Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review if carefully.

Our Pledge Regarding Medical Information

At Jewett Orthopaedic Clinic, we are committed to treating and using protected health information about you responsibly. This Notice of Privacy 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 Notice is effective 4/14/03, and applies to all protected health information as defined by federal regulations. We are required by law to:

• Make sure that medical information that identifies you is kept private;
• Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the Notice that is currently in effect.

If you have any questions about this Notice, please contact Jewett's Privacy Officer at 407-643-1376.

Understanding Your Medical Medical Record/Information

Each time you visit Jewett Orthopaedic Clinic, we make a record of your visit. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• Basis for planning your care and treatment;
• Means of communication among the many health professionals who contribute to your care;
• Legal document describing the care you received;
• Means by which you or a third-party payer can verify that services billed were actually provided;
• A tool in education health care professionals;
• A source of data for medical research;
• A source of information for public health officials charged with improving the health of this state and the nation;
• A source of data for our business planning and marketing; and
• A tool with which we can assess and continually work to improved the quality of the care we render and the outcomes we achieve.

How We May Use and Disclose Medical Information About You

• For treatment
  We may use medical information bout you to provide you with medical treatment or services. For example, we may disclose medical information about you to people outside our office who may be involved in your care after you leave the office, including third party physicians, hospitals, nursing homes, pharmacies or clinical labs with whom the office consults or takes referrals.
• For Payment
  We may use and disclose medical information about you so that the treatment and services you receive at our office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about procedures you received at the office so your health plan will pay us or reimburse you for the services.
• For Health Care Operations
  We may use and disclose medical information about you for medical office operations. 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 evaluated the performance of our staff in caring for you.
• Appointment Reminders
  We may use and disclose medical information to contact you as a reminder that you have an appointment.
• Treatment Alternatives
  We may use and disclosed medical information to inform you of possible treatment options or alternatives that may be of interest to you.
• Health-Related Benefits and Services
  We may use and disclose medical information to tell you about health-related benefits or services that interest you.
• Individuals Involved in Your Care of Payment for Your Care
  We may release medical information about you to a family member or friend who is involved in your medical care provided you have consented to such disclosure. We may also give information to someone who helps pay for your care.
• As Required By Law
  We will disclose medical information about you when required to so by federal, state or local law.
• To Avert a Serious Threat to Health of Safety
  We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
• Workers' Compensation
  We may disclose medical information other extent authorized by and to the extent necessary to comply with worker's compensation laws.
• Research
  With your authorization, we may disclose information to researchers when their research has been approved by an institutional review board that has established protocols to ensure the privacy of your medical information.
• Health Oversight Activities
  We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with laws.
• Lawsuits and Disputes
  If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process by someone else involved in the dispute.
• Law Enforcement
  We may disclose medical information for law enforcement purposes as required by law or in response to a valid subpoena.
• Coroners, Medical Examiners and Funeral Directors
  We amy disclose medical information to a coroner, medical examiner or funeral director as necessary to carry out their duties.

Your Rights regarding Medical Information About You

In order to exercise your rights listed below, you must submit a request in writing to the Jewett Orthopaedic Clinic's Director of Medical Records at 1285 Orange Avenue, Winter Park, FL 32789; phone 407-643-1377.

• Right to Inspect and Copy
  You have the right to inspect and request a copy of your medical information that may be used to make decisions about your care, If you request a copy of the information, we may charge a fee for processing your request. We amy deny your request to inspect and copy in certain very limited circumstances.
• Right to Amend
  If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by of for our office. We may deny your request for an amendment. We will provide you a written explanation of our reasons for the denial.
• Right to an Accounting of Disclosures
  You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical informational bout you for purposes other than treatment, payment, or operations. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, during any 12-month period, we may charge you for the costs of providing the list.
• Right to Request Restrictions
  You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment of health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care of the payment for you care, like a family member of friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
• Right to Request Confidential Communications
  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to a Paper Copy of This Notice
  You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. You may obtain a copy of this Notice at our web site, www.jewettortho.com.

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.

Changes to the Notice

We reserved 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 the effective date on the first page, in the top right-hand corner.

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. All complaints must be submitted in writing. To file a complaint with our office regarding your privacy rights or to obtain information concerning how tot file a Complaint with Department of Health and Human Services, contact the Director of Medical Records at 407-643-1377. You will not be penalized or retaliated against for filing a complaint.