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

Who will follow this notice?

This notice describes the practices of TestDepot and the practices that will be followed by ALL of the TestDepot workforce members who handle your medical information.

Our Pledge Regarding Your Protected Health Information:

TestDepot understands that medical information about you and your health is personal. We are committed to protecting medical information about you. We maintain our records and conduct our treatment environment to provide the highest level of protection for your medical information while still providing you with the highest level of medical care. This notice applies to all records of your medical care received or created by TestDepot.

Your other medical treatment providers may have different policies or notices regarding using and disclosing your medical information.

This notice will tell you how TestDepot may use and disclose your medical information. Your medical information, also called “protected health information,” is information about you, including demographic information, that may identify you and relate to your past, present, or future physical or mental health information and related health care services.

In this notice, we also describe your rights and certain obligations TestDepot has regarding using and disclosing your protected health information. We are required by law to:

Ensure that medical and other information that identifies you is protected and kept private.
Give you this notice of our legal duties and privacy practices concerning protected health information about you.
Follow the terms of the notice that is currently in effect.

Users and disclosures for treatment, payment, and health care operations:

By becoming a patient of TestDepot, you are giving consent for TestDepot to use your protected health information for certain activities, including treatment, payment, and other healthcare operations. Sometimes, you may hear these three activities called “TPO.”

First, we may use and disclose your protected health information so that TestDepot and its medical professionals can treat you. For example, we may use your past medical information to diagnose your present condition or provide information regarding your medical condition to another doctor to whom we refer you for additional care. We may also use and disclose protected health information about you so that we may be paid for the medical treatment we provide you. For example, we will submit protected health information about you to your insurance company to receive payment for services we have provided to you. We may also use and disclose protected health information about you for TestDepot healthcare operations; in other words, we need to perform those other tasks to ensure that you are provided the highest quality of medical care. For example, we may use your protected health information to evaluate how we can better meet your needs, or we may provide protected health information about you to an auditor who reviews our books to keep our license to provide medical services in Florida.

Other uses and Disclosures of your protected health information:

The following uses of your protected health information may be made without any additional authorization from you. (Not every use or disclosure is listed, but be assured that all uses and disclosures made by TestDepot are only those that are permitted under the law):

Uses and Disclosures for appointment reminders:

We may use and disclose your medical information to contact you as a reminder that you have an appointment at the office. If you request such communications be made confidentially, please contact our office in writing at 12751 S. Cleveland Ave., Fort Myers, Florida 33907. We will accommodate all reasonable requests.

Uses and Disclosures to others involved in your health care:

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 medical care. Suppose you are unable to agree or object to this disclosure. In that case, we may disclose such information as necessary if we determine that it is in your best interests based on our professional judgment. We may also use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person 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.

Uses and Disclosures in emergency situations:

We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician will attempt to obtain your acknowledgment of the notice as soon as reasonably practicable after the delivery of treatment.

Uses and Disclosures for health-related benefits or services:

From time to time, TestDepot may use and disclose protected health information to tell you about certain health-related benefits or services that may interest you.

Uses and Disclosures required by law:

We will use or disclose protected health information about you when required to do so by federal, state, or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified of any such uses or disclosures if the law requires us to do so. We must make disclosures to you and, when required by the Secretary of the Department of Health and Human Services, investigate or determine our compliance with the law.

Uses and Disclosures for public health activities:

We may disclose your protected health information for public health activities, and disclosure for such purposes will be to a public health authority permitted by law to collect or receive the information. The disclosure will be made for purposes such as controlling disease, injury, or disability. Disclosures to public health authorities may include disclosure to a foreign authority that is working with the public health authority.

Uses and Disclosures related to 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.

Uses and Disclosures for health oversight activities:

We may disclose protected health information to a health oversight agency for activities authorized by law. These activities include, for example, audits, investigations, and inspections. These activities are necessary for the government to monitor the health care system, the delivery of health care, government benefit programs, other government regulatory programs, and civil rights laws.

Uses and Disclosures of abuse or neglect:

We may disclose your protected health information to a public health authority authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to a governmental entity or agency authorized to receive such information. In such cases, the disclosure will only be made in accordance with Florida law.

Disclosures to the Food and Drug Administration:

We may disclose your protected health information to a person or company required by the Food and Drug Administration (FDA) to report adverse events, product defects or other problems, biological product deviation, track products, enable product recalls, make repairs or replacements, or to conduct post-market surveillance, as required.

Disclosures for Lawsuits and Disputes:

If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court order, administrative order, or as requested evidence. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. If our fees are unpaid or disputed by you, or if you institute a chargeback, we may disclose your protected health information in communicating with your bank or credit card account.

Disclosures to Law Enforcement:

We may relate protected health information if a law enforcement official asks to do so in response to a court order, subpoena, warrant, summons, or similar process. Other related disclosures may include disclosures relating to individuals who are Armed Forces personnel, to national security and intelligence agencies, as well as disclosures to authorized federal officials for the protection of the President of the United States or other authorized persons or foreign heads of state.

Disclosures to coroners, funeral directors, and organ donation:

We may disclose protected health information about you to a coroner or medical examiner for identification purposes, to determine the cause of death, or for the coroner or medical examiner to perform other duties required by law. We may also disclose your protected health information to a funeral director to permit the funeral director to carry out legal duties. We may do so if death is reasonably anticipated. Your protected health information may also be disclosed for specific organ donations to which you may have agreed.

Disclosures for research:

We may disclose your protected health information to researchers when their research has been approved and protocols have been established to ensure the privacy of your information. We may also disclose a limited set of your information for research purposes, as allowed under the law.

Disclosures related to criminal activity:

We may disclose your protected health information, consistent with federal Florida laws, if we believe that the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public or if law enforcement authorities must identify or apprehend an individual.

Disclosures for workers compensation:

We may release your protected health information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

Your rights regarding protected health information about you.

Right to inspect and copy. You have the right to inspect and copy protected health information that may be used to make decisions about your medical care. Usually, this right includes both medical and billing records. You must submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. Your request to inspect and copy your information may only be denied in very limited circumstances, and you have a right to request that any such denial be reviewed.

Right to Request Restrictions. You have the right to request that we restrict the use and disclosure of your protected health information for treatment, payment, and healthcare operations. 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 with emergency treatment. To request restrictions, you must make your request in writing to 12751 S. Cleveland Ave. #102, Fort Myers, Florida 33907. We will not ask you why you are making this request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Amend. If you feel that the protected health information we have about you is incorrect or incomplete, you have the right to request that your protected health information be amended. Only the healthcare entity that created your protected health information is responsible for amending it. Contact our office for more information regarding the procedures for submitting such a request.

Right to an Accounting of Disclosures. You have a right to an accounting of disclosures of your protected health information for purposes other than treatment, payment, or healthcare operations by TestDepot or any of the people or companies who perform treatment, payment, or healthcare operations on our behalf. To request this list of disclosures we made of protected health information about you, you must submit a request in writing to 12751 S. Cleveland Ave, #102, Fort Myers, Florida 33907. Your request must state a time period that may not be longer than six (6) years prior to the date of your request and may not include dates before April 16, 2003. Your request should indicate the form in which you want the list.

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, and note that the signed copy will be in your chart. This chart copy requirement has been added to our practice on December 27, 2016.

Changes to this notice

TestDepot reserves the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for protected health information we already have about you and any information we create or receive in the future.

Complaints:

If you believe your privacy rights have been violated and/or that TestDepot has not followed this policy, you may file a complaint with TestDepot, the Office Manager, or The Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other uses of protected health information:

Other uses and disclosures of your protected health information not covered by this notice or the laws that apply to The TestDepot will be made only with your written permission or authorization. If you provide us permission to use or disclose protected health 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 protected health information about you for the reasons covered by your authorization. You understand that we cannot take back any disclosures we have already made with your permission and that we are required to retain our records of the medical treatment or other services we have provided to you.

Questions:

If you have any questions regarding this notice, please contact TestDepot.

Patient Acknowledgment Form