NONDISCRIMINATION NOTICE
Issa F. Baroudi, M.D., P.A. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity). Issa F. Baroudi, M.D., P.A. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity).
Issa F. Baroudi, M.D., P.A. provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
Issa F. Baroudi, M.D., P.A. provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact 941-627-5155
If you believe that Issa F. Baroudi, M.D., P.A. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity), you can file a grievance with the: HIPPA/Compliance Officer at 3222 Tamiami Trail, Port Charlotte, FL 33952 or (941) 627-5155 or admin@baroudimd.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, HIPPA/Compliance Officer is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION PURSUANT TO FEDERAL REGULATIONS. PLEASE REVIEW IT CAREFULLY.
At Issa Baroudi MD, PA (“Practice”), we understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive directly from one of our physicians. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice of Privacy Practices (“Notice”) applies to all the records of your care generated by Practice.
This Notice will tell you about the ways in which Practice may use and disclose your protected health information (“PHI”). This Notice also describes your rights and certain obligations Practice has regarding the use and disclosure of PHI.
REGULATORY REQUIREMENTS.
Practice is required by law to maintain the privacy of your PHI, to provide individuals with notice of Practice’s legal duties and privacy practices with respect to PHI, and to abide by the terms described in the Notice currently in effect.
RIGHTS.
You have the following rights regarding your PHI:
Restrictions.
You may request that Practice restrict the use and disclosure of your PHI. To request restrictions, you must make your request in writing to our Privacy Officer using the applicable Practice form. In your request, you must tell us (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 restrictions to apply, for example, disclosures to your spouse.
Alternative Communications.
You have the right to request that communications of PHI to you from Practice be made by particular means or at particular locations. For instance, you might request that communications be made at your work address, instead of your home address. Your requests must be made in writing using Practice’s form and sent to the Privacy Officer. Practice will accommodate your reasonable requests.
Inspect and Copy.
Generally, you have the right to inspect and copy your PHI that Practice maintains, provided you make your request in writing to Practice’s Privacy Officer. If you request copies of your PHI, we may impose a reasonable fee to cover copying and postage. If we deny access to your PHI, we will explain the basis for denial and your opportunity to have your request and the denial reviewed by a licensed health care professional (who was not involved in the initial denial decision) designated as a reviewing official. If Practice does not maintain the PHI you request and if we know where that PHI is located, we will tell you how to redirect your request.
Amendment.
If you believe that your PHI maintained by Practice is incorrect or incomplete, you may ask us to correct your PHI. Your request must be made in writing, and it must explain why you are requesting an amendment to your PHI. We can deny your request if your request relates to PHI: (i) not created by Practice; (ii) not part of the records Practice maintains; (iii) not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, we will provide you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant PHI be made with a copy of your request and Practice’s denial attached; and (iii) complain about the denial.
Accounting of Disclosures.
You generally have the right to request and receive a list of the disclosures of your PHI we have made at any time during the six (6) years prior to the date of your request (provided that such a list would not include disclosures made prior to April 14, 2003). The list will not include disclosures made at your request, with your authorization, and does not include certain uses and disclosures to which this Notice already applies, such as those: (i) for treatment, payment and health care operations; (ii) made to you; (iii) for Practice’s patient list; (iv) for national security or intelligence purposes; or (v) to law enforcement officials. You should submit any such request to Practice’s Privacy Officer. Practice will provide the list to you at no charge, but if you make more than one request in a year you will be charged a fee of the costs of providing the list.
Right to Copy of Notice.
You have the right to receive a paper copy of this notice upon request. To obtain a paper copy of this notice, please contact the Privacy Officer at the address and contact information stated at the end of this notice.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
Practice may use or disclose your PHI for the purposes described below without obtaining written authorization from you. In addition, Practice and the members of its medical and allied health professional staff who participate in the organized health care arrangement described below may share your PHI with each other as necessary to carry out their treatment, payment and health care operations related to the organized health care arrangement.
For Treatment.
Practice may use and disclose PHI while providing, coordinating or managing your medical treatment, including the disclosure of PHI for treatment activities of another health care provider.
For Payment.
Practice may use and disclose PHI to bill and collect payment for the health care services provided to you. For example, Practice may need to give PHI to your health plan to be reimbursed for the services provided to you. Practice may also disclose PHI to its business associates, such as billing companies, claims processing companies and others that assist in processing health claims. Practice may also disclose PHI to other health care providers and health plans for the payment activities of such providers or health plans.
For Health Care Operations.
Practice may use and disclose PHI as part of its operations, including for quality assessment and improvements, such as evaluating the treatment and services you receive and the performance of staff and physicians in caring for you, patient surveys, provider training, underwriting activities, compliance and risk management activities, planning and development, credentialing and peer review activities, and health care fraud and abuse detection or compliance, and management and administration. Practice may disclose PHI to doctors, nurses, technicians, students, attorneys, consultants, accountants and others for review and learning purposes, to help make sure Practice is complying with all applicable laws, and to help Practice continue to provide quality health care to its patients.
As Required by Law and Law Enforcement.
Practice may use or disclose PHI when required to do so by applicable laws and when ordered to do so in a judicial or administrative proceeding. Practice may also use or disclose PHI upon a properly documented and limited request from law enforcement agencies.
For Public Health Activities and Public Health Risks.
Practice may disclose PHI to government officials in charge of collecting information about births and deaths, preventing and controlling disease, or notifying a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition.
For Health Oversight Activities.
Practice may disclose PHI to the government for oversight activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, and other proceedings, actions or activities necessary for monitoring the health care system, government programs and compliance with civil rights laws.
Coroners, Medical Examiners and Funeral Directors.
Practice may disclose PHI to coroners, medical examiners and funeral directors for the purpose of identifying a decedent, determining a cause of death or otherwise as necessary to enable these parties to carry out their duties consistent with applicable law.
Research.
Under certain circumstances, Practice may use and disclose PHI for medical research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication with those who received another, for the same condition.
To Avoid a Serious Threat to Health or Safety.
Practice may use and disclose PHI to law enforcement personnel or other appropriate persons to prevent or lessen a serious threat to the health or safety of a person or the public.
Specialized Government Functions.
Practice may use and disclose PHI of military personnel and veterans under certain circumstances. Practice may also disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities, and for the provision of protective services to the president or other authorized persons or foreign heads of state or to conduct special investigations.
Disclosures to You or for HIPAA Compliance Investigations.
Practice may disclose your PHI to you or to your personal representative and is required to do so in certain circumstances described below in connection with your rights of access to your PHI and to an accounting of certain disclosures of your PHI. Practice must disclose your PHI to the secretary of the United States Department of Health and Human Services (the “Secretary”) when requested by the Secretary in order to investigate Practice’s compliance with privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996.
Patient List; Marketing.
Unless you object, Practice may use some of your PHI to maintain a list of patients it has served. This information may include your name, treatment facility, and the services Practice provided to you. This patient list and the information on it may be used for marketing purposes.
Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care.
Unless you object, Practice may disclose your PHI to a family member, other relative, friend, or other person you identify as involved in your health care or payment for your health care.
OTHER USES AND DISCLOSURES.
Other types of uses and disclosures of your PHI not described above will be made only with your written authorization, which with some limitations; you have the right to revoke your authorization in writing. If you revoke your authorization, Practice will no longer use or disclose PHI about you for the reasons covered in your written authorization. Please understand that Practice is unable to recover any disclosures already made with your authorization, and that Practice is required to retain records of the care provided to you.
RIGHT TO FILE A COMPLAINT.
At Practice, we value the relationships we develop with our patients, our patients’ privacy, and the trust our patients’ have in us. As such, we make every effort to remedy any issues or concerns you may have. You may submit any complaint regarding your privacy rights to:
941-627-5155 or admin@baroudimd.com
You also have the right to file a complaint with the secretary of the Department of Health and Human Services, Office for Civil Rights. You will not be penalized for filing a complaint. You may contact the Office for Civil Rights at:
Office for Civil Rights
U.S. Department of Health and Human Services
Information for regional offices
PLEASE CONTACT THE PRIVACY OFFICER IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE OF PRIVACY PRACTICES OR YOUR PRIVACY RIGHTS.
