Our Program



How We May Use and Disclose Health Information About You

1. We may use and disclose health information about you to:

    a. Provide you with medical treatment or services (such as sharing information with a consulting physician who has been asked to examine your health information).  We also may share health information about you with people who may be involved with your medical care.  These people include family members (unless you object), home health agencies, nursing homes, or others we use to help provide services that are part of your ongoing  care; b. Bill and collect payment from you, an insurance company or a third party.  For example, we may need to give a health plan information about a procedure performed on you so that they will pay us, or reimburse you, for the cost of the procedure.  We also may share health information with our business associates who assist us with billing and collection.  Our business associates include billing companies, claims processing and pre- certification companies, collection agencies, clearinghouses and others that process our health care claims.  c. Assist us with our healthcare operations.  For example, we may use health information about you to review our treatment and services and/or to evaluate the performance of our staff.  We may also share health information with our business associates that assist us with health care operations and perform other administrative activities on our behalf.


2. We may contact you to remind you that you have an appointment, to follow up on health care services that were provided to you, to tell you about treatment alternatives or to tell you about other health related benefits and services that may be of interest to you.


3. We may share health information about you with family members or friends whom you indicate are involved in your medical care.  In certain disasters and related emergency situations, we share health information about you with disaster relief organizations (such as the Red Cross, etc.) so that your family can be notified about your condition, status and location.

4. In certain situations, we may use and share health information about you for research purposes.  However, all research projects are subject to a special review and approval process designed, among other things, to ensure the privacy of your health information.  We may disclose health information about you to people preparing to conduct research (for example, to help them look for patients with specific medical needs).


7. We may use or disclose health information about you without your permission only as allowed by law.  Examples of situations where we may be required to release health information about you include: emergencies, public health, health or safety threats, reporting abuse or neglect, health oversight and audit activities, national security, coroners, medical examiners, funeral directors, organ/tissue donation, and workers’ compensation.  We also may be required by law to provide health information about you in response to requests from law enforcement officials in limited circumstances, correctional institutions, or as part of legal proceedings in response to valid judicial or administrative orders and/or other valid legal authority. 

Other Uses of Health Information

Uses or disclosures of your health information that are not covered by this Notice or the law will be made only with your written permission.  (This includes those used for marketing purposes other than materials sent to you about health care services or other treatment options).  In further support of your right to privacy, we cannot accept your blanket authorization to disclose health information for treatment you have not yet received.  If you permit us to use or share health information about you, you may take back that permission, in writing, at any time.  If you take back your permission, we will no longer use or share the health information you specified for the reasons you noted in writing.  You understand that when you take back your permission we are unable to retrieve any information we may have already shared with your permission.  We also are required to maintain original records of the care that we provide to you.

Your Rights Regarding Health Information About You

1. You have the right to see and receive a copy of health information about you.  To do so, you must submit your request in writing.  If you request a copy, it must be requested in advance and we may charge a fee for the cost of copies, postage and/or other supplies.  In certain situations, we may deny your request.  If we deny  your request, we will tell you, in writing, why your request was denied and explain to you your right to have the denial reviewed.

2. If you feel that our record of your health information is incorrect or incomplete, you have the right to request to amend the information.  You may do this by sending your request in writing, including your reason for the request.  We may deny your request if the information was not created by us, is not part of the health information maintained by us, or if it is determined that the health information is correct.  You may appeal our decision by sending a written request to us.

3. You have the right to request a list of all of our disclosures of your health information, except for information disclosed for treatment, payment or health care operations, or for those disclosures you specifically authorized and for certain other activities.  To request this list, you must send your request in writing.  Your request must tell us a specific time period (beginning after April 14, 2003) of not more than six years.  The first disclosure list you request in any 12-month period is     free.  We may charge a fee for additional lists.

4. You have the right to ask that we limit how we use and disclose health information about you.  You may do so by submitting a request in writing, telling us how and what information to limit.  We will consider your request but we are not legally required to accept it.  We also are not required to agree to your request.  If we do agree, we will follow your request unless the information is needed to provide you with emergency treatment.

5. You have the right to ask us to send information to you at a different address (for example, sending information to your work address instead of your home address) or in a different way (for example, in an unmarked envelope instead of our regular mailing envelope).  You may do so by sending a request in writing.  We have the right to decide whether the request is reasonable.  We do not have to comply with an unreasonable request.

6. You have the right to receive a paper copy of this Notice.  You may ask us to give you a copy of this Notice at any time.



 If you feel that your privacy rights have been violated, you may file a complaint by calling our office manager at _______________or with Tampa Bay Surgical Group’s Administrative Office at 606 S. Boulevard, Tampa, FL 33606.  You also may file a complaint with the Secretary of the Department of Health and Human Services.  You will not be penalized for filing a complaint.

Changes to this Notice

We reserve the right to change this Notice and our privacy policies at any time.  Before we make an important change to our policies, we will promptly revise this Notice and post a new Notice.   Any changes will apply to the health information we have on file and health information we create or receive after the effective date of the new Notice.  You may request a copy of the current Notice from our office.  The effective date of this Notice is: May 1, 2009.