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Privacy Statement
Central Florida Health Care, Inc.

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 CAREFULLY.

Treatment is the provision, coordination, or management of healthcare and related services by one or more healthcare providers, including the coordination or management of healthcare by a healthcare provider with a third party; consultation between healthcare providers relating to a patient; or the referral of a patient for healthcare from one healthcare provider to another. Example: A copy of your most recent lab work may be sent to a specialist that we refer you to. Payment is the activities undertaken to obtain reimbursement for the provision of healthcare under the health plan; obtain or provide reimbursement for the provision of healthcare; and determination of eligibility or coverage and adjudication of claims; risk adjustment; billing, claims management, collection activities, obtaining payment, and related healthcare data processing; review of services with respect to medical necessity, coverage, appropriateness of care, or justification of charges; utilization review activities; and disclosure to consumer reporting agencies relating to collection of reimbursement Example: Supporting documentation from your chart may be released to your insurance company to support a claim made.

Healthcare Operations means performing any activities related to covered functions, including: conducting quality assessment; reviewing competence or qualifications of healthcare professionals; conducting or arranging for medical review, legal services, and auditing functions, Including fraud and abuse detection and compliance program. Example: A consultant may review your medical record for appropriate documentation.

You have the right to:

Restrict disclosures to individuals who may be involved in your care or payment related to your care - a provider is not required to agree to a restriction, but if they do agree, it must ensure the restriction is followed except when the individual needs emergency treatment.

Receive confidential communication - via alternative means or location.

Inspect and copy protected health Information about you - individuals do not have the right of access to psychotherapy notes, Information compiled for use in a civil, criminal, or administrative action or proceeding.

Request an amendment to your medical record - when an amendment is accepted in whole or in part, the provider must notify the individual to obtain with whom the amendment needs to be shared. The provider may deny amendment If the provider did not create the information, it is not part of the provider's designated record set, or the information Is accurate and complete.

Request an accounting of disclosures - pertains to disclosures of protected health information unless the disclosure was to; carry out treatment, payment, or healthcare operations, to the individual about themselves, to person's involved with the individuals care, for national security purposes, to law enforcement or custodial situation, or occurred prior to the compliance date of the privacy rule.

For further information contact the facility's Compliance Officer by calling (863) 452-3000 or in writing to: CFHC Compliance Officer, 950 County Road 17-A West, Avon Park, Florida 33825
 

Patient Signature ___________________________________

Date ___________________________________

Form 260 (3/03)