Jhonny Salomon, M.D., P.A.
305-270-1361
Fax: 305-270-9138
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our
practice is dedicated to protecting your medical information. We are required
by law to maintain the privacy of protected health information and to provide
you with this Notice of our legal duties and privacy practices with respect to
protected health information. Our practice is required by law to abide by the
terms of this Notice.
This
Notice of Privacy Practices describes how we may use and disclose your
protected health information to carry out treatment, payment or health care
operations and for other purposes that are permitted or required by law. It
also describes your rights to access and control your protected health
information. “Protected Health Information” is information about you, including
demographic information, that may identify you and that relates to your past,
present or future physical or mental health or condition and related health
care services.
Our
office is required to abide by the terms of this Notice of Privacy Practices.
We may change the terms of our notice, at any time. The new notice will be
effective for all protected health information that we maintain at that time.
Upon your request, we will provide you with any revised Notice of Privacy
Practices. To request a revised notice you may call the office and request that
a revised copy be sent to you in the mail or asking for one at the time of your
next appointment.
HOW
YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED:
We
will use your medical information as part of rendering patient care. For
example, your medical information may be used by the doctor or nurse treating
you, by the business office to process your payment for the services rendered
and in order to support the business activities of the practice, including, but
not limited to, use by administrative personnel reviewing the quality of the
care you receive, employee review activities, training of medical students,
licensing, contacting, or arranging for other business activities.
We
may also use and/or disclose your information in accordance with federal and
state laws for the following purposes:
Appointment Reminders
We may contact you to provide appointment reminders.
Treatment Information
We may contact you with information
about treatment alternatives or other health-related benefits and services that
may be of interest to you.
Fund Raising
We may contact you to raise funds
for our practice.
Disclosure to Department of Health and Human Services
We may disclose medical information
when required by the United States Department of Health and Human Services as
part of an investigation of determination of our compliance with relevant laws.
Family and Friends
Unless you object, we may disclose
your medical information to family members, other relatives, or close personal
friends when the medical information is directly relevant to that person’s
involvement with your care.
Notification
Unless you object, we may use or
disclose your medical information to notify a family member, a personal
representative, or another person responsible for your care of your location,
general condition, or death.
Disaster Relief
We may disclose your medical
information to a public or private entity, such as the American Red Cross, for
the purpose of coordinating with that entity to assist in disaster relief
efforts.
Health Oversight Activities
We may use or disclose your medical
information for public health activities, including the reporting of disease,
injury, vital events, and the conduct of public health surveillance,
investigation and/or intervention. We may disclose your medical information to
a health oversight agency for oversight activities authorized by law, including
audits, investigations, inspections, licensure, or disciplinary actions,
administrative and/or legal proceedings.
Abuse or Neglect
We may disclose your medical
information when it concerns abuse, neglect or violence to you in accordance
with federal and state law.
Legal Proceedings
We may disclose your medical
information in the course of certain judicial or administrative proceedings.
Law Enforcement
We may disclose your medical
information for law enforcement purposes or other specialized governmental
functions.
Coroners, Medical Examiners, and Funeral Directors
We may disclose your medical
information to a coroner, medical examiner, or a funeral director.
If you are an organ donor, we may disclose your medical
information to an organ donation and procurement organization.
Research
We may use or disclose your medical information for
certain research purposes if an Institutional Review Board or a privacy board
has altered or waived individual authorization, the review is preparatory to
research or the research is on only decedent’s information.
Public Safety
We may use or disclose your medical information to
prevent or lessen a serious threat to the health or safety of another person or
to the public.
Worker’s Compensation
We may disclose your medical information as authorized
by laws relating to worker’s compensation or similar programs.
Business Associates
We may disclose your health information to a business
associate with whom we contract to provide services on our behalf. To protect
your health information, we require our business associates to appropriately
safeguard the health information of our patients.
We
will not use or disclose your medical information for any other purpose without
your written authorization. Once given, you may revoke your authorization in
writing at any time. To request a Revocation of Authorization form, you may
contact:
Barby Gonzalez
Jhonny Salomon, M.D., P.A.,
Telephone: 305-270-1361 Fax: 305-270-9138
You have the following rights
with respect to your medical information:
You
may ask us to restrict certain uses and disclosures of your medical
information. We are not required to agree to your request, but if we do, we
will honor it.
You
have the right to receive communications from us in a confidential manner.
Generally,
you may inspect and copy your medical information. This right is subject to
certain specific exceptions, and you may be charged a reasonable fee for any
copies of your records.
You
may ask us to amend your medical information. We may deny your request for
certain specific reasons. If we deny your request, we will provide you with a
written explanation for the denial and information regarding further rights you
may have at that point.
You
have the right to receive an accounting of the of the disclosures of your
medical information made by our practice during the last six years (or
following April 14, 2003,) except for disclosures for treatment, payment or
healthcare operations, disclosures which you authorized and certain other
specific disclosure types.
You may request a paper copy
of this Notice of Privacy Practices for Protected Health Information.
You
have the right to complain to us and/or to the United States Department of
Health and Human Services if you believe that we have violated your privacy
rights. If you choose to file a complaint, you will not be retaliated against
in any way. To complain to us, please contact:
Barby Gonzalez
Jhonny Salomon, M.D., P.A.,
Telephone: 305-270-1361 Fax: 305-270-9138
If you would like further
information regarding your rights or regarding the uses and disclosures of your
medical information, you may contact:
Barby Gonzalez
Jhonny Salomon, M.D., P.A.,
Telephone: 305-270-1361 Fax: 305-270-9138
THIS NOTICE IS EFFECTIVE AS
OF ________________________. If not date is entered, this Notice is effective
on April 14, 2003.
REVISION OF NOTICE OF
PRIVACY PRACTICES
We reserve the right to change the terms of this Notice, making any revision applicable to all the protected health information we maintain. If we revise the terms of this Notice, we will post a revised notice at our office and will make paper copies of the revised Notice of Privacy Practices available upon request.