HIPAA Information

CARROLLWOOD FAMILY MEDICAL & REHABILITATION CENTER, INC.

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

PLEASE REVIEW THIS NOTICE CAREFULLY.

This Practice is committed to maintaining the privacy of your protected
health information ("PHI"), which includes information about your health
condition and the care and treatment you receive from the Practice. The
creation of a record detailing the care and services you receive helps this
office to provide you with quality health care. This Notice details how your
PHI may be used and disclosed to third parties. This Notice also details your
rights regarding your PHI. The privacy of PHI in patient files will be
protected when the files are taken to and from the Practice by placing the
files in a box or brief case and kept within the custody of a doctor or
employee of the Practice authorized to remove the files from the Practice's
office. It may be necessary to take patient files to a facility where a
patient is confined or to a patient's home where the patient is to be
examined or treated.

NO CONSENT REQUIRED

The Practice may use and/or disclose your PHI for the purposes of:

· (a) Treatment - In order to provide you with the health care you require,
the Practice will provide your PHI to those health care professionals,
whether on the Practice's staff or not, directly involved in your care so that they may
understand your health condition and needs. For example, a physician treating you
for a condition or disease may need to know the results of your latest
physician examination by this office.

· (b) Payment - In order to get paid for services provided to you, the
Practice will provide your PHI, directly or through a billing service, to appropriate
third party payors, pursuant to their billing and payment requirements. For example,
the Practice may need to provide the Medicare program with information about
health care services that you received from the Practice so that the Practice
can be properly reimbursed. The Practice may also need to tell your insurance
plan about treatment you are going to receive so that it can determine whether or
not it will cover the treatment expense.

· (c) Health Care Operations - In order for the Practice to operate in
accordance with applicable law and insurance requirements and in order for the
Practice to continue to provide quality and efficient care, it may be necessary for
the Practice to compile, use and/or disclose your PHI. For example, the Practice may
use your PHI in order to evaluate the performance of the Practice's personnel in
providing care to you.

1. The Practice may use and/or disclose your PHI, without a written Consent
from you, in the following additional instances:

· (a) De-identified Information - Information that does not identify you
and, even without your name, cannot be used to identify you.

· (b) Business Associate - To a business associate if the Practice obtains
satisfactory written assurance, in accordance with applicable law, that
the business associate will appropriately safeguard your PHI. A business
associate is an entity that assists the Practice in undertaking some essential
function, such as a billing company that assists the office in submitting claims for payment to
insurance companies or other payers.

· (c) Personal Representative - To a person who, under applicable law, has
the authority to represent you in making decisions related to your health
care.

· (d) Emergency Situations -

· (i) for the purpose of obtaining or rendering emergency treatment to
you provided that the Practice attempts to obtain your Consent as soon as
possible; or

· (ii) to a public or private entity authorized by law or by its
charter to assist in disaster relief efforts, for the purpose of coordinating your care
with such entities in an emergency situation.
· (e) Communication Barriers - If, due to substantial communication
barriers or inability to communicate, the Practice has been unable to obtain
your Consent and the Practice determines, in the exercise of its professional
judgment, that your Consent to receive treatment is clearly inferred from the
circumstances.
· (f) Public Health Activities - Such activities include, for
example, information collected by a public health authority, as authorized by
law, to prevent or control disease and that does not identify you and, even
without your name, cannot be used to identify you.
· (g) Abuse, Neglect or Domestic Violence - To a government
authority if the Practice is required by law to make such disclosure; if the
Practice is authorized by law to make such a disclosure, it will do so if it
believes that the disclosure is necessary to prevent serious harm.
· (h) Health Oversight Activities - Such activities, which must
be required by law, involve government agencies and may include, for example,
criminal investigations, disciplinary actions, or general oversight
activities relating to the community's health care system.
· (i) Judicial and Administrative Proceeding - For example, the Practice
may be required to disclose your PHI in response to a court order or a
lawfully issued subpoena.
· (j) Law Enforcement Purposes - In certain instances, your PHI may have to
be disclosed to a law enforcement official. For example, your PHI may be the
subject of a grand jury subpoena. Or, the Practice may disclose your PHI if
the Practice believes that your death was the result of criminal conduct.
· (k) Coroner or Medical Examiner - The Practice may disclose your PHI to a
coroner or medical examiner for the purpose of identifying you or determining
your cause of death.
· (l) Organ, Eye or Tissue Donation - If you are an organ donor, the
Practice may disclose your PHI to the entity to whom you have agreed to
donate your organs.
· (m) Research - If the Practice is involved in research activities, your
PHI may be used, but such use is subject to numerous governmental
requirements intended to protect the privacy of your PHI and that does not
identify you and, even without your name, cannot be used to identify you.
· (n) Avert a Threat to Health or Safety - The Practice may disclose your
PHI if it believes that such disclosure is necessary to prevent or lessen a
serious and imminent threat to the health or safety of a person or the public
and the disclosure is to an individual who is reasonably able to prevent or
lessen the threat.
· (o) Workers' Compensation - If you are involved in a Workers'
Compensation claim, the Practice may be required to disclose your PHI to an
individual or entity that is part of the Workers' Compensation system. APPOINTMENT REMINDER
The Practice may, from time to time, contact you to provide appointment
reminders or information about treatment alternatives or other health-related
benefits and services that may be of interest to you. The following
appointment reminders are used by the Practice: a) a postcard mailed to you
at the address provided to you; b) telephoning your home and leaving a
message on your answering machine or with the individual answering the phone;
c) telephoning you at your work and leaving message for you on the answering
machine/voice mail or person answering the phone; and d) telephoning you on
your cell phone number or pager number that you leave at the office. SIGN-IN LOG
The Practice maintains a sign-in log for individuals seeking care and
treatment in the office. The sign-in log is located in a position where staff
can readily see who is seeking care in the office, as well as the
individual's location within the Practice's office suite. This information
may be seen by, and is accessible to, others who are seeking care or services
in the Practice's offices.

FAMILY/FRIENDS
The Practice may disclose to your family member, other relative, a close
personal friend, or any other person identified by you, your PHI directly
relevant to such person's involvement with your care or the payment for your
care. The Practice may also use or disclose your PHI to notify or assist in
the notification (including identifying or locating) a family member, a
personal representative, or another person responsible for your care, of your
location, general condition or death. However, in both cases, the following
conditions will apply:

· (a) If you are present at or prior to the use or disclosure of your PHI,
the Practice may use or disclose your PHI if you agree, or if the Practice can
reasonably infer from the circumstances, based on the exercise of its professional
judgment, that you do not object to the use or disclosure.

· (b) If you are not present, the Practice will, in the exercise of
professional judgment, determine whether the use or disclosure is in your best
interests and, if so, disclose only the PHI that is directly relevant to the person's
involvement with your care.

AUTHORIZATION

Uses and/or disclosures, other than those described above, will be made
only with your written authorization.

YOUR RIGHTS

1. You have the right to:

· (a) Revoke any Authorization and/or Consent, in writing, at any time and
to request a revocation, you must submit a written request to the Practice's
COMPLIANCE OFFICER

· (b) Request restrictions on certain use and/or disclosure of your PHI as
provided by law, however, the Practice is not obligated to agree to any
requested restrictions .To request restrictions, you must submit a written
request to the Practice's COMPLIANCE OFFICER. In your written request, you
must inform the Practice of what information you want to limit, whether you
want to limit the Practice's use or disclosure, or both, and to whom you
want the limits to apply. If the Practice agrees to your request, the
Practice will comply with your request unless the information is needed in
order to provide you with emergency treatment.

· (c) Receive confidential communications or PHI by alternative means or at
alternative locations; you must make your request in writing to the
Practice's COMPLIANCE OFFICER. The Practice will accommodate all reasonable
requests.

· (d) Inspect and obtain a copy of your PHI as provided by law. To inspect
and copy your PHI, you are requested to submit a written request to the
Practice's COMPLIANCE OFFICER. The Practice can charge you a fee for the cost of
copying, mailing or other supplies associated with your request.

· (e) Amend your PHI as provided by law. To request an amendment, you must
submit a written request to the Practice's COMPLIANCE OFFICER. You must
provide a reason that supports your request. The Practice may deny your
request if it is not in writing, if you do not provide a reason in support of
your request, if the information to be amended was not created by the Practice (unless the
individual or entity that created the information is no longer
available), if the information is not part of your PHI maintained by the Practice, if the
information is not part of the information you would be permitted to inspect
and copy, and/or if the information is accurate and complete. If you disagree
with the Practice's denial, you will have the right to submit a written
statement of disagreement.

· (f) Receive an accounting of disclosures of your PHI as provided by law.
The request should indicate in what form you want the list (such as a paper
or electronic copy).

· (g) Receive a paper copy of this Privacy Notice from the Practice upon
request to the Practice's COMPLIANCE OFFICER.

· (h) Complain to the Practice or to the Office of Civil Rights, U.S.
Department of Health and Human Services, 200 Independence Avenue. S.W., Room 509F, HHH Building, Washington, D.C. 20201, 202/619-0257, email:OCRMAIL@HHS.GOVor to the Florida Attorney General, Office of the Attorney General, PL-01 The
Capitol, Tallahassee, FL 32399-1050, 850/414-3300, if you believe your
privacy rights have been violated. To file a complaint with the Practice, you
must contact the Practice's COMPLIANCE OFFICER. All complaints must be in
writing.

· (i) To obtain more information on, or have your questions about your
rights answered, you may contact the Practice's COMPLIANCE OFFICER,
Dr. Barry D. Shapiro, D.C., P.A. at (813) 960-8866 or via email at
DRSHAPIRO@CARROLLWOODFAMILY MEDICAL.COM.

PRACTICE'S REQUIREMENTS

1. The Practice:

· (a) Is required by federal law to maintain the privacy of your PHI and to
provide you with this Privacy Notice detailing the Practice's legal duties and
privacy practices with respect to your PHI.

· (b) Is required by State law to maintain a higher level of
confidentiality with request to certain portions of your medical information that is provided
for under federal law. In particular, the Practice is required to comply with the
following States statutes:

Section 381.004 relating to HIV testing, Chapter 384 relating to sexually
transmitted diseases and Section 456.057 relating to patient records
ownership, control and disclosure.

· (c) Is required to abide by the terms of this Privacy Notice.

· (d) Reserves the right to change the terms of this Privacy Notice and to
make the new Privacy Notice provisions effective for all of your PHI that it
maintains.

· (e) Will distribute any revised Privacy Notice to you prior to
implementation.

· (f) Will not retaliate against you for filing a complaint.

QUESTIONS AND COMPLAINTS

You may obtain additional information about our privacy practices or
express concerns or complaints to the person identified below who is the
COMPLIANCE OFFICER and Contact person appointed for this practice. The
COMPLIANCE OFFICER is Dr. Barry D. Shapiro, D.C., P.A.

You may file a complaint with the COMPLIANCE OFFICER if you believe that
your privacy rights have been violated relating to release of your protected
health information. You may, also, submit a complaint to the Department of
Health and Human
Services the address of which will be provided to you by the COMPLIANCE
OFFICER. We will not retaliate against you in any way if you file a complaint.

EFFECTIVE DATE

This Notice is in effect as of April 14, 2003.