Please read our Notice of Privacy Practice information. The information was revised on 9/17/2013.
NOTICE OF PRIVACY PRACTICES
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.
I. Our Duty to Safeguard Your Protected Health Information.
We understand that medical information about you is personal and confidential. Be assured that
we are committed to protecting that 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. We are required by law to abide by the terms of this Notice,
and 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 and make paper and electronic copies of this Notice of Privacy Practices for Protected Health
Information available upon request. We are required by law to notify you in the event of a breach of your
protected health information.
In general, when we release your personal information, we must release only the information
needed to achieve the purpose of the use or disclosure. However, all of your personal health information
that you designate will be available for release if you sign an authorization form, if you request the
information for yourself, to a provider regarding your treatment, or due to a legal requirement. We will
not use or sell any of your personal information for marketing purposes without your written
II. How We May Use and Disclose Your Protected Health Information.
For uses and disclosures relating to treatment, payment, or health care operations, we do not need
an authorization to use and disclose your medical information:
For treatment: We may disclose your medical information to doctors, nurses, and other health
care personnel who are involved in providing your health care. We may use your medical information to
provide you with medical treatment or services. For example, your doctor may be providing treatment for
a heart problem and need to make sure that you don’t have any other health problems that could interfere.
The doctor might use your medical history to determine what method of treatment (such as a drug or
surgery) is best for you. Your medical information might also be shared among members of your
treatment team, or with your pharmacist(s).
To obtain payment: We may use and/or disclose your medical information in order to bill and
collect payment for your health care services or to obtain permission for an anticipated plan of treatment.
For example, in order for Medicare or an insurance company to pay for your treatment, we must submit a
bill that identifies you, your diagnoses, and the services provided to you. As a result, we will pass this
type of health information on to an insurer to help receive payment for your medical bills.
For health care operations: We may use and/or disclose your medical information in the course
of operating our practice. For example, we may use your medical information in evaluating the quality of
services provided, or disclose your medical information to our accountant or attorney for audit purposes.
In addition, unless you object, we may use your health information to send you appointment
reminders or information about treatment alternatives or other health related benefits that may be of
interest to you. For example, we may look at your medical record to determine the date and time of your
next appointment with us, and then send you a reminder to help you remember. Or, we may look at your
medical information and decide that another treatment or a new service we offer may interest you.
We may also use and/or disclose your medical information in accordance with federal and state
laws for the following purposes:
• We may disclose your medical information to law enforcement or other specialized government
functions in response to a court order, subpoena, warrant, summons, or similar process.
• We may disclose medical information when a law requires that we report information about
suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in
response to a court order. We must also disclose medical information to authorities who monitor
compliance with these privacy requirements.
• We may disclose medical information when we are required to collect information about disease
or injury, or to report vital statistics to the public health authority. We may also disclose medical
information to the protection and advocacy agency, or another agency responsible for
monitoring the health care system for such purposes as reporting or investigation of unusual
• We may disclose medical information relating to an individual’s death to coroners, medical
examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or
tissue donations or transplants.
• In certain circumstances, we may disclose medical information to assist medical/psychiatric
• In order to avoid a serious threat to health or safety, we may disclose medical information to law
enforcement or other persons who can reasonably prevent or lessen the threat of harm, or to help
with the coordination of disaster relief efforts.
• If people such as family members, relatives, or close personal friends are involved in your care
or helping you pay your medical bills, we may release important health information about your
location, general condition, or death.
• We may disclose your medical information as authorized by law relating to worker’s
compensation or similar programs.
• We may disclose your medical information in the course of certain judicial or administrative
Other uses and disclosures of your medical information not covered by this notice (such as for
marketing purposes) or the laws that apply to us will be made only with your written authorization. If
you provide permission to use or disclose medical information about you, you may revoke that
permission, in writing, at any time. You understand that we 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
III. Your Rights Regarding Your Medical Information.
You have several rights with regard to your health information. If you wish to exercise any of these
rights, please contact our Medical Records Department in our office. Specifically, you have the following
• You have the right to ask that we limit how we use or disclose your medical information. For
example, for services you request no insurance claim be filed and for which you pay privately,
you have the right to restrict disclosures for these services for which you paid out of pocket.
You have the right to ask that we send you information at an alternative address or by alternative
means. We will consider your request, but are not legally bound to agree to the restriction. We
will agree to your request as long as it is reasonably easy for us to do so. To request confidential
communications, you must make your request in writing to the Assistant Office Manager. We
will not ask you the reason for your request. Your request must specify how or where you wish
to be contacted. You have the right to opt out of communications for fundraising purposes.
• With a few exceptions (such as psychotherapy notes or information gathered for judicial
proceedings), you have a right to inspect and copy your protected health information if you put
your request in writing. If we deny your access, we will give you written reasons for the denial
and explain any right to have the denial reviewed. We may charge you a reasonable fee if you
want a copy of your health information. You have a right to choose what portions of your
information you want copied and to have prior information on the cost of copying. Consent is
required prior to use or disclosure of an individual’s psychotherapy notes or the use of the
individuals PHI for marketing purposes.
• If you believe that there is a mistake or missing information in our record of your medical
information you may request that we correct or add to the record. Your request must be in
writing and give you a reason as to why your health information should be changed. Any denial
will state the reasons for denial and explain your rights to have the request and denial, along
with any statement in response that you provide, appended to your medical information. If we
approve the request for amendment, we will amend the medical information and so inform you.
• In some limited circumstances, you have the right to ask for a list of the disclosures of your
health information we have made during the previous six years. The list will not include
disclosures made to you; for purposes of treatment, payment or healthcare operations, for which
you signed an authorization or for other reasons for which we are not required to keep a record
of disclosures. There will be no charge for up to one such list each year. There may be a charge
for more frequent requests.
• You have a right to receive a paper copy of this Notice and/or an electronic copy from our Web
site. If you have received an electronic copy, we will provide you with a paper copy of the
Notice upon request.
IV. Questions and Complaints:
If you want more information about our privacy practices or have questions or concerns, we encourage
you to contact us.
If you think we may have violated your privacy rights, or you disagree with a decision we made about
access to your medical information, we encourage you to speak or write to our Privacy Officer. You also
may file a written complaint with the Secretary of the U.S. Department of Health and Human Services at
the Office for Civil Rights’ Region IV office. We will provide the mailing address at your request.
We will take no retaliatory action against you if you make complaints, whether to us or to the Department
of Health and Human Services. We support your right to the privacy of your health information.
If you have questions about this Notice or any complaints about our privacy practices, please contact our
Privacy Officer, either by phone or in writing at:
Maurice M. Rosenberg, PHR
Human Resources Manager
FWC Management Company, LLC
d/b/a Unified Physician Management
3731 FAU Blvd.
Boca Raton, FL 33431
P: (561) 300-2410, ext. 135
F: (561) 953-4152
Effective Date: This Notice was effective on August 27, 2013.