We respect your
privacy!
The patient's medical record is strictly private. We do
not reveal information regarding your health to your employer, friends or
relatives without your permission. The only exception to this is when we
need to communicate with your other physicians to facilitate your care, or
when release of information is required by law, as by court order.
Our complete
privacy policy, is required by HIPPA Regulation to be offered to all our
patients. It follows below.
CHARLES
V. KLUCKA, D.O.,P.A.
NOTICE OF PRIVACY PRACTICES
As
Required by the Privacy Regulations Created as a Result of the Health
Insurance Portability and Accountability Act of 1996 (HIPAA)
THIS
NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS
PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR
INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI).
PLEASE
REVIEW THIS NOTICE CAREFULLY.
- OUR COMMITMENT TO YOUR PRIVACY
Our practice is
dedicated to maintaining the privacy of your individually identifiable
health information (IIHI). In conducting our business, we will
create records regarding you and the treatment and services we provide to
you. We are required by law to maintain the confidentiality of health
information that identifies you. We are also required by law to
provide you with this notice of our legal duties and the privacy practices
we maintain in our practice concerning your IIHI. By federal and state law,
we must follow the terms of the notice of privacy practices that we have in
effect at this time.
We realize these
laws are complicated, but we must provide you with the following important
information:
- How we may use and disclose your IIHI.
- Your privacy rights in your IIHI.
- Our obligation concerning the use and disclosure of
your IIHI.
The terms of
this notice apply to all records containing your IIHI that are created or
retained by our practice. We reserve the right to revise or amend this
Notice of Privacy Practices. Any revision or amendment to this notice
will be effective for all of your records that our practice has created or
maintained in the past, and for any of your records that we may create or
maintain in the future. Our practice will post a copy of our current
Notice in our offices in a visible location at all times, and you may
request a copy of our most current Notice at any time.
- IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE
CONTACT:
ATTENTION:
PRIVACY OFFICER
CHARLES V. KLUCKA, D.O., P.A.
9671 GLADIOLUS DRIVE, #104
FORT MYERS, FL 33908
(239) 939-2246
C. WE MAY
USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI)
IN THE FOLLOWING WAYS
The following
categories describe the different ways in which we may use and disclose
your IIHI.
- Treatment. Our
practice may use your IIHI to treat you. For example, we may ask
you to have laboratory tests (such as blood tests) and we may use the
results to reach a diagnosis. We might use your IIHI in order to
write a prescription for you, or we might disclose your IIHI to a
pharmacy when we order a prescription for you. Many of the people
who work for our practice—including, but not limited to doctors,
nurses, or techs—may use or disclose your IIHI in order to treat you
or to assist others in your treatment. Additionally, we may
disclose your IIHI to others who may assist in your care, such as your
spouse, children or parents. Finally, we may also disclose your
IIHI to other health care providers for purposes related to your
treatment.
- Payment. Our practice may use
and disclose your IIHI in order to bill and collect payment for the
services and items you receive from us. For example, we may
contact your health insurer to certify that you are eligible for
benefits (and for what range of benefits), and we may provide your
insurer with details regarding your treatment to determine of your
insurer will cover, or pay for, your treatment. We may also
use and disclose your IIHI to obtain payment from third parties that
may be responsible for such costs, such as employers or family
members. Also, we may use your IIHI to bill you directly for
services and items. We may disclose your IIHI to other health
care providers and entities to assist in their billing and
collection efforts.
- Health Care Operations. Our practice may use and disclose your IIHI
to operate our business. Some examples may be to evaluate the quality
of care you received form us, or to conduct
cost-management and business planning activities for our
practice. We may
- disclose your IIHI to other health care providers
and entities to assist in their healthcare operations. In
general, however, our practice rarely would undertake such operations.
- Appointment Reminders. Our practice may use and disclose your IIHI to
contact you and remind you of an appointment.
- Treatment Options. Our practice may use and disclose your IIHI to
inform you of potential treatment options or alternatives.
- Health Related Benefits and Services. Our practice may use and disclose your IIHI to
inform you of health-related benefits or services that may be of
interest to you.
- Release of Information to Family/Friends: Our practice may release your IIHI to a friend or
family member that is involved in your care, or who assists in taking
care of you. For example, a parent or guardian may ask that their
babysitter or grandmother take their child to our office for the
treatment of a cold, as long as a note gives us permission to treat
the patient. In this instance, the babysitter or grandmother may
have some access to this child’s medical information.
- Disclosures required by law. Our practice will use and disclose your IIHI when
we are required to do so by federal, state, or local law.
- USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL
CIRCUMSTANCES
The following
categories describe unique scenarios in which we may use or disclose your
IIHI:
- Public Health Risks. Our practice may disclose your IIHI to public
health authorities that are authorized by law to collect information
for the purpose of:
Maintaining vital
records, such as births and deaths
Reporting child
abuse or neglect
Preventing or
controlling disease, injury, or disability
Notifying a person
regarding potential exposure to a communicable disease
Notifying a person
regarding a potential risk for spreading or contracting a disease or
condition
Reporting
reactions to drugs or problems with products or devices
Notifying
individuals if a product or device they may be using has been recalled
Notifying
appropriate government agency (ies) or authority
(ies) regarding the potential abuse or neglect of
an adult patient (including domestic violence); however, we will only
disclose this information if the patient agrees or we are required or
authorized by law to disclose this information.
Notifying your
employer under limited circumstances related primarily to workplace injury
or illness or medical surveillance.
- Health Oversight Activities. Our practice may disclose your IIHI to a health
oversight agency for activities authorized by law. Oversight
activities, may include, for example, investigations, inspections,
audits, surveys, licensure and disciplinary actions; civil,
administrative, and criminal procedures or actions; or other
activities necessary for the government to monitor government
programs, compliance with civil rights laws and the health care system
in general.
- Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in
response to a court or administrative order, or if you are involved in
a lawsuit or similar proceeding. We also may disclose your IIHI
in response to a discovery request, subpoena, or other lawful process
by another party involved in the dispute, but only if we have made an
effort to inform you of the request or to obtain an order protecting
the information the party has requested.
- Law Enforcement. We may release IIHI if asked to do so by a
law enforcement official:
Regarding a crime
victim in certain situations, if we are unable to obtain the person’s
agreement
Concerning a death we believe has resulted from criminal conduct
Regarding criminal
conduct in our offices
In response to a
warrant, summons, court order, subpoena or similar legal process
To identify/locate
a suspect, material witness, fugitive or missing person
In an emergency,
to report a crime (including the location of victim(s) of the crime, or the
description, identity, or location of the perpetrator)
- Deceased Patients. Our practice may release IIHI to s medical
examiner or coroner to identify a deceased individual or to
identify the cause of death. If necessary, we may also
release information in order for funeral directors to perform their
jobs.
- Organ and Tissue Donation. Our practice may release your IIHI to
organizations that handle organ, eye, or tissue procurement or
transplantation, including organ donation banks, as necessary to
facilitate organ or tissue donation or transplantation if you are an
organ donor.
- Research.
Our practice may use and disclose your IIHI for research purposes in
certain limited circumstances. This office generally does not,
however, conduct research. We will, however, obtain written authorizations
for research purposes, or inform you of any exception.
- Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when
necessary to reduce or prevent a serious threat to your health and
safety or the health and safety or another individual or the
public. Under these circumstances, we will only make disclosures
to a person or organization able to help prevent the threat.
- Military.
Our practice may disclose your IIHI if you are a member of U.S. or
foreign military forces (including veterans) AND if required by the
appropriate authorities.
- National Security. Our practice may disclose your IIHI to
federal officials for intelligence and national security activities
authorized by law. We may also disclose your IIHI to federal
officials in order to protect the president, other officials or
foreign heads of state, or to conduct investigations.
- Inmates. Our practice may
disclose your IIHI to correctional institutions or law enforcement
officials if you are an inmate under custody of a law enforcement
official. Disclosure for these purposes would be necessary: (a)
for the institution to provide health care services to you, (b)
for the safety and security of the institution, and/or (c) to protect
your health and safety or the health and safety of other individuals.
- Worker’s Compensation. Our practice may disclose your IIHI for worker’s
compensation and similar programs.
- YOUR RIGHTS REGARDING YOUR IIHI
You have the
following rights regarding the IIHI that we maintain about you:
- Confidential Communications. You have the right to request that our practice
communicate with you about your health and related issues in a
particular manner or at a certain location. (For instance, you
may ask that we contact you at home, rather than work.) In order
to request a type of confidential information, you must make a WRITTEN
request to: Attention: Privacy Officer, Charles V. Klucka, D.O.,
P.A., 9671 GLADIOLUS DRIVE, #104 , Fort Myers, FL 33908.
(239) 939-2246,
specifying the requested method of contact, or the
location where you wish to be contacted. Our practice will
accommodate reasonable requests. You do not need
to give a reason for your request.
- Requesting Restrictions. You have the right to request a restriction in our
use or disclosure of your IIHI for your treatment, payment of
healthcare operations. Additionally, you have the right to
request that we restrict our disclosure of your IIHI to only certain
individuals involved in your care or the payment for your care, such
as family members and friends. By law, we are not required to
agree to your request; however, if we do agree, we are bound by
our agreement, except when otherwise required by law, in emergencies,
or when the information is necessary to treat you. In order to
request a restriction in our use or disclosure of your IIHI, you must
make your request in writing to: Attention: Privacy Officer,
Charles V. Klucka, D.O., P.A., 9671 GLADIOLUS DRIVE, #104 , Fort
Myers, FL 33908 (239) 939-2246. Your request must
describe in a clear and concise fashion:
- the information you wish restricted;
- whether you are requesting to limit our practice’s
use, disclosure, or both; and
- to whom you want the limits to apply.
- Inspection and Copies. You have a right to inspect and obtain a copy of
the IIHI that may be used to make decisions about you, including
medical records and billing records, but not including psychotherapy
notes. You must submit your request in writing to: Attention:
Privacy Officer, Charles V. Klucka, D.O., P.A., 9671 GLADIOLUS
DRIVE, #104 ,
Fort Myers, FL 33908. (239)939-2246, in order to inspect
and/or obtain a copy of your IIHI. or any portion thereof. Our
practice does not charge a fee for records of 25 pages or less,
requested once annually. Our practice will charge a fee of $1.00
per page for the costs of copying, mailing, labor and supplies
associated with requests involving more than 25 pages per year.
Rarely, our practice may deny your request to inspect and/or copy in
certain limited circumstances; however, you may request a review of
our denial. Another licensed healthcare professional chosen by us
will conduct reviews.
- Amendment. You may ask us to
amend your health information if you believe it is incorrect or
incomplete, and you may request an amendment for as long as the
information is kept by or for our practice. To request an
amendment, your request must be made in writing and submitted to: Attention:
Privacy Officer, Charles V. Klucka, D.O., P.A., 9671 Gladiolus Drive,
#104, Fort Myers, FL 33908. (239) 939-2246. You
must provide us with a reason that supports your request for
amendment. Our practice will deny your request if you fail to
submit your request (and the reason for supporting your request) in
writing. Also, we may deny your request if you ask us to amend
information that is in our opinion: (a) accurate and complete; (b) not
part of the IIHI kept by or for the practice; (c) not part of the IIHI
which you would be permitted to inspect and copy; or (d) not created
by our practice, unless the individual or entity that created the
information is not available to amend the information.
- Accounting of Disclosures. All of our patients have the right to request
an “accounting of disclosures.” An “accounting of disclosures” is
a list of certain non-routine disclosures our practice has made of
your IIHI for non-treatment, non-payment, or non-operations purposes.
Use of your IIHI as part of the routine patient care in our practice
is NOT required to be documented. (For example, the doctor
sharing information with a tech, or another doctor to which you are
referred, or the billing department using you information to file an insurance
claim.) In order to obtain an “accounting of disclosures”, you
must submit a request in writing to: Attention: Privacy Officer,
Charles V. Klucka, D.O., P.A., 9671 GLADIOLUS DRIVE, #104 , Fort
Myers, FL 33908. (239) 939-2246. All requests for
an “accounting of disclosures” must state a time period, which may not
be longer than six (6) years from the date of disclosure, and may not
include the dates before April 14, 2003. The first list you
request within a 12-month period is free of charge, but our practice
charges $5 for additional lists requested within the same 12-month
period.
- Right to a paper copy of this notice. You are entitled to receive a paper copy of our
“Notice of Privacy Practices.” You may ask us to give you a copy
of this notice at any time; they are available at the front desk, or
by mail: Attention; Privacy Officer, Charles V. Klucka, D.O., P.A.,
9671 GLADIOLUS DRIVE, #104 Fort Myers, FL 33908. (239)
939-2246.
- Right to file a Complaint. If you believe your privacy rights have been violated,
you may file a complaint with our practice, or with the Secretary of
the Department of Health and Human Resources. To file a complaint
with our practice, contact: Attention: Privacy Officer, Charles V.
Klucka, D.O., P.A., 9671 GLADIOLUS DRIVE, #104 , Fort Myers,
FL 33908. (239) 939-2246. All complaints must be
submitted in writing. You will not be penalized for filing a
complaint.
- Right to Provide an Authorization for Other Uses
and Disclosures. Our practice will obtain your
written authorization for uses and disclosures that are not identified
by this notice or permitted by applicable law. Any authorization
you provide to us regarding the use and disclosure of your IIHI may be
revoked at any time in writing. After you revoke your
authorization, we will no longer use or disclose your IIHI for the
reasons described in the authorization. Please note, we are
required to retain records of your care.
Again, if you
have any questions regarding this notice, or our health information privacy
policies, please contact our Privacy Officer at Charles V. Klucka, D.O.,
P.A., 9671 GLADIOLUS DRIVE, #104 , Fort Myers, FL 33908 (239)
939-2246.
© Copyright
www.DrKlucka.com 2022
All Rights Reserved
|