OUR PLEDGE REGARDING HEALTH INFORMATION (HI):

We, understand that medical information about you and your health is personal. We are committed to protecting medical information about you. Health Information (HI) in this notice means information related to your health or health services that can be used to identify you. We collect and keep HI to provide you with quality care and to comply with certain legal requirements. HI may be oral, written or electronic. We limit access to all types of your HI to our employees and service providers who manage your coverage and provide services. We have physical, electronic and procedural safeguards, per federal standards to guard your HI.

This notice tells you

• How we may use your HI.
• When we can share your HI with others.
• What other rights you have to your HI.

We MUST, by law:

• make sure that health information that identifies you is kept private;
• use and share your HI if asked for by you or your legal representative;
• use and share your HI if asked for by Secretary of the Department of Health and Human Services to make sure your privacy is protected;
• give you this notice of our legal duties and privacy practices concerning health information about you;
• notify you following a breach of unsecured protected health information; and
• follow the terms of the notice that is currently in effect.

WE ARE PERMITTED TO:

To provide for your treatment, payment of your care and to run our business, we are permitted to use and share your HI as follows.

• For Treatment. We are allowed to use and share health information about you to provide you with medical treatment or services. We may disclose health information about you to personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for nutritional counseling. We also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work and diagnostic testing.
  • To Distribute Reminders. We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care. For example, we may mail postcard reminders about appointments.
  • To Identify Treatment Alternatives. We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. For example, we may speak to providers about other ways to treat someone in your situation to provide you with best options.
  • For Health Related Benefits and Services. We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you. For example we can suggest a disease management or wellness program to improve your health.
• For Payment. We are permitted to use and share health information about you so that the treatment and services you receive may be billed for and payment may be collected. For example, we may talk to your insurer about a treatment you are going to receive to determine whether your insurance plan will cover the treatment.
  • To Communicate with Plan Sponsors. We may give enrollment and summary HI to an employer plan sponsor. We may give them other HI if they agree to limit its use per federal law.
  • To Inform Individuals Involved in Providing your Care or Involved in Payment for Your Care. We may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you have been seen in our office. In addition, we may disclose health information about you to a friend or family member should an emergency situation arise.
• For Health Care Operations. We are allowed to use and share health information about you to run our business. For example we may use HI to make sure that all of our patients receive quality care and to monitor the performance of our staff in caring for you. We may also combine and study health information about many patients.

IN ADDITION, WE MAY USE HI:

• To Comply with Laws. We will disclose health information about you when required to do so by federal, state or local law.
• For Public Health Activities. We may disclose health information about you for public health activities, such as preventing disease outbreak.
• About victims of abuse, neglect or domestic violence. We may share information about an individual believed to be a victim of abuse, neglect or domestic violence to an authorized government entity, including social service or protective services agency.
• To Support Health Oversight Activities. We may disclose health information to an agency that is allowed by law to receive HI. These agencies may perform audits, fraud and abuse investigations, inspections, or licensure activities.
• In Response to Lawsuits and Disputes. We may disclose health information about you in response to court order, subpoena, warrant, summons or similar process.
• To Law Enforcement. We may release health information to a law enforcement official for example, to find a missing person or to report a crime
• To Coroners, Medical Examiners and Funeral Directors. We may release 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 release health information about patients to funeral directors as necessary to carry out their duties.
• For Organ and Tissue Donation. To help get, store or transplant organs, eyes or tissue. For example, if you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
• For Research. To study disease or disability, as allowed by law.
• To Avoid a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
• For Government Functions. This may be for military and veteran use, national security, Intelligence Activities or the Protective Services. For example, if you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority. For persons in the custody of a law enforcement official(s) we may release health information to (1) provide you with health care; (2) protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• For Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

OTHER USES OF HI:

• Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission.
• If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

YOU HAVE THE FOLLOWING RIGHTS REGARDING HI:

• Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to our Compliance Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
• Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to our Compliance Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must tell us how or where you wish to be contacted. If you do not tell us how or where you wish to be contacted, we do not have to follow your request.
• Right to Inspect and Copy. You have the right to inspect and obtain a copy of HI that may be used to make decisions about your care. Usually, this includes medical and billing records. This does not include psychotherapy notes. To inspect and copy health information that may be used to make decisions about you, please submit your request in writing to the Compliance Officer at the address on the last page of this notice. If you request a copy of the Information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request, in writing, that the denial be reviewed. A licensed health care professional will then review your request and the denial. The person conducting the review will not be the person who previously denied your request. We will comply with the outcome of the review. You have the right to access the information in the form and format you request, or in hard copy. We may provide a designee with the requested information, if such a request is in writing.
• Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to include additional information in your medical record. You have the right to request an amendment for as long as all of the health information is maintained by us. To request an amendment, your request must be made in writing, include the reason that supports your request and be submitted to our Compliance Officer. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: o Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; o Is not part of the HI kept by us; o Is not part of the HI which you would be permitted to inspect and copy; or o Is accurate and complete.
• Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of health information about you, excluding disclosures for the purpose of treatment, payment and healthcare operations. To request this list or accounting of disclosures, you must submit your request in writing to the Compliance Officer. Your request must state a time period, which may not be more than six. Your request should indicate in what form you want the list (for example, on paper, or electronically). The first list you request within a 12- month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
• Right To Restrict Release of Information For Certain Services- You have the right to restrict the disclosure of information regarding services for which you have paid in full or on an out of pocket basis. This information can be released only upon your written authorization.
• Right to a Paper Copy of This Notice. You have the 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 have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy, please submit your written request to the Compliance Officer at the address noted below.
• Right To Breach Notification You have the right to be notified of any breach of your unsecured healthcare information.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our offices and on the website. The notice will contain on the first page, the effective date. In addition, each time you are seen for treatment or health care services at our office, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint.

• To file a complaint please contact:
  Nancy DiGioacchino, Compliance Officer
  (866)255-1154
  compliance@chsamerica.com
  KGHealth Partners
  TheCampus at Icot Center
  13360Icot Blvd
  Clearwater FL 33760
• You will not be penalized for filing a complaint.