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.
For purposes of this Notice “us” “we” and
“our” refers to John D. Dos Passos, II, D.M.D., P.A.
and “you” or “your” refers to our patients
(or their legal representatives as determined by us in accordance
with Florida informed consent law). When you receive health-care
services from us, we will obtain access to your medical information
(e.g., your health history). We are committed to maintaining the
privacy of your health information and we have implemented numerous
procedures to ensure that we do so.
Florida law and the Health Insurance Portability & Accountability
Act of 1996 (HIPAA) require us to maintain the confidentiality of
all your health-care records and other individually identifiable
health information used by or disclosed to us in any form, whether
electronically, on paper, or orally(“PHI” or Protected
Health Information). HIPAA is a federal law that gives you significant
new rights to understand and control how your health information
is used. HIPAA and Florida law provide penalties for covered entities
and records owners, respectively, that misuse or improperly disclose
PHI. Also, we honor the Hippocractic Oath and our profession’s
ethical guidelines.
Starting April 14, 2003, HIPAA requires us to provide you with
this Notice of our legal duties and the privacy practices we are
required to follow when you first come into our office for health-care
services. If you have any questions about this Notice, please ask
to speak to our privacy officer, Vivian L. Wilson, at 813-963-0307
or john.dospassos@verizon.net.
Our doctors, clinical staff, Business Associates (outside contractors
we hire), employees and other office personnel follow the policies
and procedures set forth in this notice. If your regular doctor
is unavailable to assist you (e.g. illness, on-call coverage, vacation,
etc.), we may provide you with the name of another health-care provider
outside our practice for you to consult with by telephone. If we
do so, that provider will follow the policies and procedures set
forth in this notice or those established for his or her practice,
so long as they substantially conform to those for our practice.
OUR RULES ON HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH
INFORMATION
Under the law (§456.074, Fla. Stats., and HIPAA), we must
have your signature on a written, dated Consent form and/ or an
Authorization form (not an Acknowledgment form) before we will use
and disclose your PHI for certain purposes as detailed in the rules
below.
Documentation You will be asked to sign a Consent form and/or an
Authorization form when you receive this Notice of Privacy Practices.
If you did not sign such a form or need a copy of the one you signed,
please contact our privacy officer. You may take back or revoke
your Consent or Authorization at any time (unless we already have
acted based on it) by submitting our Revocation form in writing
to us at our address listed above. Your revocation will take effect
when we actually receive it. We cannot give it retroactive effect,
so it will not affect any use or disclosure that occurred in our
reliance on your Consent or Authorization prior to revocation (e.g.,
if after we provide services to you, you revoke your Authorization
or Consent in order to prevent us billing or collecting for those
services, your revocation will have no effect because we relied
on your Authorization or Consent to provide services before you
revoked it).
General Rule If you do not sign our Consent form or if you revoke
it, as a general rule (subject to exceptions described below under
“Healthcare Treatment, Payment and Operations Rule”
and “Special Rules”), we cannot in any manner use or
disclose to anyone (excluding you, but including payers and Business
Associates) your PHI or any other information in your medical record.
Under Florida law, we are unable to submit claims to payers under
assignment of benefits without your signature on our Consent form.
We will not condition treatment on your signing an Authorization,
but we may be forced to decline you as a new patient or discontinue
you as an active patient if you choose not to sign the Consent or
revoke it.
Health-care Treatment, Payment and Operations Rule With your signed
Consent, we may use or disclose your PHI in order:
• To provide you with or coordinate health-care treatment
and services. For example, we may review your health history form
to form a diagnosis and treatment plan, consult with other doctors
about your care, delegate tasks to ancillary staff, call in prescriptions
to your pharmacy, disclose needed information to your family or
others so they may assist you with home care, arrange appointments
with other health-care providers, schedule lab work for you, etc.;
• To bill or collect payment from you, an insurance company,
a managed-care organization, a health benefits plan or another third
party. For example, we may need to verify your insurance coverage,
submit your PHI on claim forms in order to get reimbursed for our
services, obtain pre-treatment estimates or prior authorizations
form your health plan or provide your X-rays because your health
plan requires them for payment; or
• To run our office, assess the quality of care our patients
receive and provide you with customer service. For example, to improve
efficiency and reduce costs associated with missed appointments,
we may contact you by telephone, mail or otherwise remind you of
scheduled appointments, we may leave messages with whomever answers
your telephone or e-mail to contact us (but we will not give out
detailed PHI), we may call you by name from the waiting room, we
may ask you to put your name on a sign-in sheet, we may tell you
about or recommend health-related products and complementary or
alternative treatments that may interest you, we may review your
PHI to evaluate our staff’s performance, or our privacy officer
may review your records to assist you with complaints. If you prefer
that we not contact you with appointment reminders or information
about treatment alternatives or health-related products and services,
please notify us in writing at our address listed above and we will
not use or disclose your PHI for these purposes.
Special Rules Notwithstanding anything else contained in this Notice,
only in accordance with applicable law, and under strictly limited
circumstances, we may use or disclose your PHI without your permission,
Consent or Authorization for the following purposes:
• When required under federal, state or local law;
• When necessary in emergencies to prevent a serious threat
to your health and safety or the health and safety of other persons;
• When necessary for public health reasons (e.g., prevention
or control of disease, injury or disability; reporting information
such as adverse reactions to anesthesia; ineffective or dangerous
medications or products; suspected abuse, neglect or exploitation
of children, disabled adults or the elderly; or domestic violence);
• For federal or state government health-care oversight activities
(e.g., civil rights laws, fraud and abuse investigations, audits,
investigations, inspections, licensure or permitting, government
programs, etc.);
• For judicial and administrative proceedings and law enforcement
purposes (e.g., in response to a warrant, subpoena or court order;
by providing PHI to coroners, medical examiners and funeral directors
to locate missing persons, identify deceased persons or determine
cause of death);
• For workers’ compensation purposes (e.g., we may disclose
your PHI if you have claimed health benefits for a work-related
injury or illness);
• For intelligence, counterintelligence or other national
security purposes (e.g., Veterans Affairs, U.S. military command,
other government authorities or foreign military authorities may
require us to release PHI about you);
• For organ and tissue donation (e.g., if you are an organ
donor we may release your PHI to organizations that handle organ,
eye or tissue procurement, donation and transplantation);
• For research projects approved by an Institutional Review
Board or a privacy board to ensure confidentiality (e.g., if the
researcher will have access to your PHI because involved in your
clinical care, we will ask you to sign an Authorization);
• To create a collection of information that is “de-identified”
(e.g., it does not personally identify you by name, distinguishing
marks or otherwise and no longer can be connected to you);
• To family members, friends and others, but only if you verbally
give permission; we give you an opportunity to object and you do
not; we reasonably assume, based on our professional judgment and
the surrounding circumstances, that you do not object (e.g., you
bring someone with you into the operatory or exam room during treatment
or into the conference area when we are discussing your PHI); we
reasonably infer that it is in your best interest (e.g., to allow
someone to pick up your records because they knew you were our patient
and you asked them in writing with your signature to do so); or
it is an emergency situation involving you or another person (e.g.,
your minor child or ward) and, respectively, you cannot consent
to your care because you are incapable of doing so or you cannot
consent to the other person’s care because, after a reasonable
attempt, we have been unable to locate you. In these emergency situations
we may, based on our professional judgment and the surrounding circumstances,
determine that disclosure is in the best interests of you or the
other person, in which case we will disclose PHI, but only as it
pertains to the care being provided and we will
• notify you of the disclosure as soon as possible after the
care is completed.
Minimum Necessary Rule Our staff will not use or access your PHI
unless it is necessary to do their jobs (e.g., doctors uninvolved
in your care will not access your PHI; ancillary clinical staff
caring for you will not access your billing information; billing
staff will not access your PHI except as needed to complete the
claim form for the latest visit; janitorial staff will not access
your PHI). Also, we disclose to others outside our staff only as
much of your PHI as is necessary to accomplish the recipient’s
lawful purposes. For example, we may use and disclose the entire
contents of your medical record:
• To you (and your legal representatives as stated above)
and any one else you list on a Consent or Authorization to receive
a copy of your records;
• To health-care providers for treatment purposes (e.g. making
diagnosis and treatment decisions or agreeing with prior recommendations
in the medical record);
• To the U.S. Department of Health and Human Services (e.g.,
in connection with a HIPAA complaint);
• To others as required under federal or Florida law;
• To our privacy officer and others as necessary to resolve
your complaint or accomplish your request under HIPAA (e.g., clerks
who copy records need access to your entire medical record).
In accordance with the law, we presume that requests for disclosure
of PHI from another Covered Entity (as defined in HIPAA) are for
the minimum necessary amount of PHI to accomplish the requester’s
purpose. Our privacy officer will individually review unusual or
non-recurring requests for PHI to determine the minimum necessary
amount of PHI and disclose only that. For non-routine requests or
disclosures, the Plan’s Privacy Officer will make a minimum
necessary determination based on, but not limited to, the following
factors:
• The amount of information being disclosed;
• The number of individuals or entities to whom the information
is being disclosed;
• The importance of the use or disclosure;
• The likelihood of further disclosure;
• Whether the same result could be achieved with de-identified
information;
• The technology available to protect confidentiality of the
information; and
• The cost to implement administrative, technical and security
procedures to protect confidentiality.
If we believe that a request from others for disclosure of your
entire medical record is unnecessary, we will ask the requester
to document why this is needed, retain that documentation and make
it available to you upon request.
Incidental Disclosure Rule We will take reasonable administrative,
technical and security safeguards to ensure the privacy of your
PHI when we use or disclose it (e.g., we require employees to talk
softly when discussing PHI with you, we use computer passwords and
change them periodically [e.g., when an employee leaves us], we
allow access to areas where PHI is stored or filed only when we
are present to supervise and prevent unauthorized access).
Business Associate Rule Business Associates and other third parties
(if any) that receive your PHI from us will be prohibited from re-disclosing
it unless required to do so by law or you give prior express written
consent to the re-disclosure. Nothing in our Business Associate
agreement will allow our Business Associate to violate this re-disclosure
prohibition.
Super-confidential Information Rule If we have PHI about you regarding
HIV testing, alcohol or substance abuse diagnosis and treatment,
or psychotherapy and mental health records (super-confidential information
under the law), we will not disclose it under the General or Health-care
Treatment, Payment and Operations Rules (see above) without you
first signing and properly completing our Consent form (i.e., you
specifically must initial the type of super-confidential information
we are allowed to disclose). If you do not specifically authorize
disclosure by initialing the super-confidential information, we
will not disclose it unless authorized under the Special Rules (see
above) (e.g., we are required by law to disclose it). If we disclose
super-confidential information (either because you have initialed
the Consent form or the Special Rules authorize us to do so), we
will comply with state and federal law that requires us to warn
the recipient in writing that re-disclosure is prohibited.
Changes to Privacy Policies Rule We reserve the right to change
our privacy practices (by changing the terms of this Notice) at
any time as authorized by law. The changes will be effective immediately
upon us making them. They will apply to all PHI we create or receive
in the future, as well as to all PHI created or received by us in
the past (i.e., to PHI about you that we had before the changes
took effect). If we make changes, we will post the changed Notice,
along with its effective date, in our office. Also, upon request,
you will be given a copy of our current Notice.
Authorization Rule We will not use or disclose your PHI for any
purpose or to any person other than as stated in the rules above
without your signature on a specifically worded, written Authorization
form (not a Consent or an Acknowledgement). If we need your Authorization,
we must obtain it on our Authorization form, which is separate from
any Consent or Acknowledgment we may have obtained from you. We
will not condition treatment on whether you sign the Authorization
(or not).
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
If you got this Notice via e-mail or web-site, you have the right
to get, at any time, a paper copy by asking our privacy officer.
Also, you have the following additional rights regarding PHI we
maintain about you:
To Inspect and Copy You have the right to see and get a copy of
your PHI including, but not limited to, medical and billing records
by submitting a written request to our privacy officer on our Request
to Inspect, Copy or Summarize form. Original records will not leave
the premises, will be available for inspection only during our regular
business hours, and only if our privacy officer is present at all
times. You may ask us to give you the copies in a format other than
photocopies (and we will do so unless we determine that it is impracticable)
or ask us to prepare a summary in lieu of the copies. We may charge
you a fee not to exceed Florida law to recover our costs (including
postage, supplies and staff time as applicable, but excluding staff
time for search and retrieval ) to duplicate or summarize your PHI.
We will not condition release of the copies or summary on payment
of your outstanding balance for professional services (if you have
one), but we may condition release of the copies or summary on payment
of the copying fees. We will respond to requests in a timely manner,
without delay for legal review, in less than thirty days if submitted
in writing on our form or otherwise, and in ten business days or
less if malpractice litigation or pre-suit production is involved.
We may deny your request in certain limited circumstances (e.g.,
we do not have the PHI; it came from a confidential source, etc).
If we deny your request, you may ask for a review of that decision.
If required by law, we will select a licensed health-care professional
(other than the person who denied your request initially) to review
the denial and we will follow his or her decision. If we select
a licensed health-care professional who is not affiliated with us,
we will ensure a Business Associate agreement is executed that prevents
re-disclosure of your PHI without your consent by the outside professional.
To Request Amendment / Correction If another doctor involved in
your care tells us in writing to change your PHI, we will do so
as expeditiously as possible upon receipt of the changes and will
send you written confirmation that we have made the changes. If
you think PHI we have about you is incorrect, or that something
important is missing from your records, you may ask us to amend
or correct it (so long as we have it) by submitting a Request for
Amendment / Correction form to our privacy officer. We normally
will act on your request within 60 days from receipt, but we may
extend our response time (within the 60-day period) no more than
once and by no more than 30 days, in which case we will notify you
in writing why and when we will be able to respond. If we grant
your request, we will let you know within five business days, make
the changes by noting (not deleting) what is incorrect or incomplete
and adding to it the changed language, and send the changes within
5 business days to persons you ask us to and persons we know may
rely on incorrect or incomplete PHI to your detriment (or already
have). We may deny your request under certain circumstances (e.g.,
it is not in writing, it does not give a reason why you want the
change, we did not create the PHI you want changed (and the entity
that did can be contacted), it was compiled for use in litigation,
or we determine it is accurate and complete). If we deny your request,
we will (in writing within 5 business days) tell you: why and how
to file a complaint with us if you disagree, that you may submit
a written disagreement with our denial (and we may submit a written
rebuttal and give you a copy of it), that you may ask us to disclose
your initial request and our denial when we make future disclosures
of PHI pertaining to your request, and that you may complain to
us and the U.S. Department of Health and Human Services.
To an Accounting of Disclosures You may ask us for a list of those
who got your PHI from us by submitting a Request for Accounting
of Disclosures form to us. The list will not cover some disclosures
(e.g. PHI given to you, given to your legal representative, given
to others for treatment, payment or health-care-operations purposes).
Your request must state in what form you want the list (e.g., paper
or electronically) and the time period you want us to cover, which
may be up to but no more than the last six years (excluding dates
before April 14, 2003). If you ask us for this list more than once
in a 12-month period, we may charge you a reasonable, cost-based
fee to respond, in which case we will tell you the cost before we
incur it and let you choose if you want to withdraw or modify your
request to avoid the cost.
To Request Restrictions You may ask us to limit how your PHI is
used and disclosed (i.e. in addition to our rules as set forth in
this Notice) by submitting a written Request for Restrictions on
Use / Disclosure form to us (e.g., you may not want us to disclose
your surgery to family members or friends involved in paying for
our services or providing your home care). If we agree to these
additional limitations, we will follow them except in an emergency
where we will not have time to check for limitations. Also, in some
circumstances we may be unable to grant your request (e.g., we are
required by law to use or disclose your PHI in a manner that you
want restricted; you signed an Authorization form, which you may
revoke, that allows us to use or disclose your PHI in the manner
you want restricted; in an emergency).
To Request Alternative Communications You may ask us to communicate
with you in a different way or at a different place by submitting
a written Request for Alternative Communication form to us. We will
not ask you why and we will accommodate all reasonable requests
(including, e.g., to send appointment reminders in closed envelopes
rather than by postcards, to send your PHI to a post office box
instead of your home address, to communicate with you at a telephone
number other than your home number). You must tell us the alternative
means or location you want us to use and explain to our satisfaction
how payments to us will be made if we communicate with you as you
request.
To Complain or Get More Information We will follow our rules as
set forth in this Notice. If you want more information or if you
believe your privacy rights have been violated (e.g., you disagree
with a decision of ours about inspection / copying, amendment /
correction, accounting of disclosures, restrictions or alternative
communications), we want to make it right. We never will penalize
you for filing a complaint. To do so, please file a formal, written
complaint within 180 days with:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Ave., S.W.
Washington, D.C. 20201
(877) 696-6775 (toll free)
Or, submit a written Complaint form to us at the following address:
John D. Dos Passos, II, D.M.D., P.A.,
6552 Gunn Highway,
Tampa, Fl. 33625,
Phone 813-963-0307
Fax 813-968-3210,
john.dospassos@verizon.net
You may get your complaint form by calling our privacy officer.
These privacy practices will be effective April 14, 2003, and will
remain in effect until we replace them as specified above
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