Effective Date: April 14, 2003

Revision Date:

THIS NOTICE DESCRIBES HOW PERSONAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respect patient confidentiality and only release personal health information about you in accordance with the State and federal law. This notice describes our policies related to the use of the records of your care generated by the Northwest Florida Heart Group, PA.

Privacy Contact. If you have any questions about this policy or your rights contact the Privacy Officer, at 850-969-7979

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

In order to effectively provide you care, there are times when we will need to share your personal health information with others beyond Northwest Florida Heart Group, PA. This includes for:

Treatment . We may use and disclose personal health information about you to provide, coordinate, or manage your care or any related services, including sharing information with others outside the Northwest Florida Heart Group that we are consulting with or referring you to. For example, a pharmacy to fill a prescription, a laboratory to order a blood test , or other treatment provider.

Payment. Information will be used to obtain payment for the treatment and services provided. This will include contacting your health insurance company for prior approval of planned treatment or for billing purposes.

Healthcare Operations . We may use information about you to coordinate our business activities. This may include setting up your appointments, reviewing your care, training staff, and disclosure to another health care provider or health plan for their health care operations.

Information Disclosed Without Your Consent. Under State and federal law, information about you may be disclosed without your consent in the following circumstances:

Emergencies. Sufficient information may be shared to address the immediate emergency you are facing.

Follow Up Appointments/Care. We will be contacting you to remind you of future appointments or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

As Required by Law. This would include situations where we have a subpoena, court order, or are mandated to provide public health information, such as communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or institutional abuse.

Coroners, Funeral Directors. We may disclose personal health information to a coroner or personal health examiner and funeral directors for the purposes of carrying out their duties.

Governmental Requirements. We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations inspections and licensure. There also might be a need to share information with the Food and Drug Administration related to adverse events or product defects. We are also required to share information, if requested with the Department of Health and Human Services to determine our compliance with federal laws related to health care.

Criminal Activity or Danger to Others. If a crime is committed on our premises or against our personnel we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement and to warn any potential victims when we believe an immediate danger may exist to someone, or if we believe you present a danger to yourself .

USES AND DISCLOSURES PERMITTED WITHOUT AUTHORIZATION BUT WITH OPPORTUNITY TO OBJECT

We may disclose your protected health information to your family member or a close personal friend if it is directly relevant to the person's involvement in your medical care or payment related to your medical care. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.

You may object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to the person's involvement with your care, we may disclose your protected health information as described.

PATIENT RIGHTS

You have the following rights under State and federal law:

Copy of Record. You are entitled to inspect the personal health record Northwest Florida Heart Group,PA has generated about you. We may charge you a reasonable fee for copying and mailing your record.

Release of Records. You may consent in writing to release of your records to others, for any purpose you choose. This could include your attorney, employer, or others who you wish to have knowledge of your care. You may revoke this consent at any time, but only to the extent no action has been taken in reliance on your prior authorization.

Restriction on Record. You may ask us not to use or disclose part of the personal health information. This request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. Northwest Florida Heart Group. PA is not required to agree to your request. We will notify you if we deny your request to a restriction. If we agree to your restriction we will not disclose your personal health information unless it is needed to provide emergency treatment.. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Privacy Officer.

Contacting You. You may request that we send information to another address or by alternative means. We will honor such request as long as it is reasonable and we are assured it is correct. We have a right to verify that the payment information you are providing is correct.

Amending Record. If you believe that something in your record is incorrect or incomplete, you may request we amend it. To do this contact the Program Director and ask for the Request to Amend Health Information form. In certain cases, we may deny your request. If we deny your request for an amendment you have a right to file a statement you disagree with us. We will then file our response and your statement and our response will be added to your record.

Accounting for Disclosures. You may request a listing of any disclosures we have made related to your personal health information, except for information we used for treatment, payment, or health care operations purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003 , please submit your request in writing to our Privacy Officer. We will notify you of the cost involved in preparing this list.

Questions and Complaints. If you have any questions, or wish a copy of this Policy or have any complaints you may contact our Privacy Officer in writing at our office for further Information. You also may complain to the Secretary of Health and Human Services if you believe Northwest Florida Heart Group, PA has violated your privacy rights. We will not retaliate against you for filing a complaint.

Changes in Policy. Northwest Florida Heart Group, PA reserves the right to change its Privacy Policy based on the needs of Northwest Florida Heart Group. PA and changes in state and federal law.

Contact Person:

Our contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. If you have additional questions or feel that your privacy rights have been violated you may submit a complaint to our Privacy Officer by sending it to:

Northwest Florida Heart Group, PA

ATTN: Privacy Officer

PO BOX 11339

Pensacola, fl 32524