OBGYN Specialists of North Florida, LLC
NOTICE OF PRIVACY PRACTICES

Your Information. Your Rights. Our Responsibilities.

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.

[Effective Date: 10.01.2025]

Your Rights

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

You have the right to:

• Get a copy of your paper or electronic medical record
  • You can ask to inspect or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

• Amend (correct) your paper or electronic medical record
  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

• Request confidential communication
  • 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 say “yes” to all reasonable requests.

• Ask us to limit the information we share
  • You can ask us not to use or share certain health 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 you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
    • • We will say “yes” unless a law requires us to share that information.

• Get a list of those with whom we’ve shared your information
  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Get a copy of this privacy notice
  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

• Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

• In these cases, you have both the right and choice to tell us to:
  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation

• If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe 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.

• In these cases, we never share your information unless you give us written permission:
  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

• In the case of fundraising:
  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways:

• Treatment: We can use your health information and share it with other professionals who are treating you (i.e., a doctor treating you for an injury asks another doctor about your overall health condition)
• Payment: We can use and share your health information to bill and get payment from health plans or other entities (i.e., we give information about you to your health insurance plan so it will pay for your services)
• Healthcare Operations: We can use and share your health information to run our practice, improve your care, and contact you when necessary (i.e., we use health information about you to manage your treatment and services)
• Appointment Reminders, Treatment Alternatives, and Health-Related Benefits and Services: We may use and disclose health information to contact you as a reminder that you have an appointment with us. We may use and disclose health information to tell you about treatment options or alternatives or health-related benefits and services that may be of interest to you. We also may make your health information available for you to access through a secure online patient portal (if applicable).
• De-identified Health Information: We may use your health information to create “de-identified” information that is not identifiable to any individual in accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Federal law does not restrict the use of patient health information once it becomes “de-identified” data in a manner provided under HIPAA so as to not disclose your identity. We may create data sets of de-identified information of many patients to share with outside persons and companies to discover methods and products to diagnose and treat diseases. We may also disclose your health information to a business associate for the purpose of creating de-identified information.
• Limited Data Set: We may use your health information to create a “limited data set” by removing certain identifying information. We may also disclose your health information to a business associate for the purpose of creating a limited data set. We may use and disclose a limited data set only for research, public health or healthcare operations purposes. We may create a limited data set of many patients to share with outside persons and companies to perform research, public health or healthcare operations. Persons or companies receiving the limited data set must sign an agreement to protect your health information.
• Business Associates: We may disclose your health information to our business associates who perform functions on our behalf or provide us with services, if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated by law and under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
• Participation in Health Information Exchanges (HIE): We may share information about you with one or more HIEs that we may participate in. HIEs are secure electronic systems that allow health care providers to exchange patient information in order to better coordinate your care and to help us make more informed decisions regarding the best way to treat you. For example, if you were to visit another provider or hospital that also participates in the same HIE, we would receive treatment information from that provider. If you do not wish to participate in the HIE, we will provide you a HIE Opt-Out Form to complete. You can receive services from us even if you decide to opt out of participation in the HIE.
• Incidental Uses and Disclosures: Incidental uses and disclosures of information may occur. An incidental use or disclosure is a secondary use or disclosure that cannot reasonably be prevented, is limited in nature, and that occurs as a by-product of an otherwise permitted use or disclosure. However, such incidental uses or disclosure are permitted only to the extent that we have applied reasonable safeguards and do not disclose any more of your PHI than is necessary to accomplish the permitted use or disclosure. For example, disclosures about a patient within a physician’s office that might be overheard by persons not involved in your care would be permitted.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions under applicable law before we can share your information for these purposes. For more information see:  www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

• Help with public health and safety issues
  • We can share health information about you for certain situations such as:
    • Preventing disease
    • Helping with product recalls
    • Reporting adverse reactions to medications
    • Reporting suspected abuse, neglect, or domestic violence
    • Preventing or reducing a serious threat to anyone’s health or safety
• Do research: We can use or share your information for health research.
• Comply with the law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
• Respond to organ and tissue donation requests: We can share health information about you with organ procurement organizations.
• Work with a medical examiner or funeral director: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• Address workers’ compensation, law enforcement, and other government requests
  • We can use or share health information about you:
    • For workers’ compensation claims
    • For law enforcement purposes or with a law enforcement official
    • With health oversight agencies for activities authorized by law
    • For special government functions such as military, national security, and presidential protective services
• Respond to lawsuits and legal actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena.

USES AND DISCLOSURES THAT REQUIRE YOUR WRITTEN AUTHORIZATION

We will seek your specific written authorization for at least the following information unless the use or disclosure would be otherwise permitted or required by law as described above:

• HIV/AIDS information: In most cases, we will NOT release any of your HIV/AIDS related information unless your authorization expressly states that we may do so. There are certain purposes, however, for which we may be permitted to release your HIV/AIDS information without obtaining your express authorization. For example, we may release information regarding your HIV/AIDS status to your insurance company or HMO for purposes of receiving payment for services we provide to you. We may also release information regarding HIV/AIDS status of yourself and other patients where the information has been “de-identified” (meaning, the information cannot be used in any way to identify you). Other instances where we may use or disclose HIV/AIDS information without your express authorization include:
  • For your diagnosis and treatment;
  • For scientific research;
  • For management audits, financial audits, or program evaluation;
  • For medical education;
  • For disease prevention and control, when permitted by the State Department of Health
  • To comply with certain court orders; and
  • When otherwise required by law, to the Department of Health or another entity.
• Sexually transmitted disease information: We must obtain your specific written authorization prior to disclosing any information that would identify you as having or being suspected of having a sexually transmitted disease. We may use and disclose information related to sexually transmitted diseases without obtaining your authorization only when permitted by law, including to the Department of Health, to your physician or a health authority, or to a prosecuting officer or court if you are being prosecuted under state law. Where necessary, your provider or a health authority may further disclose such information to protect your health and welfare, or the health and welfare of your family or the public.
• Mental health information: We must obtain your specific written authorization prior to disclosing certain mental health information where required by state law. There may be cases where you see a mental health provider in a primary care setting and collaborative care is provided by the mental health provider and your primary care physician. In these situations, the mental health provider is not operating as a psychotherapist, and your mental health information may be stored within your primary care notes.
• [If Applicable]: Substance Use Disorder Treatment Records (42 CFR Part 2)
  • If we receive records related to substance use disorder (“SUD”) treatment from a federally assisted program, those records are protected by federal law (42 CFR Part 2). These laws may apply even if our organization is not a Part 2 program and we are not Part 2 providers.
  • We will not use or disclose SUD treatment records without your written consent, except in limited circumstances permitted by law (i.e., medical emergency). We may rely on your written consent that permits the use and disclosure of Part 2 records for treatment, payment, and healthcare operations, and we may redisclose such records as permitted by HIPAA, except that the records may not be redisclosed for legal proceedings involving you. Consent may be revoked at any time.
  • Records protected by Part 2 cannot be used in court, administrative, or legal proceedings against you unless:
    • You give specific written consent; or
    • A court issues an order permitting the disclosure.
  • Any permitted disclosure of SUD treatment records will include the required statement that further use or redisclosure is prohibited unless allowed by federal law.
• Genetic information: We must obtain your specific written authorization prior to obtaining or retaining your genetic information, or using or disclosing your genetic information for treatment, payment, or health care operations purposes. For example, before conducting any genetic testing, we will ask for your written authorization to conduct such testing. We may use or disclose your genetic information, or the genetic information of your child, without your written authorization only where it would be permitted by law, such as for paternity tests for court proceedings, anonymous research, newborn screening requirements, identifying a body, for the purposes of criminal investigations or otherwise authorized by a court order.
• Information related to treatment of a minor in special circumstances: If you are a minor who sought certain types of treatment from us (to which treatment you were able to consent on your own behalf), such as treatment related to your pregnancy or treatment related to your child, or a sexually transmitted disease, we must obtain your specific written authorization prior to disclosing any of your PHI related to such treatment to another person, including your parent(s) or guardian(s), unless we would otherwise be permitted by law to do so.
• Marketing Activities: We must obtain your specific written authorization to use any of your PHI to mail or email you marketing materials. However, we may provide you with marketing materials face-to-face without obtaining authorization, in addition to communicating with you about services or products that relate to your treatment, case management, or care coordination, alternative treatments, therapies, providers or care settings. If you do provide us with your written authorization to send you marketing materials, you have a right to opt-out of receiving these communications in the future and may do so at any time. If you wish to opt-out of receiving these communications in the future, please contact the Privacy Officer at the email or address below.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
• For more information see: www.hhs.gov/ocr/privacy/hipaa/ understanding/consumers/noticepp.html

HOW TO EXERCISE YOUR RIGHTS

To exercise your rights described in this notice (other than to obtain a copy of this notice), you must email privacy@toplinemd.com or send a request, in writing, to the following address:

• OBGYN Specialists of North Florida, LLC
  Attention: Privacy Officer
  Address: 111 Nature Walk Pkwy., Unit 107, St. Augustine, FL 32092

• File a complaint if you believe your privacy rights have been violated
  
  • You can complain if you feel we have violated your rights by contacting us using the information on the back page.

• • You can file a complaint with the U.S. Department  of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-6966775, or visiting https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

• • We will not retaliate against you for filing a complaint.

COMPLAINTS OR QUESTIONS

If you believe your privacy rights have been violated, you may file a complaint with us by contacting our Privacy Officer at privacy@toplinemd.com or send your complaint, in writing, to the following address:

• OBGYN Specialists of North Florida, LLC
  Attention: Privacy Officer
  Address: 111 Nature Walk Pkwy., Unit 107, St. Augustine, FL 32092

CHANGES TO THE TERMS OF THIS NOTICE

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.