Wilkinson Snowden Otolaryngology Consultants, P.A.

WILKINSON SNOWDEN OTOLARYNGOLOGY CONSULTANTS
NOTICE OF PRIVACY PRACTICES

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IMPORTANT: THIS NOTICE DESCRIBES YOUR RIGHTS AS A PATIENT AND HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED.

The terms of this Notice of Privacy Practices apply to Wilkinson Snowden Otolaryngology Consultants (WSOC) and are effective April 14, 2003. This organization and its employees will share individual patient health information as is necessary to provide quality health care and receive reimbursement for those services as permitted by law. This office is required by law to maintain the privacy of our patients' individual health information. We reserve the right to change the terms of this Notice of Privacy Practices as necessary. A copy of any revised notices will be available in this office, or, upon request to Wilkinson Snowden Otolaryngology Consults at 836 Prudential Drive North, Suite 807, Jacksonville, FL 32207, a copy may be mailed to your address maintained on file.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Except as described below, this office will maintain the confidentiality of your individual health information. Your individual health information may be used and disclosed as customary and reasonable for purposes of treatment, payment, and health care operations and pursuant to a signed authorization form permitting the use or disclosure. You have the right to revoke that authorization in writing unless any action has been taken in reliance on the authorization.

Treatment, Payment, and Health Care Operations. Except as otherwise provided, or with your signed consent, This office will use and disclosure your individual health information as necessary for purposes of your treatment, payment, and as necessary and permitted by law, for our health care operations which include clinical improvement, professional peer review, business management, accreditation and licensing, etc.

Family and Friends. With your approval and using our best judgment, individual health information may be disclosed to designated family, friends, and others who are involved in your care or in payment of your care. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited individual health information with such individuals without your approval.

Business Associates. At times it may be necessary for us to provide your individual health information to certain outside persons or organizations that assist us with our health care operations, such as auditing, accreditation, legal services, etc. These business associates are required to properly safeguard the privacy of your information.

Appointments and Services. This office may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your individual health information from us by alternative means or at alternative locations. You may request such confidential communication in writing and may send your request to Wilkinson Snowden Otolaryngology Consultants, 836 Prudential Drive North, Suite 807, Jacksonville, FL 32207. You also have the right to request that we not send you any future marketing materials and we will use our best efforts to honor such request. You may make the request by sending your name and address to Wilkinson Snowden Otolaryngology Consultants, 836 Prudential Drive North, Suite 807, Jacksonville, FL 32207, with your request to be removed from our marketing mailing lists.

Other uses and disclosures of your individual health information, permitted or required by law, may be made without your consent or authorization.

· The release of your individual health information for any purpose required by law;

· The release of your individual health information for public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations;

· The release of your individual health information as required by law if we suspect child abuse or neglect; we may also release your individual health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;

· The release of your individual health information to the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls;

· The release of your individual health information to your employer when we have provided health care to you at the request of your employer; in most cases you will receive notice that information is disclosed to your employer;

· The release of your individual health information if required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;

· The release of your individual health information if required to do so by a court or administrative ordered subpoena or discovery request; in most cases you will have notice of such release;

· The release of your individual health information to law enforcement officials as required by law to report wounds and injuries and crimes;

· The release of your individual health information to coroners and/or funeral directors consistent with law;

· The release of your individual health information if necessary to arrange an organ or tissue donation from you or a transplant for you;

· The release of your individual health information if you are a member of the military as required by armed forces services; we may also release your individual health information if necessary for national security or intelligence activities; and

· The release of your individual health information to workers' compensation agencies if necessary for your workers' compensation benefit determination.

YOUR RIGHTS

1.	Access to Individual Health Information. You have the right to copy and/or inspect much of the individual health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative. We will charge you $1.00 per page for the first 25 pages then 25 cents per page there after if you request a copy of the information. We will also charge for postage if you request a mailed copy and will charge for preparing a summary of the requested information if you request such a summary. You may obtain an access request form from our office.
2.	Amendments to Individual Health Information. You have the right to request in writing that individual health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction request. If an amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. You may obtain an amendment request form from our office.
3.	Accounting for Disclosures of Individual Health Information. You have the right to receive an accounting of certain disclosures made by us of your individual health information after April 14, 2003. Requests must be made in writing and signed by you or your representative. Accounting request forms are available from our office. The first accounting in any 12-month period is free; you will be charged a fee of $10.00 for each subsequent accounting you request within the same 12-month period.
4.	Restrictions on Use and Disclosure of Individual Health Information. You have the right to request restrictions on certain of our uses and disclosures of your individual health information. We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate and we retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, and agreed-to restriction by sending such termination notice to our office address.
Complaints If you believe your privacy rights have been violated, you can file a complaint with our office. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.

ADDITIONAL INFORMATION
If you have questions or need additional assistance regarding this Notice, you may contact our office manager in our office.