NOTICE OF PRIVACY PRACTICES
(Effective 04/14/2003)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Federal Law requires Jerome Golden Center to keep your protected health information private. The law also requires us to provide you with a copy of this notice. Jerome Golden Center must follow the terms of this notice.

Your privacy is important to us. We want you to understand:
The common ways in which we may use and share your medical information.
Ways in which we may use and share your medical information without your permission.
There will be no other use of your medical information without your permission.
Your rights concerning your medical information.
How to file a complaint if you believe your privacy rights have been violated.

What are the common ways in which we may use and share your medical information?
Treatment Purposes: We will share your information with those at Jerome Golden Center who are caring for you. For example, if you come in for services and are in need of medication, the doctor may share your information with the pharmacist.

Payment Purposes: With your authorization, we may share your medical information with the insurance company paying for your care.

Health Care Operations. We may use your medical information to improve the way we provide care to you and others. For example, a team of experts from our staff may review your medical information to insure quality of care.

Appointment Reminders: We may call you or send you a letter to remind you about your appointment. You may request alternatives for confidential communication.

Sign-in Sheets: We may use sign-in sheets in our offices and call your name when it is time for you to be seen.

Research: We may share your information for research. If we do this, the law requires us to take extra steps to protect your privacy, including review by an internal Privacy Board.

Family and Others in Your Personal Life: With your authorization, we may share specific information with a specific person. Otherwise, we will never share any information with these persons.

Satisfaction Surveys: We may send a survey to you in the mail. Your answers will help us provide better care.

As Required By Law: We must contact the police if we suspect you are involved in child abuse or neglect.

To stop a serious threat to health or safety: We have a duty to warn others if we feel you could cause them harm.

For Public Health: If you have a specific, contagious disease, then we may share your medical information with a public health agency such as the Centers for Disease Control or the Health Department.

Law Enforcement: We may cooperate with law enforcement as permitted or required. For example, we may contact the police or abuse hotline if we believe you are a victim of abuse. We may also contact the police if you commit a crime at our facility.

Reviews by Outside Agencies: We may share your medical information when being reviewed by outside agencies that have authority over us. This includes state, federal and other licensing agencies.

Court Order: We may share your medical information when responding to a court order or when initiating involuntary court proceedings (Baker Act/Marchman Act).

Children: In some cases we may not share your child’s medical information with you. For example, there are times when your child can seek care without your permission.

In Case of Death: We may share your medical information with the medical examiner.

Inmates: If you are a prisoner, we may share your information as appropriate.

We will not use your medical information in any other way without your permission.

Use and Disclosure of Your Information: We will not share your medical information except in the ways indicated in this Notice unless you give us your written authorization.
Right To Revoke Your Authorization: You have the right to revoke your authorization at any time. This revocation can affect only future uses of your health information.

What are your rights concerning your medical information?
Right to a copy of our Notice of Privacy Practices: You must be given a copy of this notice. As permitted by law, we reserve the right to make changes to this Notice in the future. Revised Notices will be made available to you.

Right to Access Protected Health Information: You have the right to see and get a copy of your medical information for as long as we have it. We may charge a fee for giving you a copy. Sometimes the law does not allow us to let you see all or parts of your medical information. If this happens, you can appeal our decision. Your appeal must be made in writing.

Right to Request Amendment to Protected Health Information: You can ask us to change the information that we keep about you, if you believe it is wrong or incomplete. For example, you can ask us to correct errors such as your date of birth. This request must be made in writing. The law does not require us to agree to your request. If we deny your request to change your medical information you can appeal our decision. Your appeal must be made in writing.

Right to Request Alternative Means of Communicating Protected Health Information: You can ask us to contact you in certain ways. For example, you can ask that we not send your bills or appointment reminders to your home address or call you at your work number. This request must be made in writing and tell us how you would like to be contacted. We will agree to reasonable requests.

Right to Request Restrictions: You can ask us not to share your medical information for treatment, payment and health care operations. You must make this request in writing. Usually, we will not agree to this request because it would make it difficult for us to care for you. The law does not require us to agree to your request. Please note, if you need emergency medical treatment we may share your medical information even if you have asked us not to.

Right to an Accounting: You can ask us to give you a list of people we have shared your medical information with, since April 14, 2003. The list may not include disclosures for treatment, payment and healthcare operations; disclosures authorized by you; or other disclosures required or permitted by law. This request must be made in writing.

Right to Complain about our Privacy Practices: You have the right to complain if you feel your privacy rights have been violated by anyone who works for Jerome Golden Center. There will be no retaliation against you for filing a complaint. The quality of the health care or services we provide will not be affected in any way because a complaint was filed.

How can you complain about our handling of your privacy?
If you have any concerns about your privacy or feel any of your privacy rights have been violated, please file a written complaint with the Jerome Golden Center Privacy Office at the address below. You can also call us at 561-383-5720 for assistance.

Privacy Office
Jerome Golden Center of the Palm Beaches, Inc.
1041 45th Street
West Palm Beach, FL 33407

You also have the right to file a complaint with the Secretary of the U.S. Department of Health and Human Services, but we ask that you first allow us the opportunity to correct any issues you may have concerning your privacy.