Health Insurance Portability & Accountability Act

HIPAA Notice of Privacy Practices

MidState Skin Institute, LLC

Effective Date: March 26, 2013

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.

This Notice is provided to you pursuant to the Health Insurance Portability and Accessibility Act of 1996 and its implementation regulations (“HIPAA”). It is designed to tell you how we may, under federal law, use or disclose your Health Information. It has been updated to the HITECH Omnibus Rule requirements.

    1. Your Rights

You have the right to request restrictions on the uses and disclosures of your Health Information. However, we are not required to comply with all requests. You are allowed to restrict transmittal of health care charges to your insurance carrier if you pay for those services, in full, by other means.

You have the right to receive your Health Information through confidential means and in a manner that is reasonably convenient for you and us.

You have the right to inspect and copy your Health Information. You may request your records in digital format and have your records sent digitally to another provider with written authorization. You have the right to request that we amend your Health Information that is incorrect or incomplete. We are not required to change your Health Information and will provide you with information about our denial and how you can disagree with the denial.

You have a right to receive an accounting of disclosures of your Health Information made by us, except that we do not have to account for disclosures: authorized by you; made for treatment, payment, health care operations; provided to you; provided in response to an Authorization; made in order to notify and communicate with approved family members; and/or for certain government functions, to name a few.

You have been provided with a paper copy of this Notice of Privacy Practices. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, please contact our HIPAA Compliance Officer at 352-512-0092.

  • We may Use or Disclose Your Health Information for Purposes of Treatment, Payment or Healthcare Operations without Obtaining Your Prior Authorization and Here Is One Example of Each:


We may provide you health Information to other health care professionals – including doctors, nurses and technicians – for purposes of providing you with care.

Our billing department may access your information – and send relevant parts to insurance companies to allow us to be paid for the services we render to you.

We may access or send your information to our attorneys or accountants in the event we need the information in order to address one of our own business functions. Our attorneys and accountants are required to maintain confidentiality when they receive patient information.


  • We May Also Use or Disclose Your Health Information Under Certain Circumstances without Obtaining Your Prior Authorization.


However, in general, we will attempt to ensure that you have been made aware of the use or disclosure of your Health Information prior to providing it to another person. Some instances where we may need to disclose information include but are not limited to: To Notify and/or Communicate with Your Family. We will only communicate with family members that we are authorized to communicate with based on your completion of the Authorization to Disclose Health Information to Family and Friends form.

As Required by Law.

For Health Oversight Activities. We may use or disclose your Health Information to health oversight agencies during the course of audits, investigations, certification and other proceedings.

In Response to Civil Subpoenas or for Judicial Administrative Proceedings. We may use or disclose your Health Information, as directed, in the course of any civil administrative or judicial proceeding.

To Law Enforcement Personnel. We may use or disclose your Health Information to a law enforcement official to comply with a court order or grand jury subpoena and other law enforcement purposes.

For Purposes of Organ Donation. We may use or disclose your Health Information for purposes of communicating to organizations involved in procuring, banking or transplanting organs and tissues.

For Worker’s Compensation. We may use or disclose your Health Information as necessary to comply with worker’s compensation laws.


  • For all Other Circumstances, We May Only Use or Disclose Your Health Information After You Have Signed an Authorization.


If you authorize us to use or disclose your Health Information for another purpose, you may revoke authorization in writing at any time.

Fundraising. Should our practice use patient information for fund raising we will inform individuals that they have the right to opt out of fundraising solicitations and explain that process. You do have the capability to opt back in with written notice.

Marketing. Should our practice use patient information for marketing purposes we will first obtain your written authorization and fully explain the uses an disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI will require a separate written authorization.

Use or Disclosure of Psychotherapy Notes. Written authorization is required if our practice intends to use or disclose psychotherapy notes.

Breach Notice. All patients will be informed if there is a breach, as defined by federal rules, of their unsecured protected health information as required by the HIPAA regulations.

Right to Request Restrictions for Disclosures Related to Self-Payment. Our practice is required to comply with a request not to disclose health information to a health plan for treatment when the individual has paid in full out-of-pocket for a health care item or service and signed our “Do Not File Insurance Form”.


  • You Should Be Advised that We May Also Use or Disclose Your Health Information for The Following Purposes:


Appointment Reminders. We may use your Health Information in order to contact you to provide appointment reminders or to give information about other treatments or health-relate benefits and services that may be of interest to you.

Change of Ownership. In the event that our Business is sold or merged with antoehr organization, your Health Information/record will become the property of the new owner.

Electronic Exchange. Your information may be shared with other providers, labs and radiology groups through our EMR/HER system as listed below:

1) (Gateway EDI) Electronic Exchange #1


  • Our Duties


We are required by law to maintain the privacy of your Health Information and to provide you with a copy of this Notice.

We are also required to abide by the terms of this Notice.

We reserve the right to amend this Notice at any time in the future and to make the new Notice provisions applicable to all your Health Information – even if it was created prior to the change in the Notice. If any such amendment is made that materially changes this Notice, we will send you another copy.


  • Complaints to our Practice and the Government.


You may make complaints to our HIPAA Privacy Offer or the Security of the Department of Health and Human Services (“DHHS”) if you believe your rights have been violated.
We will review all complaints in a professional manner and keep you informed of your rights as our patient.

We promise not to retaliate against you for any complaint you make about our privacy practices.


  • Contact Information


You may contact us about our privacy practices or file a complaint by calling our Privacy Offer:
Thomas Cauthen at 352-512-0092.

You may contact the DHHS at: The U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201, Telephone: 202-619-0257, Toll Free: 1-877-696-6775.