Pain Healing Center
Notice of Privacy Practices

This notice contains important information about our privacy practices which were revised pursuant to the Health Insurance Portability and Accountability Act of 1996 and related regulations. This notice describes how your Protected Health Information may be used and disclosed, and indicates how you get access to this information. Please review it carefully.

If you have any questions about this notice, please contact our Privacy Officer:
Abd AlrahmanBenni
(813) 333-1819
Abdulbenni@yahoo.com

OUR COMMITMENT TO YOUR PRIVACY

Summary

1. We are dedicated to maintaining the privacy of your medical information. In conducting our business, we will create records regarding the treatment and services we provide to you.
2. Your medical records are our property. However, we are required by law:
a. To maintain the confidentiality of your medical information;
b. To provide you with this notice of our legal duties and privacy practices concerning your medical information called Notice of Privacy Practices;
c. To follow the terms of our notice of privacy practices in effect at the time.
3. This notice provides you with the following important information:
a. How we may use and disclose your medical information;
b. Your privacy rights regarding your medical information; and
c. Our obligations concerning the use and disclosure of your medical information.

Changes to this Notice
The terms of this notice apply to all records containing your medical information that are created or retained by us. We reserve the right to revise, change or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of the information that we already have about you, as well as any medical information that we may receive, create, or maintain in the future. You may request a copy of our most current notice during any visit to our practice.

HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
The following categories describe the different ways in which we may use and disclose your Protected Health Information. Please note that each particular use or disclosure is not necessarily listed below. However, the different ways we are permitted to use and disclose your medication information do fall within one of the listed categories.

Treatment
We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We may also disclose protected health information to their physicians who may be treating you when we have the necessary permission from you to disclose your protected health information. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

Payment
We may use and disclose your medical information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for your treatment. We also may use and disclose your medical information to obtain payment from other third parties who may be responsible for such costs. Also, we may use your medical information to bill you directly for services and items under applicable law.


Health Care Operations
We may use and disclose your medical information to operate our business. These uses and disclosures are important to ensure that you receive quality care and that our organization is well run. An example of the way in which we may use and disclose your information for our operations would be to evaluate the quality of care you received from us. We may also disclose your information to doctors, nurses and students for review and learning purposes. We maintain safeguards to protect your Protected Health Information against unauthorized access and uses. We may share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you.

Appointment Reminders
Our organization may use and disclose your protected health information to remind you that you have any appointment.

Disclosure
We shall only disclose protected health information as permitted by law or with your permission. In addition, we shall make every effort to prevent unintentional disclosure although the regulations consider such disclosure legal. When necessary for your care or treatment, our operations and related activities, we use protected health information internally and may disclose such information to other healthcare providers (doctors, dentists, hospitals, nursing homes or other covered healthcare providers, insurers, third party administrators, payers, and others who may be financially responsible for payment for services and benefits you receive, vendors, consultants, government authorities and other surveying entities and their respective agents). These parties are required to keep your protected health information confidential, as provided by law. Some examples of what we do with the information we collect and the reasons:

1. Administration of health benefits policies or contracts which may involve claims payment and management; utilization review and
Management; medical necessity review; coordination of care and benefits;
2. Quality assessment and improvement activities, such as peer review and credentialing of participating providers, program development and accreditation;
3. Performance measurement and outcomes assessment and health claims analysis;
4. Data and Information systems management; and
5. Performing regulatory compliance/reporting, and public health activities; responding to requests for information from regulatory authorities, responding to government agency or court subpoenas as required by law, reporting suspected or actual fraud or other criminal activity; conducting litigation, arbitration and performing third-party liability, subrogation and related activities.

Others Involved in Your Healthcare
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Emergencies
We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physician or another physician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.

Communication Barriers
We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.


Treatment Alternatives/Health-Related
We may use and disclose your medical information to inform you of treatment alternatives and/or health-related benefits and services that may be of interest to you.


Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object

We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:

Required by law
We will use or disclose medical information about you when required by applicable law.

Public Health Activities
Our organization may disclose your medical information for public health activities, including;
1. To prevent or control disease, injury or disability;
2. To maintain vital records, such as births and deaths;
3. To report child abuse or neglect;
4. To notify a person regarding potential exposure to a communicable disease;
5. To notify a person regarding a potential risk for spreading or contracting a disease or condition;
6. To report reactions to drugs or problems with products or devices;
7. To contact public health surveillance, investigation or intervention;
8. To notify individuals if a product or device they may be using has been recalled;
9. To notify appropriate government agencies and authorities 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; and
10. To notify your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

Abuse, Neglect and Domestic Violence
We may disclose your medical information to a government authority if we believe you are a victim of abuse, neglect or domestic violence. If we make such a disclosure, we will inform you of it, unless we think informing you places you at risk of serious harm or if we were to inform your personal representative, is otherwise not in your best interest.

Communicable Diseases
We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight Activities
We may disclose your medical information to a health oversight agency for activities authorized by law. Oversight activities can 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 and compliance with civil rights laws.

Lawsuits and Similar Proceedings
We may use and disclose your medical information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your medical information 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 medical information if asked to do so by law enforcement officials:

1. Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement per state law;
2. Concerning a death we believe might have resulted from criminal conduct;
3. Regarding criminal conduct at our practice.
4. In response to a warrant, summons, court order, subpoena or similar legal process;
5. To identify/locate a suspect, material witness, fugitive or missing person; and
6. In an emergency, to report a crime (including the locating or victim(s) of the crime, or the description, identity or location of the perpetrator).

Coroners, Medical Examiners, and Funeral Directors
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also release medical information about our patients to funeral directors as necessary to carry out their duties.

Organ and Tissue Donation
We may use or disclose your medical information to organizations that handle organ and tissue procurement, banking or transplantation.

Serious Threats to Health or Safety
We may use or disclose your medical information when necessary to reduce or prevent a serious threat to your 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.

Specialized Government Functions
We may disclose your medical information if you are a member of the U. S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. In addition, we may disclose your medical information to federal and/or state and/or local officials for intelligence and national security activities authorized by law. We also may disclose your medical information to federal officials in order to protect the President, other officials or foreign heads of state or to conduct investigations.

Furthermore, we may disclose your medical information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary:
1. For the institution to provide health care services to you;
2. For safety and security of the institution; and
3. To protect your health and safety or the health and safety of other individuals.

Workers’ Compensation or Disability Claims
We may release your medical information for your workers’ compensation and disability claims and similar program to appropriate agencies.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding the medical information that we maintain about you:

Requesting Restrictions
When requested in writing, you have the right to request a restriction in your medical information for treatment, payment or healthcare operations. Additionally, you have the right to request that we limit our disclosure of your medical information to individuals involved in your care or the payment for your care, such as family members and friends. 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 and disclosure of your medical information you must make your request in writing to the Privacy Officer specifying the requested method of contact, or the location where you wish to be contacted. We will accommodate reasonable requests. You need not give a reason for your request.

Confidential Communications
You have the right to request that we 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 by mail, rather than by telephone, or at home rather than work. In order to request a type of confidential communication, you must make a written request to the Privacy Officer specifying the requested method of contact, or the location where you wish to be contacted. We will accommodate reasonable requests. You do not need to give a reason for your request.

Inspection and Copies
You have the right to inspect and obtain a copy of the medical information that may be used to make decisions about you, including patient medical records and billing records. Please make all record requests through the secure messaging service on our website. Otherwise, you must submit your request in writing to the Privacy Officer in order to inspect/or obtain a copy of your medical information. In accordance with state law we may charge a fee. In accordance with law and our best judgement, we may deny your request to inspect and/or copy your medical information in certain limited circumstances; however, you may request a review of our denial.

Amendment
You may ask to amend your medical information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by our Practice. To request an amendment, your request must be made in writing to our Practice. You must provide us with a reason that supports your request for amendment. We may deny your request if you fail to submit your request and the reason supporting your request in writing. Also, we may deny your request if the amendment would violate any law or statute or if you ask us to amend information that is:
1. Accurate and complete;
2. Was not created by us; or
3. If the individual who created the information is no longer an employee of our Practice.

Accounting of Disclosures
An accounting of disclosures is a list of certain disclosures we have made of your medical information that you did not specifically authorize. You have the right to request a copy of our accounting of disclosures for your medical information. Your request must be made in writing to the Privacy Officer. All requests for an accounting of disclosures must state a time period that may be no longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge. A charge for subsequent requests in the same 12-month period will be imposed in accordance with state law.

Right to a Paper Copy of This Notice
You have the right to receive a paper copy of our Notice of Privacy Practices. You may print a copy of this notice from our website. To obtain a copy of this notice, ask any member of our staff or contact the Privacy Officer.

Right to File a Complaint
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.

Right to Provide an Authorization for other Used and Disclosures
We shall make a good faith effort to obtain your written authorization for uses and disclosures that are not identified by this notice or are not permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your medical information may be revoked at any time in writing by sending a written, signed and dated request to the Privacy Officer. After you revoke your authorization, we will no longer use or disclose your medical information for the reasons described in the authorization. Of course, we are unable to take back any disclosures that we have already made with your permission. Please note that we are required to retain records of your care.

                                                          TELEMEDICINE CONSENT

1. I understand that my health care provider wishes me to engage in a telemedicine consultation.
2. My health care provider has explained to me how the video conferencing technology will be used to affect such
a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be
in the same room as my health care provider.
3. I understand there are potential risks to this technology, including interruptions, unauthorized access and
technical difficulties. I understand that my health care provider or I can discontinue the telemedicine
consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
4. I understand that my healthcare information may be shared with other individuals for scheduling and billing
purposes. Others may also be present during the consultation other than my health care provider and
consulting health care provider in order to operate the video equipment. The above mentioned people will all
maintain confidentiality of the information obtained. I further understand that I will be informed of their
presence in the consultation and thus will have the right to request the following: (1) omit specific details of my
medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave
the telemedicine examination room: and or (3) terminate the consultation at any time.
5. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a
telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted
by individuals at my location at the direction of the consulting health care provider.
6. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to
advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the
video conference connection.
7. I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am
presented.
8. I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in regard to
this procedure. My questions have been answered and the risks, benefits and any practical alternatives have
been discussed with me in a language in which I understand.
By signing this form, I certify:
 That I have read or had this form read and/or had this form explained to me
 That I fully understand its contents including the risks and benefits of the procedure(s).
 That I have been given ample opportunity to ask questions and that any questions have been answered to
my satisfaction.