JSA Healthcare Corporation
Notice of Privacy Rights

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

Article I. Typical Uses and Disclosures of Medical Information

Section 1.01 JSA Healthcare will keep your health care information confidential, using it for the following purposes:

A.     Treatment – JSA Healthcare will use the health care information we learn about you to provide you with health care services.

1.      The following people in our office will have access to your information:

  1. Medical staff – doctors, physician assistants, and nurse practitioners.

  2. Nursing staff – registered nurses, licensed practical nurses, and medical assistants.

  3. Other clinical staff – phlebotomists, laboratory technologists and technicians, x-ray technicians.

  4. Reception and Administrative staff.

  5. Medical records personnel.

  6. Referral Coordinators

2.      JSA Healthcare has established standards and procedures that limit various staff members’ access to your health information according to their primary job functions. These standards and procedures may change from time to time. All of our staff is required to sign a confidentiality statement.

3.      JSA Healthcare will share your health care information with other health care providers involved in your care.

  1. When a physician admits you to the hospital, we will share your health care information with personnel of that hospital. That hospital will have a privacy notice like this one. If you have questions about their policy, you should ask them for a copy of their notice.

  2. When JSA refers you to a specialist, we will share your health care information with them. We will send this information whether you actually see the specialist (for example, a surgeon) or not (for example, if we send a specimen to a laboratory for analysis). That specialist will have a privacy notice like this one. If you have questions about a provider’s policy, you should ask the provider.

  3. When we submit laboratory specimen to reference laboratories, and/or pathologists.

B.     Payment – JSA Healthcare will use and disclose your health care information to seek reimbursement for services we render to you. In this process, other parties may have access to the information you give us.
Some examples include providing your health information to:

  1. The insurance organizations involved in your care.

  2. Federal or state health programs, such as Medicare and Medicaid.

  3. An organization that mails our billing statements to you.

  4. If one is required, the collection agency we use to collect unpaid balances.

  5. Other firms that become involved in the processing or reviewing payment activities.

C.     Health Care Operations – JSA Healthcare will use and disclose your health information in our company’s operations. Examples of such uses and disclosures include:

  1. Our medical records staff

  2. Outside health or management reviewers

  3. Other contracted business associates

D.     Governmental Oversight Activities – JSA Healthcare will use and disclose your health information to support activities associated with audits, investigations, license reviews, applications for privileges, and in compliance with governmental programs and laws.

E.      As required by law – JSA Healthcare will use and disclose your health care information as required by a court or administrative order, subpoena or other lawful process. We will use and disclose your information when requested by national security, intelligence, and other State or Federal officials, and/or if you are an inmate or otherwise under the custody of law enforcement.

F.      For appointment reminders – JSA Healthcare  will remind you of appointments you have made in our office or elsewhere that may contain basic information such as the date and time of your appointment.

G.     Treatment alternatives – JSA Healthcare may use and disclose your health information to educate you about treatment alternatives.

H.     Research – JSA Healthcare may use and disclose your  de-identified health information to participate in research programs that have proper governmental approval. If your information is to be presented in a format that would allow individual identification, we will seek your written authorization before disclosing it.

I.        By the request of the military – if you currently serve in the military or are a veteran, JSA Healthcare will disclose your information upon proper military request.

J.       To prevent a serious threat to health or safety – if a licensed member of our staff determines, in his or her best professional judgment, that there is a serious threat to your health and/or safety or that of another person, JSA Healthcare will disclose your health information to the proper authorities.

K.     To meet public health requirements – JSA Healthcare will disclose your health care information to report deaths, child abuse, neglect, domestic violence, problems with products, reactions to medications, product recalls, disease/infection exposure, and to prevent and control disease, injury, and disability.

Section 1.02 Uses and disclosures with your agreement or objection:

In certain cases, we may use or disclose your personal health information, provided that you agree to the use or disclosure. For example:

1.       In case of a disaster, to disaster management agencies to let them know that you have received treatment in a JSA facility.

2.       To family members or friends, to inform them about how they may be involved in your follow-up care.

3.       To people inquiring about your presence in a JSA facility or your general condition.

Section 1.03 Authorization and right to revocation – JSA Healthcare will request written authorization from you to use or disclose your personal health information to anyone for any purpose or situation not included in this document.

If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. We will not use or disclose your personal health information for any reason not permitted by law without your written authorization.

Article II. Your Privacy Rights

This section of the notice describes your rights with respect to your health information and a brief description of how you may exercise these rights.

Section 2.01 Inspect and copy your health care information, or that of an individual for whom you are a legal guardian or designated personal representative.

A.  You have a right to inspect and copy your health information for as long as we maintain the information. However, you do not have an automatic right to access psychotherapy notes or information compiled for a criminal, civil or administrative action or proceeding. 

            1.  If you request access of your personal health information:

  1. JSA Healthcare will act on a request for access within 30 days of receiving your request if the information is maintained and accessible on-site or within 60 days otherwise (with a possible 30-day extension).

  2. JSA Healthcare may provide you with a summary of the health information requested if you agree in advance to the summary and to the fees imposed. 

B.  JSA Healthcare may deny your request for access to your health information under certain circumstances such as when access would endanger the life or safety of you or others.

  1. If your request is denied, JSA Healthcare will send you a written denial that explains our reason for the denial, your review rights if any, and how to file a complaint with JSA or Secretary of the Department of Health and Human Services (DHHS).

  2. If your request for access is denied, in certain instances JSA Healthcare will provide you with an opportunity for review. The review decision must be made in a reasonable period of time and we will provide you with a written notice of the review decision.

C.   JSA Healthcare will charge a fee of $1.00 per page up to 25 pages and $0.25 per page thereafter, plus mailing costs, for providing you with copies of your health information. This fee is based on our copying, mailing and summary preparation costs.

Section 2.02 You have the right to amend health care information, if you feel it is inaccurate or incomplete.

  1. If you would submit a request to amend your personal health information:

1.    JSA will respond to your written request to amend your health information within 60 days of the request (with a possible 30-day extension).

  1. If your request for amendment is granted. JSA will notify you in writing that your amendment request was accepted and we will make reasonable efforts to inform relevant people’s, including our business associates, to amend their records as well.

  2. If your request for amendment is denied, JSA will provide you with a timely, written notice that explains the reason for denial.

  1.     JSA Healthcare may deny your request to amend your health information if:
     

  1. We did not create the health information.

  2. The information is not part of our designated record set.

  3. The information was not available for inspection or the information is accurate and complete

  1. If your request is denied, you have the right to submit a written statement of disagreement or to have the request for amendment included with future disclosures. You also have the right to complain to JSA Healthcare or the Secretary of DHHS. We may prepare a rebuttal statement to your statement of disagreement. JSA Healthcare will provide you with a copy of the rebuttal statement.

  2. Any future disclosures of your health information will include the statement of disagreement or request for amendment, the denial notice, and the rebuttal or summary of this information.

Section 2.03 You have the right to receive a list of non-routine disclosures we have made of your health care information.

  1. You have the right to receive a list or accounting of the disclosures of your health information made by us during the six years prior to the request. If you submit a request to receive an accounting of disclosures of your PHI:

  1. We will act on your request for an accounting of disclosures within 60 days (with a possible 30-day extension).

  2. This accounting of disclosures will not include the following disclosures:

  1. Disclosures for treatment, payment and operations,

  2. Disclosures to you, the individual,

  3. Disclosures for national security or intelligence purposes,

  4. Disclosures for judicial and civil procedures or upon issuance of a subpoena,

  5. Disclosures made prior to April 14, 2003,

  6.  Any other disclosures permitted by law where accounting is not required.

  1. The written accounting of disclosures will include the following information for each disclosures:

  1. The date of the disclosure,

  2. The person to whom the information was disclosed,

  3. A brief description of the information disclosed,

  4. A brief statement of the purpose of the disclosure,

  5. Or in lieu of the summary, a copy of the authorization or request for disclosure.

  1. JSA Healthcare will provide you with one free accounting each calendar year. For each subsequent request within the twelve-month period, we will charge $10.00.

Section 2.04 You have the right to request a limit to the health care information JSA Healthcare discloses about you.

  1. You have the right to request that JSA Healthcare restrict uses and disclosure of your health information for activities related to payment and operations as described above. 

  1. Your request for the restriction must be in writing. 

  2. Give your written request to the center administrator or mail to JSA Healthcare c/o Privacy Officer, 111 2nd Avenue E., Suite 1500, St. Petersburg, FL 33701.

  3. JSA Healthcare will evaluate all requests for restrictions, however, we may not agree to the restriction.

  1. If JSA Healthcare agrees to the restriction, you will be notified in writing and we will abide by it except in emergencies.

  2. JSA Healthcare will terminate our agreement to a restriction if you agree to or request the termination of the restriction in writing. 

  3. If JSA Healthcare decides to terminate our agreement to the restriction, we will notify you in writing of our decision.

Section 2.05 You have the right to request confidential communications.

  1. You may request that JSA Healthcare communicate with you by alternative means or at alternative locations. (For example, you may wish to receive communications from us at your work location rather than your home.)

  2. JSA Healthcare, although not required, may accommodate your request if you clearly state that the disclosure of all or part of your health information could endanger you and such request is determined to be reasonable.

Section 2.06 You have the right to a paper copy of this notice.

  1. Upon your request, you have the right to receive a paper copy of this notice from JSA.  This notice is available at the front desk of any JSA facility.

Article III. Your Right to Complain

Section 3.01 You have the right to file a complaint with us or to the Secretary of DHHS about our adherence to these policies.

  1. You may complain to JSA Healthcare or the Secretary of DHHS if you believe your privacy rights have been violated. 

  2. To file a complaint with JSA Healthcare, contact the Privacy Officer at (727) 894-3013. 

 

JSA Healthcare will not intimidate, discriminate against, or retaliate against you if you exercise any right or process described in this notice, including the filing of a complaint or testifying, assisting, or participating in an investigation, compliance review, or hearing.

Article IV. Effectiveness and Subsequent Modification

Section 4.01 JSA Healthcare reserves the right to change this policy, and the associated procedures, without notice.

  1.  JSA Healthcare will provide you with a revised privacy notice whenever we make a material change to our policies for use and disclosure, individual privacy rights, our responsibilities or any other practices described in this notice that affect you.

  2. While JSA Healthcare reserves the right to implement changes to its privacy practices without prior notice, we will provide you with a revised notice as soon as possible when appropriate to do so. 

  3. JSA Healthcare is required by a federal law, the Health Insurance Portability and Accountability Act (HIPAA), and applicable state laws, to maintain the privacy of your health information and to provide you with this notice of privacy practices.

  4. JSA Healthcare will abide by the terms of this notice of privacy practices.

Section 4.02 This policy is effective on and after April 14th, 2003. Complete copies are available from the Privacy Officer and JSA Healthcare clinics.

We will treat all information the same as maintained regardless of when the information was received.