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Our Pledge Regarding Medical Information:
Citrus Spine Institute (CSI) understands that medical information about you and your health is personal, and we are committed to protecting that information.
This notice applies to all the records of your care generated by our clinic, whether made by clinic personnel or treating physicians. This notice will tell you about the ways in which we may use and disclosure your protected health information, (protected health information includes medical and identifying information about you). We also describe your rights and certain obligations we have regarding the use and disclosure of your protected health information.
Who Will Follow This Notice:
This notice describes our clinic's practices and that of:
• All employees, staff and other CSI personnel.
• Any health care professional authorized to enter information into or access information from your clinic chart (e.g. physicians, students, and other nonemployee health care providers).
• Any member of a volunteer group we allow to help you while you are under our care.
We are required by law to:
• Maintain the privacy of your protected health information.
• Give you this notice of our legal duties and privacy practices.
• Notify you in the event of an improper disclosure of your unsecured protected health information.
• Follow the terms of the notice that is currently in effect.
How We May Use and Disclose Protected Health Information About You:
The following categories describe different ways that we use and disclose your protected health information. We provide examples, but not every use or disclosure in a category
will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment: We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses,
technicians, health care students, or other clinic personnel who are involved in taking care of you at the clinic. For example, a doctor treating you will want to know your medical
history to determine a proper course of treatment. Also, different departments of the clinic may need to share health information about you in order to coordinate the care provided.
We also may disclose health information about you to people outside the clinic who may be involved in your medical care after you leave the clinic, such as transport companies,
community agencies, family members, or others we use to provide services that are part of your care.
For Payment: We may use and disclose your health information so that the treatment and services you receive at the clinic may be billed to, and payment may be collected
from, you, an insurance company or a third party. Information may also be disclosed for physician billing. For example, we may need to give your health plan information about
treatment you received at the clinic so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about future treatment to obtain prior
approval or to determine whether your plan will cover the treatment.
For Health Care Operations: We may use and disclose health information about you for clinic operations. These uses and disclosures are necessary to improve quality of care,
for clinic management, and medical staff purposes. For example, we may use your information to review our treatment and services and to evaluate the performance of our
staff. We may disclose information to doctors, and other health personnel for review and learning purposes. We may also combine the information we have with information from other clinics to see where we can make improvements in the care and services we offer. In addition, we may remove information that identifies you from this set of information so
others may use it to study health care and health care delivery.
Other Communications with Family and Friends Involved in Your Care: We may release health information about you to a friend or family member who is involved in your
medical care or payment related to your care. We may tell such individuals your condition and that you are in our clinic. In addition, we may disclose health information about you to assist in a disaster relief effort so that your family can be notified about your condition, status and location.
As Required By Law: We will disclose health information about you when required to do so by federal or state law.
Research: CSI supports certain approved medical research efforts and your health information may be used or disclosed for research purposes. Your medical record may
also be reviewed and data included in a research study after you leave the clinic. In addition, your health information may be reviewed in preparation for research or used in a
format that will not specifically identify you, or very limited information may be used and no additional authorization is required. For example, a research study may review the
medical records of all patients who received a particular medication in a certain time period. A Privacy Board will determine whether your authorization is necessary for your
health information to be included. You will not be included in a clinical study unless you provide informed consent.
To Avert Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and
safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent or lessen the threat.
Public Health Risks: We may disclose health information about you for public health activities. We will only make these disclosure if you agree or when required or authorized
by law. These activities generally include the following:
• To prevent or control disease (such as cancer and tuberculosis); injury or disability;
• To report births and deaths;
• To report child abuse or neglect;
• To report reactions to medications, food, or problems with products;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify your employer of a work-related illness or injury, if the health care was provided at the request of the employer and the employer is required to record the
• To notify a school of proof of immunization;
• To notify the appropriate government authorities and agencies if we believe a patient has been the victim of abuse, neglect, or domestic violence
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include audits,
investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance
with the law
Legal Actions: In connection to a lawsuit or other legal proceedings, we may disclose health information about you in response to a court or administrative order. We may also
disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been
made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement: We may release certain health information if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness or missing person;
• About the victim of a crime if the victim is unable to consent;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at CSI; and
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors: We may release health information to a coroner, medical examiner or funeral director. This may be necessary, for
example, to identify a deceased person or determine the cause of death.
Organ and Tissue Donations: If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue
transplant or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation
Special Government Functions:
• Military and Veterans: If you are a member of the armed forces, we may release health information about you as required by military authorities. We may also
release health information about foreign military personnel to the appropriate foreign military authority.
• National Security and Intelligence Activities: We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
• Protective Services for the President and Others: We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations authorized by law.
• Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional official as authorized or required by law.
Workers’ Compensation: We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related
injuries or illnesses.
Psychotherapy Notes: means notes recorded by a mental health professional documenting or analyzing the contents of conversation during a private counseling
session or a group, joint, or family counseling session. Psychotherapy notes are kept separate from your individual medical record and may only be disclosed (without your written authorization) in the following limited circumstances:
• Use or disclose by the CSI for its own training programs;
• Use or disclosure by CSI to defend itself in a proceeding brought by you or your representative;
• Use or disclosure required in an action against CSI regarding compliance with privacy regulations;
• Use or disclosure otherwise required by law;
• Use or disclosure to a health oversight agency for activities authorized by law with respect to the oversight of the creator of the psychotherapy notes;
• Use or disclosure to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death; or
• Use or disclosure to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
Other Uses of Health Information: Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written
authorization. Some types of uses and disclosures that require your written authorization are:
• Psychotherapy Notes: Psychotherapy notes may not be used or disclosed without your written authorization except as otherwise noted above.
• Marketing: Your health information may not be used or disclosed for marketing purposes without your written authorization, unless the communication is a face-to-face communication made by CSI to you, or a promotional gift of nominal value provided by the CSI.
• Selling your information: Your health information may not be sold to a third party without your written authorization.
If you provide us with permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will
no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we
have already made with your permission, and that we are required to retain our records of the care that we provide to you.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health
operation. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a
family member or friend. However, we are not required to agree to your request, unless the disclosure pertains solely to a health care item or service for which you or someone else other than your insurance has paid for the item or service in full. For example, you could ask that we not disclose information about a particular surgery that you had and paid for out-of-pocket.
To request restrictions, you must make your request in writing to the Office Manager. In your request, you must indicate (1) what information you want to limit; (2) whether you
want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to a relative.
Right to Receive Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For
example, you can ask that we only contact you at work. To request confidential communications, you must specify how or where you wish to be contacted and make your request in writing to the Office Manager. We will not ask you the reason for your request. We will accommodate all reasonable requests.
Right to Inspect and Receive a Copy: You have the right to inspect and/or receive a copy of the records that the clinic maintains to make decisions about your care. Those
records include your medical and billing records. To inspect and/or obtain a copy of your medical records you must submit your request in writing to the Office Manager. If you request a copy of the records, we will charge you the costs of copying, mailing or other supplies associated with your request. In certain limited circumstances, the law authorizes CSI to deny your request to inspect and receive a copy of your records. If you are denied access to your health information, you will be provided a written explanation for the denial and an explanation of your right to request a review of the decision to deny your request.
Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an
amendment for as long as the information is kept by or for the clinic.
To request an amendment, you must provide a reason that supports your request and your request must be submitted in writing to the Office Manager. We may deny your
request for an amendment if you ask us to amend information that:
• Was not created by Citrus Spine Institute;
• Is not part of the health information kept by or for the clinic;
• Is not part of the information which you would be permitted to inspect and receive a copy; or
• Is accurate and complete.
Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures," made by CSI in the six years prior to the date of your request, The accounting is a list of certain disclosures of your health information.
To request this accounting of disclosures, you must submit your request in writing to the Office Manager. Your request should indicate in what form you want the list (for example, on paper, or electronically). You are entitled to one accounting of disclosures within any 12-month period at no charge. For additional requests during that same 12-month period, we will charge you for the costs of providing it to you. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. To obtain a paper copy of this notice contact the Facility Privacy Official (Office Manager) in writing or you may download a copy from our web site at www.citrusspine.com.
Changes to This Notice: We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have
about you as well as any information we receive in the future. If we make a material change to the terms of this notice, we will make the revised notice available to you upon request. We will post a copy of the current notice in the clinic, and it will include the effective date for the notice. In addition, each time you register at or are admitted to the clinic for treatment or health care services as an outpatient, we will offer you a copy of the current notice in effect.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with Citrus Spine Institute and/or with the Secretary of the Department of Health and Human Services. You will not be retaliated against Citrus Spine Institute for filing a complaint.
To file a complaint with Citrus Spine Institute, contact the Facility Privacy Officer (Office Manager) in writing at 6099 W. Gulf to Lake Highway, Crystal River, FL 34429.
To file a complaint with the Secretary of the Department of Health and Human Services, contact: Department of Health and Human Services, Office for Civil Rights. If you need help filing a complaint or have a question, you may e-mail OCR at OCRMail@hhs.gov.
If you have any questions about this notice, you may contact the Facility Privacy Officer (Office Manager) at:
Citrus Spine Institute
Constantina M. Mavros
Facility Privacy Official/Office Manager
6099 W. Gulf to Lake Highway
Crystal River, FL 34452
Or by telephone at (352) 794-6868.
Effective Date: January 1, 2016.
6099 W. Gulf to Lake Hwy
Crystal River, FL 34429
As a boutique medical practice offering non-surgical and surgical treatment options for spine patients, we provide white-glove service paired with trusted expertise.