Your Rights and Confidentiality

You have the right to leave treatment at any time without penalty, although you do have a responsibility to make sure we know you are discontinuing treatment. Your personal physician must be able to assume your medical care. From time to time, patient treatment information is used in the collection of statistics to compare results and improve the treatment of obesity. This information may be shared with other practitioners, researchers and the scientific and medical community. Strict confidentiality of individual personal information and records will be maintained.

HIPAA

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

Uses and Disclosures of Information That We Make Without Written Authorization: Treatment, payment, healthcare operations, required by law, abuse or neglect, or communicable diseases, public health activities, health oversight activities, judicial and administrative proceedings, law enforcement, organ donation, research, workers compensation, appointments and services, marketing, business associates, military, inmates or persons in police custody.

Uses and Disclosures of Information That We May Make Unless You Object: We may use and disclose protected health information in the following instances without your written authorization unless you object. If you object, please notify the Privacy Contact identified at the end of this document.

Persons Involved in Your Health Care: Unless you object, we may disclose protected health information to a member of your family, relative, close friend, or other person identified by you who is involved in your health care of the payment for your health care. We will limit the disclosure to the protected health information relevant to that person’s involvement in your health care or payment. We may leave messages for you to call us or leave basic lab test results on your home phone unless you direct otherwise.

Notification: Unless you object, we may use or disclose protected health information to notify a family member or other person responsible for your care of your location and condition.

Your Rights Concerning Your Protected Health Information: You have the following rights concerning your protected health information. To exercise any of these rights, you must submit a written request to our Privacy Officer. 

  1. To request additional restrictions. 
  2. To receive communications by alternative means. 
  3. To inspect and copy records 
  4. To request amendment to your record. 
  5. To request accounting of certain disclosures. 
  6. To receive a copy of our complete confidentiality notice. 
  7. To receive a copy of the bill to submit to your insurance. We will code your visit as medically correct as possible. 

Please note in rare instances a new diagnosis or prescription that you submit to your insurance may affect your insurability and your insurance rates.

Complaints: You may complain to us of to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our Privacy Officer. All complaints must be in writing. We will not retaliate against you for filing a complaint.

Entities to Whom this Notice Applies: This notice applies to César A. Lara, M.D.; Center for Weight Management, their associated clinics, the physicians, employees and volunteers who work there.

Privacy Officer Contact: If you have any questions about this notice, to request a copy of the complete notice or if you want to object to or complain about any use of disclosure of exercise any right as explained about, please contact our Privacy Officer Christina Bertsos: Address 1217 Ewing Ave, Clearwater, FL 33756; (727) 446-3021.

 

I, the undersigned, have reviewed this information on this document, and have had an opportunity to ask questions and have them answered to my satisfaction.

Patient Name:

Patient Signature & Date: