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.

Your Rights
Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record.
• We will provide a copy or a summary of your health information, within 30 days of your request. We can charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information that you think is incorrect or incomplete.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care out-of-pocket in full, you can ask us not to share that information for the purpose of payment with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list of the times we’ve shared your health information, who we shared it with, and why.
• We will include all the disclosures except for those not required by law.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
You can file a complaint with the BG Privacy Officer if you feel we have violated your right.
Fleming Island Surgery Center
4800 Belfort Road
Jacksonville, FL 32256
Telephone (904) 398-3262
http://flemingislandsurerycenter.com

U.S. Department of Health
Please contact BG Clinic for address and phone

We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest or to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

Fund raising

We can contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures: How do we typically use or share your information?

Treat you

We can use your information and share it with other professionals who are treating you or for electronic health information networks to facilitate the provision of care.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We can use health information about you to manage your treatment and services. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

Help with public health and safety issues
We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications (FDA)
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We can share health information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with medical examiner, coroner, or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with law enforcement officials
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Business Associates

We can share health information with third parties to provide services on our behalf so that they can perform the job we’ve asked them to do. The law requires the business associate to appropriately safeguard your information.

Open Treatment Areas

While special care is taken to maintain patient privacy, others may overhear some patient information while receiving treatment.

Communication with Family/Friends

We can, using our best judgment, disclose to a family member, other relative, close personal friend or any other person, health information relevant to that person’s involvement in your care or payment. When a family member(s) or a friend(s) accompany you into the exam room, it is considered implied consent that a disclosure of your PHI is acceptable.

Communication

We can communicate with you, using any provided number or information, to leave a message on voice mail, speak in person, by encrypted e-mail, patient portal, or text appointment reminders, insurance items, care correspondence, patient satisfaction surveys and patient statements about your health care.

We can record your phone calls in order to monitor the quality of the service we provide you over the phone.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• Provide you with notice of our legal duties and privacy practices with respect to your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.