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 IT CAREFULLY.

Updated October 6, 2022

OUR COMMITMENT TO YOUR PRIVACY

Greenbrook Medical Practice, PLLC (referred to as “Greenbrook Medical,” “we,” or “us”) is dedicated to maintaining the privacy of your medical information. We are required by law to maintain the confidentiality of your medical information, provide you with this Notice of our legal duties and the privacy practices that we maintain concerning your medical information, and to notify you of a breach of your unsecured health information. We are required to follow the terms of this Notice that are in effect at the time.

Applicability and Changes to this Notice.

The terms of this Notice apply to all records containing your medical information that are created or retained by us.  This Notice will be followed by all health care professionals, employees, medical staff, and other individuals providing services at Greenbrook Medical. We reserve the right to revise or amend this Notice. Any revision or amendment to this Notice will be effective for all of your medical records that we have created or maintained in the past, and for any of your records that we may create or maintain in the future. We will post a current copy of this Notice on our website at: https://greenbrookmedical.com/.   You may also request a copy of the current Notice at any time by reaching out to us at the contact information provided below.

YOUR RIGHTS

When it comes to your medical information, you have certain rights.  This section explains your rights and some of our responsibilities to help you exercise those rights.

Right to Inspection and Copies. 

You have the right to get an electronic or paper copy of your medical record.  This right does not include psychotherapy notes or health information that is not part of your designated record set.  To obtain copies or request inspection of your medical information, you must submit your request in writing to the Greenbrook Medical Privacy Officer, whose contact information is included at the end of this Notice. We may charge a reasonable fee that will be in compliance with applicable law. We may deny your request in limited circumstances.  If your request is denied, you may request a review of our denial.

Right to Request an Amendment.  You can ask us to correct the medical information we maintain about you if you believe it is incorrect or incomplete. To request an amendment, your request must be made in writing and submitted to the Greenbrook Medical Privacy Officer. Please provide us with a reason for your request and identify the records you would like amended.  If we agree to your request, we will notify you and amend your medical information.  In certain circumstances, we may deny your request.  If your request is denied, we will inform you in writing and explain your rights. Please note that we cannot completely delete information contained in your record and the change requested by you will appear as an addendum to the existing record.

Right to an Accounting. You can ask for a list (an accounting) of the times we shared your medical information for six years prior to the date of your request, who we shared it with, and why.  Please note the accounting will not include disclosures made for treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but may charge a reasonable, cost-based fee if you ask for another one within 12 months.  To request an accounting, submit your request in writing to the Privacy Officer.

Right to Request Restrictions.  You can ask us not to use or share certain medical information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If we agree to your request, our agreement will be in writing, and we will comply with the restriction unless (i) the information is needed to provide you with emergency care or (ii) we are required or permitted by law to disclose it. If you pay in full for a service or health care item out- of-pocket, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree to this request unless a law requires us to share that information.

Right to Confidential Communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.  We will agree to all reasonable requests. To request confidential communications, you must make a written request to our Privacy Officer specifying the requested method of contact for billing purposes, or the location where you wish to be contacted. You do not need to give a reason for your request.

Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of this Notice at any time, even if you agreed to receive the Notice electronically. We will provide you with a paper copy promptly.

Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us by contacting our Privacy Officer.  All complaints must be submitted in writing to the Privacy Officer at the contact information provided at the end of this Notice.  You also have the right to file a complaint with the Secretary of the Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.

Right to a Personal Representative. If you have given someone the legal authority to exercise your rights and choices covered by this Notice, we will honor such requests once we verify their authority.  This Notice also applies to minors, disabled adults, or others that are not able to make health care decisions for themselves or who choose to designate someone to act on their behalf.   Personal Representatives (including parents and legal guardians) can exercise the rights described in this Notice.  There are, however, some situations under State Law where prior authorization of a minor patient is required before certain actions can be taken. We comply with applicable State Laws in this regard.

YOUR CHOICES

In some cases, you can decide what medical information we share, and who we share it with.

Family Members & Friends. We may disclose your health information to individuals who you have chosen to involve in your medical care unless you object to such a disclosure. If you are not able/available to tell us your preference for disclosing your medical information with others involved in your care, we may go ahead and share the information if we believe in our professional judgment that it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Disaster Relief. In the event of a disaster, we may disclose your medical information to organizations assisting in disaster relief efforts unless you tell us not to, and that decision will not interfere with our ability to respond in emergency circumstances.

Disclosures Requiring Your Authorization.  Other uses and disclosures that are not identified by this Notice will be made only with your written authorization.  We will never sell or use your medical information for marketing purposes without your authorization. Most uses and disclosures of psychotherapy notes require your prior authorization.  Any authorization you provide to us regarding the use and disclosure of your medical information may be revoked at any time by notifying us in writing. After you revoke your authorization, we will no longer use or disclose your medical information based on the authorization.  However, uses and disclosures made before we received your withdrawal will not be affected as we cannot take back any disclosures that have already been made based on your authorization.

Fundraising. We may contact you for fundraising efforts, but you will be given an opportunity to opt-out of further fundraising communications.

PERMISSIBLE USES & DISCLOSURES

We may use or share your medical information in the following ways, without your prior authorization.

Treatment. We may use your medical information as needed to provide you with treatment. For example, we may use and disclose your medical information to order laboratory tests or prescriptions, to assist other health care providers in their treatment of you, or to inform you of potential treatment alternatives or programs.

Payment. We may use and disclose your medical information to bill and collect payment for the services and items provided by us. For example, we may share your medical information with your health insurance plan so it will pay for the services provided to you. We may also share your medical information with other health care providers to assist in their billing and collection efforts.

Health Care Operations. We may use and disclose your health information to operate our practice, improve your care, and contact you when necessary. For example, we may use or disclose your medical information to evaluate the quality of care you received from us or to conduct cost-management and business planning activities.  In some circumstances, we may also share health information with other health care providers for their health care operations.

Health Information Exchanges.  We may participate in one or more Health Information Exchanges (“HIE”).  HIEs allow health care entities participating in the same HIE to quickly share medical information as necessary to support timely care coordination and quality health care.  For example, your health information related to a recent hospital visit may be shared via a HIE with us so that we can promptly coordinate necessary follow-up treatment with you.  If we participate in a HIE, we will follow applicable state law related to consent and/or opt-out requirements.

Research.  We can use or share your information for research purposes. However, we must meet many conditions in the law before we can share your information for research purposes.  We also will not share your information for research purposes without your consent when consent is required by state law.

OTHER USES & DISCLOSURES

Public Health & Safety. Subject to certain conditions, we can share your medical information for the following purposes:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions
• Reporting suspected abuse or neglect
• Preventing or reducing a serious threat to health or safety

Compliance with Law. We will share your medical information if state or federal laws require it, including with the Department of Health and Human Services for the purpose of confirming our compliance with federal privacy laws.

Organ & Tissue Donation Requests. We can share your medical information with organ procurement organizations.

Medical Examiners and Funeral Directors.  We can share medical information with a coroner, medical examiner, or funeral director in the event of death.

Workers’ Compensation. We may release your medical information for workers’ compensation and similar programs subject to the requirements of State Law.

Law Enforcement & Other Government Requests. We may share medical information for law enforcement purposes or with law enforcement officials when permitted by law. We may also share medical information with health oversight agencies for activities authorized by law, and for special government functions such as military, national security, and presidential protective services.

Court Orders and Subpoenas. We can share your medical information in response to a court or administrative order, or in response to a subpoena.

Electronic Communications Not Secure.  Using any unsecure electronic communication (such as regular email) to communicate with us can present risks to the security of information.  These risks include possible interception of the information by unauthorized parties, misdirected emails, shared accounts, message forwarding, or storage of the information on unsecured platforms and/or devices. We do not advise communicating with us via unsecured email or text message.  By choosing to correspond with us via unsecure electronic communication platforms, you are acknowledging and accepting these risks.

Patient Rights and Responsibilities

Welcome to Greenbrook Medical Practice, PLLC (“Greenbrook Medical”)! While receiving care at Greenbrook Medical, it is important to us that you know that Greenbrook Medical will recognize your rights and asks that you respect your Greenbrook Medical health care provider’s right to expect certain behavior on the part of its patients. You may request a copy, at any time, of the full text of the applicable law (§ 381.026, F.S.) that applies to the rights and responsibilities described herein from Greenbrook Medical. Below is a summary of your rights and responsibilities when you receive care at Greenbrook Medical.

Patient Rights. When receiving services from Greenbrook Medical, you have the right:

• To be treated with courtesy and respect, with appreciation of your individual dignity, and with protection of your need for privacy.
• To a prompt and reasonable response to questions and requests.
• To know who is providing medical services and who is responsible for your care.
• To know what patient support services are available, including whether an interpreter is available if you do not speak English.
• To bring any person of your choosing to the patient-accessible areas of our facility or provider’s office to accompany you while you are receiving inpatient or outpatient treatment or are consulting with your health care provider, unless doing so would risk the safety or health of you, other patients, or staff of the facility or office or cannot be reasonably accommodated by the facility or provider.
• To know what rules and regulations apply to your conduct.
• To be given by your health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
• To refuse any treatment, except as otherwise provided by law.
• To be given, upon request, full information and necessary counseling on the availability of known financial resources for your care.
• A patient who is eligible for Medicare has the right to know that Greenbrook Medical accepts the Medicare assignment rate.
• To receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
• To receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.
• To impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.
• To treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
• To know if medical treatment is for purposes of experimental research and to give your consent or refusal to participate in such experimental research.
• To express grievances regarding any violation of your rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served you and to the appropriate state licensing agency.

Patient Responsibilities. When you are receiving services from Greenbrook Medical, you have the responsibility:

• To provide to the health care provider, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to your health.
• To report unexpected changes in your condition to your health care provider.
• To report to the health care provider whether you comprehend a contemplated course of action and what is expected of you.
• To follow the treatment plan recommended by your health care provider.
• To keep appointments and, when you are unable to do so for any reason, to notify the health care provider or health care facility.
• To be responsible for your actions if you refuse treatment or does not follow the health care provider’s instructions.
• To assure that the financial obligations of your health care are fulfilled as promptly as possible.
• To follow health care facility rules and regulations affecting patient care and conduct.

Questions & Concerns

If you have any questions about this Notice or would like to notify us of a privacy concern, please contact:

Attn: Privacy Officer

Greenbrook Medical Practice, PLLC

11200 E. Dr. Martin Luther King Jr. Blvd, Suite 107, Seffner, FL 33584

1. (813) 443-3399

Email: [email protected]