disclose Health lnfomaton fo「 yo間 軸ta雨的叩V柑ey関w軸闘 he郡h c訓e serviees, Fo「 examp心We may disc10Se J]ea臨lnfoma的n to doctoiS,剛rSeS, teChnieians, or Other persomeL剛ing people ou朗e our office, Who are invoived i[ yOur medieal ca記and need the infomafron to provide you w肌mediea血別e. Pay朋e〃寄 We may use and disdose Hea冊Infomaton so thatwe O「 Oth師may b… and 「eceive paymentfrom you, an insuran∞ ∞mPany, or a th潤party for the廿eatment and Serviees you 「eceived. For examp時We may give you「 hea剛p加infomation so that they刷pay for your 什eat爪印し H開聞∽鳩Ope館的膿 We may use and discIose Iea皿lnfo町滑的m fo「 heam care oper翻on purposes. These uses and disctosures are necessary to make sure that訓of oIIr Patents 「eCeive qua時care and to operate and manage our o範e. For example, We may use andl discIose infor隔個on to make SUre the ob§tetricahor gyne∞kyJical care you receive is Of the hishest qua時We aiso may share infoma的n W臨othe「 entities that have a 「e闘onsh巾W胸you 〈for example' yOur heaIth pfan〉 for thei「 hea肌cgre operation ac館∨摘es. Appo加納)en〔 Rem加ders, nlca(mentA/(ematives and Hea筋Reね!ed βene舶and ServIbes. We may use and disdose IeaIt出nfom軸to ∞ntact yOll and to remind you that yo両ave an appointment w軸us. We aiso may use and discIose Hea間冊omaton to te" you about廿eatme∩t aItematives o「 heaIth寸e胤ed benefits andふ肌府es that may be of interest to you. 加脇du細面面ve伽n Ybur Care oI Paymen筋子 YouI C訓e, When appr。P南te, We may Share Hea伽 Informatio[ With a person who is invoived in your medieal care or payment foryour care, Such as you「 fam時o「 a CIose friend. We also may notry your fam時about your bca的[ O「 general co[ditio[ O「 disc10se Such infomafro[ to a[ enfty assis僧ng in a disaste「 「eifef effch Research. Jnder cehain cfroumstances, We may uSe and discIose Hea臨lnfoma償m fo「 「esearch. For examp時a reseaI℃h p「o軸may invoive ∞mPa血g the heaIth of patents who rec宙ved one treatment to those who 「eceived anotheL for庇same cond柑on. Before ue use or disclose Hea聞lnfomaton fo「 「esea「くれ小e project wi= go伽「ough a special approvaI process. Even Without specfaI app「oval, We may Pemit researchers to hok at records to help the両dentry patients who may be included in their research project or for other s刷ar 恥やOS玲弱め的aS小印的not「emo鳴0南船a oopy of any HeaIth Infoma on, Fmd帽扇ig Ac脇飲獅・ We may llSe O「 disclose yo]「 Protected Hea剛nfomation, as [eceSSary, in order to contact you for fundraising activ楓es. You have the right め叩く〇両が記∞廟的軸両面g ∞m皿n軸s. (Optonal) If you de rot w飢t tO reCeive these materials, PIease submit a writt飢「equeSt tO the Privacy OffroeL SPECIAL S町UATIQl埠 As Requ存ed OyLaw. We wi" discIose Hea胸 囲Oma的n wh飢reqU圃to de so by internatio帽L federal, State Or id faw, 7b Averfa Se面ous m朋t t州ea仰OISafefy, We may use a[d disclose Ieam lnfomatio[ Whe…eCeSSary tO PreVe[t a Serious冊eatto you「 heaIth and safety o川e hea伽and safety Of the public or anothe「 person. DiscIosures, howeve「, W紺be made onIy to someone who may be able to heip prevent the 小幅at. Business Associates. We may discIose HeaI帥nfomaton to Oll「 business associates that perform func鱈ons on ou「 behaIf o「 PrOVide us w柵services if the infomaton is necessa「y for such functio[S Or Servi∝rs. Fo「 example, We may uSe a[Other COmPany tO Perfom b冊g services on oll「 behalf. All of ou「 business associates a「e o胡gated to p「otect the privaey of you「 infomaton and are not a=owed to use o「 discIose arly infomation other than as spec胸ed in o]r ∞[tract. O細B朋ch M朋c∂的n Pu坤oses. We may use your contact infomation to provide legalIy-required notices of unaし他orized acquis胸on, aCCeSS, Or disc10Su「e Of your heaIth informa6o[. We may send notice di「ectly to you o「 p「ovide no晦to肌e sponso「 ofyou「 pIa[ through which you 「eceive cOVerag e. O岬紬and T樽sue Do朋的n. 1fyou are an organ donori We may use or 「elease Hea伽l[fomafro[ to O喝a[iza的ns that handIe organ叩C]rement O「 Othe「 e嗣es engaged in PrOCurement; ba[king o「 transportato[ Of o喝an§, eyes, 0「 tissues to facii触e organ, eye O「tissue donation; a[d 鳴nspIan刷On. M据わry and l佃や周"S. Ifyou are a membe「 ofthe amed fo鵬s, We may 「eIease HeaIth lnfomaton as required by m胸ry ∞mmand authorities. We also may 「eiease HeaIth infoma的[ to the app「op南te foreign m蝿ry aし個orty if you a「e a member of a foreign m冊tary. 胸筋ers’Compensa(jon. We may reiease HeaIth lnfomation for workersi ∞mPenSation or simiiar p「ograms. These P「OgramS Provide be[efits fo「 work-related injuries or冊ess. Pub侮Hea聞朋sks. We may discIose Iealt=nfomation for PubIic hea凪activities. These ac帥ties generally incIude discIosu「es to preve[t O「 COntrOI disease,岬ry or disabi時 「eport b柵S and deaths; rePOrt Ch胸abuse o「 negIec臣eport 「eactions to medications o「 p「obiems w瓶products; nOfty PeOPIe of reca‖s of products they may be using; a Pe「SO[ Who may have bee[ eXPOSed to a disease o「 may be at risk for contrac師g o「 SPreading a disease o「 condition; and the approp南te govemme[t aJthorty if we be"eve a patient has been the v融m of abuse, neglect o「 domestic vioience. We wi= Only make榔S discIosure ifyou ag「ee orwhen requi「ed o「 authorized by iaw. 立 YOJR RiGHTS: You have the following rights 「egarding Hea剛nfomaton we have about you: Access to e/ecfro扉c ′ecO′ds. The Hea皿Infoma的n TechnoIogy for Economic and C嗣cal Iea肌Ac川lTECI Act 訓ows people to ask for eIectronic ∞Pies of thei「 PHI contained in electronic heath re∞「ds o「 to request in w軸g or electronha=y that another pe「son receive an electronic copy of these re∞「ds. The final o面bus rules expa[d an脚viduai,s right to access electronic reco「ds or to di「ect tha川ey be sent to another pe「son to incIude not oniy eIecfronic hea肌「e∞「ds but aIso a=y re∞「ds in one o「 more designated 「eco「d sets. 1f the individuaI requests a[ elect「onic copy言t must be provided in the fomat 「equested or in a mufually ag「eed-uPO[ fomat. Covered en帥es may charge individuaIs for the cost of any elecfronic media (SuCh as a JSB [ash drive) used to provide a COPy Ofthe eIecf面c PHI. R馴れo hspect and CopyL You have a right to inspect and ∞Py HeaIth l[fomaton that may be used to make decisions about yo]「Care O「 Payment foryou「 ca「e. This includes medical and b冊g 「ecords, Othe「 than psychotherapy notes. To inspeot a〔d copy榔s Iea刷nfomation, yOu muSt make your request両W嗣g. 的航o Am帥掴you fee冊rat Hea刷nfo have is in(摘O「 incomplete, you amend the infomaton. You have伽e an amendmentfo「as tong as伽e in or for our o冊冷To request an am make you「 「equest, in w珊ng. Rjg伽fo an Accom伽g ofDischs the right to 「equest a略et of cehe ma鳴面白舗剛的帆的両o「甲やOS総0小針伽an treatment, Payment and hea個care whieh you provided writt飢authori a∝則[個ng of discIesures, you must 「印u銃口[ W相即 榊のRe押勝洞es伽c海00. Yo両a博聞e request a 「estictio[ O「柵itaton on Infoma同いWe use O「 discIose for or hea胸care operattons. You ais request a linlit or¥ the HeaIth ln SomeOne鵬in you「 ca「e o川e p Ca「e,臨e a fam母memberor制. Fo ∞u旧ask thatwe [Ot Share informa Partjcu胤dfagnosis or treatm飢t W request a restriction, yOu muSt m W朋的. We訓e no requ新od to ayIee to ag「ee. we刷comply w肌you「 「equest infomlafron is needed to p「ovid 龍田同園蘭 Rjg励to Request Con刷bn細/ com have the right to request that w about med同matters i[ a ce南面w 脚on. Fo「example, you ca[ aSk contact you by ma用or at work. To communication, you muSt make y W爪ing. Yo]r requeSt muSt SPegiv Wish to be ∞[tacted. We w用acc 峨褐o[ab虚説qu鎧庭. Rfgh偉o a P叩e/ Cny o門部s Nof汚e right to a papercopy ofthis notic give you a ∞Py ofthis [O鵬at any CHANGES TO THIS NOTiCE: We reserve the right to change輔 the new no船e app時to Hea肌infom have as we" as any infoma的n we future. We w時OSt a COPy of ou「 o Office. The [O的e W冊CO[tain伽e effe first page言n the top right-hand c CO MPしAINTS : If you be=eve you「 privacy right yo] may file a ∞mPfaintw瓶ou「 o惰c Secrctary of the Depa巾nent of Serviees. A" ∞mP眺must be ma Yoow用博t鵬pe山繭短軸g a oo叩廟帆 Please sigrl the accompa “Acknowledgement” fo m C輔y Lewis 600 Heritage Drive/Suife J岬的「,乱3糾粥 0価c蟻〈紡1) 3塊-1515 戸種x: (稀1) 3軸・1516 2013
