PIN: To protect your privacy and ensure the confidentiality of your health records, our office utilizes a Patient PIN number system in order to share your information. Please note, our office can share information about you to individuals that have your PIN. By signing below, you agree with the St Johns Vein Center PIN System:
We are required by law to provide you with our Notice of Privacy Practices. To ensure that our records are accurate, please sign this form and return it to our receptionist to acknowledge that you have been provided with a copy of our notice. I acknowledge receipt of St Johns Vein Center’s Notice of Privacy Practices. I hereby authorize St Johns Vein Center to share and/or discuss my medical information with the following individuals (family and/or friends)
Introduction
At St Johns Vein Center, we are committed to treating and using protected health information about you responsibly. This notice of health information practices describes the personal information we collect and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This notification is effective January 1, 2012 and applies to all protected health information as defined by federal regulations. If you have any questions about this notice, please contact Sonya Casey, Practice Administrator.
Understanding Your Health Record /Information
Each time you visit St Johns Vein Center, a record of your visit is made. Typically, this record contains your symptoms, examination notes, test results, and a plan for future care or treatments. This information, often referred to as your health or medical record, serves as a:
You’re Health Information Rights
Although your health record is the physical property of St Johns Vein Center, the information belongs to you.
You have the right to:
Our Responsibilities
St Johns Vein Center is required to:
We are required by law to:
How we may use your health information:
The following categories describe different ways that we use and disclose medical information. 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 medical information about you to provide you with medical treatment or services. We may disclose medical information about you to the practice’s office personnel who are involved in taking care of you at the office or elsewhere. We also may disclose medical information about you to people outside our office who may be involved in your care after you leave the office, such as family members or others we use to provide services that are part of your care, provided you have consented to such disclosure. These
These uses and disclosures are necessary to run our office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services the office should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to our physicians, staff, and other office personnel for review and learning purposes.
Special Situations
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 medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the office. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register, 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 the office or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Sonya Casey at (904) 402-8346. All complaints must be submitted in writing.
You will not be penalized or retaliated against for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical 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 medical 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 provided to you.