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Patient Privacy

6200 Sunset Drive, Suite 501 ~ (305)667-7878



This Practice is required by law to maintain the privacy of protected health information, to provide individuals with a notice of our legal duties and privacy practices with respect to protected health information, and to abide by the terms of the information practices that are described in this Notice of Privacy Practices (“Notice”). This Notice will be provided to our patients no later than the date of the first service delivery, including service delivered electronically. We will post this Notice in a clear and prominent location where it will be accessible for you to read.

After you review the privacy notice, you will be asked to sign the acknowledgement form that you were provided a copy of our Notice of Privacy Practices.





If you have any questions about this notice, please contact our HIPAA Compliance Officer.


1. Maintain the privacy of your health information
2. Provide you with this notice as to our legal duties and privacy practices regarding health information about you
3. Follow the terms of this notice that are currently in effect

We will not use or disclose your health information without your authorization, except as described in this notice.


— For Treatment
We may use and disclose medical information about you to provide you with medical treatment and to provide you with treatment related services. For example, we may disclose your health information to doctors, nurses, technicians, or other personnel, including people outside our office, who are or who may become involved with your care and may need the information in connection with such care.

— For Payment
We may use and disclose medical information about you so that others or we may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received from us. We may also give your health plan information about you to obtain approval or to determine whether your plan will cover the treatment.

— For Regular Health Care Operations
We may use and disclose medical information about you for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office, to continually improve the quality and effectiveness of the healthcare services we provide. For example: We may use and disclose medical information to review our treatment and services and to evaluate the performance of our staff in caring for you, and in communicating with you. We may also share information with other entities that have a relationship with you (e.g. – your health plan) for their health care operation activities. We may remove information that identifies you from medical information so others may use it to study health care and health care delivery without learning the specific patients identity.

— Appointment Reminders, Treatment alternatives
We may use and disclose medical information to contact you as a reminder that you have an appointment with us. We may use and disclose medical information to tell you about health-related benefits or alternate treatment services that may be of interest to you.

— Individuals Involved in Your Care or Payment for Your Care
Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition. Additionally, we may disclose medical information about you to an entity assisting in a disaster relief.

— Research
Under certain circumstances we may disclose information for research or educational purposes. Before we use or disclose information, the project will go through a special approval process to ensure the privacy of your health information. Even without special approval, we may permit researchers to look at records at our office to help them identify patients who may be included in their research project or for similar purposes, as long as they do not remove or take a copy of any health information. We may remove information that identifies you from your medical information so others may use it to study health care and health care delivery without learning your identity.


— As Required by Law
We will disclose health information when required to do so by international, federal, state or local law.

— Workers’ Compensation
We may release health information for workers compensation or other similar programs established by law that provide benefits for work-related injuries or illness.

— Business Associates
There are some services provided by our Practice through contracts with business associates, Examples could include certain laboratory tests, transcription services or billing company services. The types of services for which this Practice contracts with business associates may change from time to time. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

— Organ and Tissue Donation

Consistent with applicable law, if you are an organ donor, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation.

— Military and Veterans
If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

— Public Health Risks
As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability; reporting births and deaths; reporting child abuse or neglect; reporting reactions to medications or problems with products; notifying people of recalls of products they may be using; notifying a person who may have been exposed to a disease, or may be at risk for contracting or spreading a disease or condition; or notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence.

— Food and Drug Administration (FDA) 
We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

–Health Oversight Activities
We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

— Lawsuits and Disputes
If there is a pending judicial or administrative proceeding, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

— Law Enforcement
We may disclose health information for law enforcement purposes as required by law for the following reasons: (1) in response to a valid subpoena, court order, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness or missing person; (3) about the victim of a crime even if, under certain circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

— Coroners, Medical Examiners, and Funeral Directors
We may release medical information to a coroner or medical examiner in order to identify a deceased person or determine the cause of death. We also may release health information to a funeral director consistent with applicable law to carry out their duties.

— National Security and Intelligence Activities 
We may release your medical information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

— Protective Services for the President and Others
We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

— Correctional Institution
Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.


You have the following rights regarding medical information we maintain about you:

— Right to Inspect and Copy 
You have the right to inspect and copy medical information that may be used to make decisions about your care and payment for your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. You must allow us a reasonable time to delivery copies of your medical information.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to this office. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by this office will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

— Right to Amend
If you feel that medical information we have about you is incorrect or incomplete; you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, your request must be made in writing and submitted to this office with a reason that supports your request. In certain circumstances, we have the right to deny your request to amend.

— Right to an Accounting of Disclosures
You have the right to request a list of the disclosures we made of your health information for purposes other than treatment, payment, and health care operations or for which you provided written authorization. To request this list or accounting of disclosures you must submit your request in writing to this office.

— Right to Request Restrictions
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example: You could ask that we not disclose information about a particular diagnosis or treatment with your spouse. To request restrictions, you must make your request in writing to this office. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

— Right to Request Confidential Communication 
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example: You can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to this office. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests, but we will not accommodate any request that we believe may impede the care we provide you.

— Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our office.


We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at our office. The notice will contain, the “Effective Date” on the first page, in the top right-hand comer. In addition, each time you register at or are admitted to this Practice for treatment or health care services, we will make available to you a copy of the current notice in effect. We will post all new notices in the waiting room of the Practice. You can request a copy of our notice at any time.

Should we revise this notice because of a material change to the uses or disclosures of protected health information, to individual’s rights, to our legal duties, or to other privacy practices stated in the notice, we will promptly revise and make available the new notice. Except when required by law, a material change in any term of the notice may not be implemented prior to the Effective Date of the notice in which such material change is reflected. Pursuant to the HIPAA privacy regulations, we will document compliance with the notice requirements by retaining copies of all notices issued.


If you have questions, complaints or would like additional information, you may contact the Practice’s Compliance Office at 6200 Sunset Drive, Suite 501, Miami, FL 33143. All complaints must be submitted in writing. If you believe your privacy rights have been violated, you can file a complaint with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.


I acknowledge that I was provided with a copy of the Hernia Institute of Florida Notice of Privacy Practices, describing how my health information may be used or disclosed under the federal law. Provided that Hernia Institute of Florida continues in its good faith effort to comply with the requirements of the federal privacy law, I hereby consent to the use and disclosure of my health information for the purposes and the activities permitted under the federal privacy law, which are described in the Notice of Privacy Practices.

I understand that I should read the Notice of Privacy Practices carefully. I am aware that the Notice may be changed at any time. I may obtain a revised copy of the Notice by calling (305) 667-7878 or by requesting one at the Hernia Institute of Florida office.

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Patient Name

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Signature of Patient or Personal Representative

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If personal representative, personal representative’s relationship to patient

If you received this form electronically, please sign and date the form and return it to Hernia Institute of Florida at 6200 Sunset Drive, Suite 501, Miami, FL 33143 or fax to (305) 667-7459.

For Physician Office’s use only:
Complete this section of the form if not signed and dated by the patient or patient’s representative.

Patient Name: __________SAMPLE ONLY_____________
Date of Birth: ______SAMPLE ONLY________
Social Security Number: _______SAMPLE ONLY________
Phone Number: ______SAMPLE ONLY________
Address: _____________SAMPLE ONLY______________
Date signature requested: _______SAMPLE ONLY__________
Reason that the signature and date not obtained:

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