How We Use or Disclose Other Use and Disclosures Your Medical Information of Your Medical Information Victims of Abuse, Neglect, or Domestic Violence - How We Use or Disclose Other Use and Disclosures We may disclose medical information about you to a How We Use or Disclose Other Use and Disclosures governmentVictims of Abuse, agency Neglect, ifComplaints we believe or Domestic you are theViolence victim - of For TreatmentYour - WeMedical will use medicalInformation information about Treatmentof AlternativesYour Medical - We may Information use and disclose Your Medical Information of Your Medical Information abuse,We may neglect, disclose or medicaldomestic information violence. about you to a you to provide you with treatment and services. We may medical information about you to contact you about Yougovernment have the agency right to if complain we believe to youus and are to the the victim United of shareFor Treatment this information - We will with use members medical of information our health careabout otherTreatment health Alternatives care treatment - Wethat may is available use and todisclose you. If States Secretary of Health and Human Services if you For Treatment - We will use medical information about Treatment Alternatives - We may use and disclose Healthabuse, neglect, Oversight or domestic Activities violence. - We may disclose medical staffyou toor providewith others you involvedwith treatment in your and care services. such as We doctors, may youmedical do not information want to receive about theseyou to communications, contact you about please other believe we have violated your privacy rights. There is no share this information with members of our health care other health care treatment that is available to you. If informationrisk in filing about a complaint. you to a health oversight agency. nurses,share this or informationhealth care facilities. with members For example, of our health a nurse care notifyhealth uscare in treatmentwriting. that is available to you. If you do Health Oversight Activities - We may disclose medical whostaff isor providing with others your involved care will in yourreport care any such changes as doctors, in notyou wantdo not to wantreceive to receivethese communications, these communications, please notify please Legalinformation Activities about - Weyou may to a disclosehealth oversight medical agency.information yournurses, condition or health to careyour facilities. doctor. We For may example, also disclose a nurse your Healthusnotify in writing. us Related in writing. Benefits and Services - We may use To file a complaint, contact us by phone or by mail: NOTICE OF who is providing your care will report any changes in about youAdministrator in response to a court proceeding. We may health information to a member of your family or other and disclose medical information about you to contact Legal Activities - We may disclose medical information your condition to your doctor. We may also disclose your Health Related BenefitsBenefits andand ServicesServices - We may use also discloseMillennium medical Physician information Group about you in response PRIVACYNOTICE PRACTICES OF person who is involved in your care. you about other health care benefits or services that about you in response to a court proceeding. We may health information to a member of your family or other and disclose medical information about you to contact to a subpoena6321 Daniels or other Pkwy legal Suiteprocess. 200 may interest you. If you do not want to receive these also disclose medical information about you in response Forperson Payment who is -involved We may in use your or disclosecare. your medical communications,you about other health please care notify benefitsbenefits us in orwriting.or servicesservices thatthat Fort Myers, Florida 33912 PRIVACYTHIS NOTICENOTICE DESCRIBESPRACTICES OF HOW Disclosuresto a subpoenaPhone: for or(855) Law other 674-7400Enforcement legal process. Purposes - We information to bill and collect payment for the services may interest you. If you do not want to receive these MEDICAL INFORMATION ABOUT For Payment - We may use or disclose your medical communications, please notify us in writing. may discloseFax Number information (855) about 674-7401 you to law enforcement THISYOUPRIVACY MY NOTICE BE USED DESCRIBESPRACTICES AND DISCLOSED HOW we provided to you. For example, we may need to give Individuals Involved in Your Care - We may disclose Disclosures for Law Enforcement Purposes - We information to bill and collect payment for the services officialsTo file afor complaint law enforcement with the purposes: United States Secretary of MEDICALAND HOW YOU INFORMATION CAN GET ACCESS ABOUT TO yourwe provided health insurance to you. For plan example, information we may about need your to give medicalIndividuals information Involved about in Your you Careto a family - We maymember, disclose may disclose information about you to law enforcement THIS NOTICE DESCRIBES HOW diagnosis,we provided treatment, to you. Forand example, supplies used.we may We need may toalso give otherIndividuals relative, Involved close friend, in Your or any Care other - We person may discloseidentified Health and Human Services, send your complaint to: YOU MAYTHIS BE USEDINFORMATION. AND DISCLOSED your health insurance plan information about your medical information about you to a family member, •officials As required for law by enforcement law purposes: MEDICAL INFORMATION ABOUT contactyour health your insurance insurance plan plan information to confirm yourabout coverage your bymedical you if information they are involved about youin your to a carefamily or paymentsmember, Region 4, Office for Civil Rights ANDPLEASE HOW REVIEW YOU CAN IT CAREFULLY. GET ACCESS diagnosis, treatment, and supplies used. We may also other relative, close friend, or any other person identified YOU MAY BE USED AND DISCLOSED orcontactdiagnosis, to request your treatment, priorinsurance approval and plan supplies forto confirma planned used. Weyour treatment may coverage also or relatedbyother you relative, toif theyyour closearecare. involved friend,We may orin also yourany useother care or orpersondisclose payments identified medical Dept. of Health & Human Services TO THIS INFORMATION. •• In As response required toby a law court order or other legal proceeding AND HOW YOU CAN GET ACCESS service.orcontact to request your insuranceprior approval plan forto confirm a planned your treatment coverage or informationrelatedby you toif theyyour about arecare. involvedyou We to may notify in also your those use care personsor ordisclose payments of yourmedical Atlanta Federal Ctr Ste 3B70 PurposePLEASE of this REVIEW Notice IT CAREFULLY. service.or to request prior approval for a planned treatment or location,informationrelated to general your about care. condition, you We to may notify or also death. those use If orpersons there disclose is of a yourfamilymedical 61 Forsyth St. SW TO THIS INFORMATION. •• To In responseidentify or to locatea court a ordersuspect, or otherfugitive, legal material proceeding Healthservice. Care Operations - We may use or disclose member,location,information othergeneral about relative, condition, you to or notify close or death. friendthose If persons to there whom is of ayou yourfamily do Atlanta, GA 30303-8909 PurposeThisPLEASE notice of thistells REVIEW Notice you about IThow CAREFUL we use and LY. Health Care Operations - We may use or disclose member,location, generalother relative, condition, or close or death. friend If to there whom is a you family do Towitness, file a complaint or missing withperson the HIPAA Privacy and disclose your medical information. It tells you your medical information for operational purposes. not want us to disclose medical information about you, • To identify or locate a suspect, fugitive, material ForyourHealth example, medical Care weOperationsinformation may use yourfor- We operational medicalmay use information or purposes. disclose to pleasenotmember, want notify usother to us discloserelative, in writing. medicalor close informationfriend to whom about you you, do Security Compliance office, send your complain t to: ThisPurposeabout notice your of tellsrightsthis youNotice and about our responsibilitieshow we use and to disclose For example, we may use your medical information to please notify us in writing. • Whenwitness, information or missing is person requested about an actual or protect the privacy of your medical information. evaluateyour medical our services, information including for operational the performance purposes. of our not want us to disclose medical information about you, Agency for Health Care Administration your medical information. It tells you about your suspected victim of a crime It also tells you how to complain to us, or the staffevaluateFor example, in caring our services, wefor mayyou. includinguseWe yourmay medicalalso the performanceuse informationthis information of ourto please notify us in writing. 2727 Mahan Drive, Mail Stop #4 rightsThis notice and our tells responsibilities you about how to weprotect use and the discloseprivacy staff in caring for you. We may also use this information • When information is requested about an actual or government, if you believe that we have violated toevaluate learn how our services,to continually including improve the performancethe quality and of our Tallahassee, FL 32308-5403 ofyour your medical medical information. information. It tellsIt also you tells about you your how to learn how to continually improve the quality and • Tosuspected report a victim death ofas a crimeresult of possible criminal any of your rights or any of our responsibilities. effectivenessstaff in caring of for the you. health We caremay servicesalso use thatthis weinformation provide Phone: (850) 412-3960 rights and our responsibilities to protect the privacy effectiveness of the health care services that we provide to complain to us, or the government, if you believe to learn how to continually improve the quality and conductFax: (850) 414-6837 of your medical information. It also tells you how toto you.you. Use or Disclosures that are Required • To report a death as a result of possible criminal thatWe weare haverequired violated by law any to of maintain your rights the privacyor any of of effectiveness of the health care services that we provide Email: [email protected] ourto complain responsibilities. to us, or the government, if you believe or Permitted by Law • Aboutconduct crimes that occur on our premises. your medical information. We are also required to Yourto you. name and address may be used to send out patient Use or Disclosures that are Required To file a complaint with the Office for Civil Rights, thatnotify we you have following violated aany breach of your of yourrights unsecured or any of . send your complaint to: our responsibilities. satisfaction surveyssurveys. Disaster Reliefor - WePermitted may use or discloseby Law medical • About crimes that occur on our premises. Wemedical are required information, by law such to maintain as when theyour privacy medical of Your name and address may be used to send out patient • To report a crime in emergency circumstances. information about you to assist in disaster relief efforts. U.S. Department of Health and Human Services yourinformation medical hasinformation. been used, We disclosed, must provide or accessed you Wesatisfaction may contact surveys you. either by telephone or by mail 200 Independence Avenue, S.W. withWein violation are a copy required ofof thisthis by noticenoticelaw to andandmaintain getFederal your the law. writtenprivacy We of ThisDisaster will Reliefbe done - Weto notify may usefamily or disclose members medical or others of Workers’• To report Compensation a crime in emergency - We may circumstances. disclose medical at your home or your officeoffice to to remind remind you you of of an an Room 509F, HHH Building, acknowledgmentyourmust medical provide information.you of with its receipt.a copy We mustofWe this must provide notice follow youand the yourinformation location, about general you condition, to assist in or disaster death in relief the eventefforts. of information about you to comply with workers’ appointmentWe may contact that you you either have withby telephone us or any or other by mail matter This will be done to notify family members or others of Washington, D.C. 20201 termswithget your a of copy this written of notice this acknowledgment noticethat are and currently get your of inits written effect. receipt. related to the health care services we provide or payment a natural or man-made disaster. compensationWorkers’ Compensation laws that provide - We maybenefits disclose for work-related medical We must follow the terms of this notice that are relatedat your tohome the healthor your care office services to remind we provide you of anor payment your location, general condition, or death in the event of HIPAA toll-free number at (866) 627-7748 acknowledgment of its receipt. We must follow the for your health care services. We may leave messages for injuriesinformation or illnesses. about you to comply with workers’ currently in effect. forappointment your health that care you services. have with We us may or anyleave other messages matter for Questions and Information Weterms will of tell this you notice if we that change are currently this notice. in effect. A copy of you. If you want us to contact you in a certain way or at Requireda natural or by man-made Law - We disaster. may use or disclose medical compensation laws that provide benefits for work-related you.related If youto the want health us tocare contact services you we in aprovide certain or way payment or at the revised notice will be available upon request or a certain location, see the “Right to Receive Confidential information about you when we are required to do so by PublicIfinjuries you have Health or illnesses. any or questions Safety - orWe want may more use orinformation disclose We reserve the right to change the terms of this afor certain your healthlocation, care see services. the “Right We tomay Receive leave messagesConfidential for postedWe will at tell our you location if we orchange on our this website. notice. We A copy may of Communications” in this notice. law.Required by Law - We may use or disclose medical about this Notice of Privacy Practices, please contact: notice and will notify you of any changes. A you. If you want us to contact you in a certain way or at medical information about you if we believe it is the revised notice will be available upon request or Communications” in this notice. information about you when we are required to do so by Public Health or Safety - We may use or disclose changecopy of our the practices, revised notice and those will bechanges available may upon apply a certain location, see the “Right to Receive Confidential necessaryMedical to prevent Records a threat Dept. to the health or safety of a posted at our location or on our website. We may Business Associates - There are some services that Communicablelaw. Diseases - We may disclose your medical information about you if we believe it is torequest medical or informationat our location we or already on our have website. about you Communications” in this notice. person orMillennium the general Physician public. Group change our practices, and those changes may apply Thereare provided are some for services us by our that business are provided associates for us such by asour medical information to a person who may have been necessary to prevent a threat to the health or safety of a asChanges well as toany this new notice information. will apply to medical 19531 Cochran Blvd. to medical information we already have about you businessaccountants, associates consultants, such as and accountants, attorneys. Wheneverconsultants, we exposedCommunicable to an infectious Diseases disease - We may or who disclose is at riskyour of person orPort the Charlotte, general public. FL 33948 information we already have about you, as well as There are some services that are provided for us by our Military - If you are a member of the Armed Forces, we as well as any new information. andshare attorneys. information Whenever with our we business share information associates, withwe will our spreadingmedical information the disease to or a condition. person who may have been Phone (941) 255-3535 Thisany newnotice information. will be given to you on the date that business associates such as accountants, consultants, may use and disclose medical information about you to businesshave a written associates, contract we withwill havethem athat written requires contract that theywith exposed to an infectious disease or who is at risk of byMilitary phone -with If you questions are a member or with of written the Armed requests Forces, for we you first receive medical products or treatment. In protectand attorneys. the privacy Whenever of your we medical share information information. with our your military command. ThisThis noticenotice willwill bebe givengiven toto youyou onon thethe datedate thatthat them that requires that they protect the privacy of your Publicspreading Health the disease Activities or condition. - We may disclose medical informationmay use and as disclose defined medical under theinformation “Your Rights” about sectionyou to an emergency, we will give you the notice as soon medicalbusiness information. associates, we will have a written contract with of this notice. Complaints or questions may be made by asyouyou possible firstfirst receive receive after themedical medical emergency products products treatment or or treatment. treatment. has been In information about you for public health activities to Nationalyour military Security command. and Intelligence - We may disclose In an emergency, we will give you the notice as them that requires that they protect the privacy of your Public Health Activities - We may disclose medical phone or in writing. given.an emergency, we will give you the notice as soon prevent or control disease. medical information about you to authorized federal soon as possible after the emergency treatment medical information. information about you for public health activities to as possible after the emergency treatment has been officialsNational forThe Security national revision and security date Intelligence of andthis intelligenceprivacy - We noticemay activities. disclose has been given. prevent or control disease. given. medical informationis aboutAugust you 26, to 2013. authorized federal 1 2 officials for national security and intelligence activities. Use or Disclosures that are Required or Workers’ Compensation - We may disclose medical Your Rights Right to Request Amendments to Your Medical Permitted by Law information about you to comply with workers’ Information - You have the right to request that we compensation laws that provide benefits for work-related The information contained in your health or medical correct your medical information. If you believe that injuries or illnesses. Disaster Relief - We may use or disclose medical record is the physical property of Millennium Physician any medical information in your record is incorrect or information about you to assist in disaster relief efforts. Group. The information in it belongs to you. You have that important information is missing, you must submit This will be done to notify family members or others of Public Health or Safety - We may use or disclose your request for an amendment in writing to Millennium medical information about you if we believe it is the following rights: your location, general condition, or death in the event of Physician Group. a natural or man-made disaster. necessary to prevent a threat to the health or safety of a person or the general public. Rights to Request Restrictions - You have the right to We do not have to agree to your request. If we deny Required by Law - We may use or disclose medical ask us not to use or disclose your medical information your request, we will tell you why. You have the right information about you when we are required to do so by Military - If you are a member of the Armed Forces, we for a particular reason related to treatment, payment, law. may use and disclose medical information about you to or our operations. You may ask that family members or to submit a statement disagreeing with our decision. your military command. other individuals not be informed of specific medical We may deny your request if we determine that the Communicable Diseases - We may disclose your information. That request must be provided to us in information: medical information to a person who may have been National Security and Intelligence - We may disclose writing. We do not have to agree to your request, unless exposed to an infectious disease or who is at risk of medical information about you to authorized federal the restriction relates to disclosure of your medical • Was not created by us spreading the disease or condition. officials for national security and intelligence activities. information relating to a specific item or service to your Security Clearance - We may use medical information health plan for payment or health care operations, and • Is not part of the medical information that we maintain Public Health Activities - We may disclose medical about you for a required security clearance. you have already paid out-of-pocket, in full, for the information about you for public health activities to specific item or service.. If we agree to your request, we • Is in records that you are not allowed to inspect and prevent or control disease. Inmates - We may disclose medical information about must keep the agreement, except in the case of a medical copy you to a correctional institution or law enforcement Victims of Abuse, Neglect, or Domestic Violence - emergency. Either you or Millennium Physician Group official who has custody of you. • Is already accurate or complete We may disclose medical information about you to a can stop a restriction at anytime. Right to an Accounting of Disclosures of Health government agency if we believe you are the victim of abuse, neglect, or domestic violence. Uses or Disclosures Right to Receive Confidential Communications - You Information - You have the right to find out what That Require Your Authorization have the right to ask that we communicate with you in disclosures of your medical information have been Health Oversight Activities - We may disclose medical a certain manner or at a certain place. If you want to made. The list of disclosures is called an accounting. The accounting may be for up to six (6) years prior to the date information about you to a health oversight agency. Other uses and disclosures will be made only with your request confidential communications, the request must on which you request the accounting, but cannot include written authorization. You may cancel an authorization be made in writing. We must agree to your request if it is Legal Activities - We may disclose medical information disclosures before April 14, 2003. at any time by notifying us in writing of your desire to reasonable. about you in response to a court proceeding. We may cancel it. If you cancel an authorization, it will not have also disclose medical information about you in response We are not required to include disclosures for treatment, any effect on information that we have already disclosed. Right to Inspect and Copy Your Medical Information to a subpoena or other legal process. payment, or health care operations or certain other Examples of uses or disclosures that require your written - You have the right to request to inspect and obtain a exceptions. Request for an accounting of disclosures authorization include the following: copy of your medical information. You must submit Disclosures for Law Enforcement Purposes - We must be submitted in writing. You are entitled to one may disclose information about you to law enforcement your request in writing. If you request a copy of the free accounting in any twelve (12) month period. We officials for law enforcement purposes: (1) most uses and disclosures of psychotherapy notes; information or if you request that we provide you with a may charge you for the costs of providing additional (2) uses and disclosures for marketing purposes; summary of the information, we may charge a fee for the accountings. If there will be a charge, we will notify you • As required by law (3) uses and disclosures that constitute the sale of your costs of copying, summarizing, and/or mailing it to you. in advance. medical information. • In response to a court order or other legal proceeding If we agree to your request, we will tell you. We may deny your request under certain limited circumstances. If Right to Obtain a Copy of the Notice - You have the • To identify or locate a suspect, fugitive, material your request is denied, we will let you know in writing right to request and get a paper copy of this notice and witness, or missing person and you may be able to request a review of our denial. any revisions we make to the notice at any time. • When information is requested about an actual or suspected victim of a crime

• To report a death as a result of possible criminal conduct

• About crimes that occur on our premises.

• To report a crime in emergency circumstances.

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