2020 Ponce de Leon Blvd, Suite 901. Coral Gables, FL 33134   
  

Notice of Privacy Practices

We are required by law to maintain the privacy and security of your protected health information.  Please make sure to review this notice.  It describes how the information we have about you may be used and disclosed.  You can ask for a paper copy of this notice at any time, by calling the number on the back of your ID card.  We will provide you with a paper copy promptly.

Notice of Privacy Practices English

Notice of Privacy Practices – Spanish

 Your Rights:

When it comes to your health information, you have certain rights. Please use the appropriate form below to notify us that you would like to invoke your rights:

Authorization for Disclosure and Revocation of Authorization

We will not use or share your information other than as described in the Notices of Privacy Practices unless you tell us we can in writing.

Authorization for Disclosure of PHI – English

Authorization for Disclosure of PHI – Spanish

An authorization can be discontinued at any time by alerting us in writing.  Please use below:

Discontinuation of Authorization – English

Discontinuation of Authorization – Spanish

 Get your medical record – Inspect and Copy

You can ask to see your medical record and other health information we have about you by completing the below form.  We will provide a copy or a summary of your health information, usually within 60 days of your request. We may charge a reasonable, cost-based fee.

Inspect and Copy – English

Inspect and copy – Spanish

Ask us to correct your medical record/Request Amendment

You can ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request an amendment – English

Request an amendment – Spanish

Request Alternate Communications

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.

Request for Alternate Communications – English

Request for Alternate Communications – Spanish

Ask us to limit what we use or share- Request Restrictions

You can ask us not to use or share certain health information for treatment, payment, or our operations.

Request Restrictions – English

Request Restrictions – Spanish

You can also discontinue or terminate the restrictions by completing below:

Restriction Termination – English

Restriction Termination – Spanish

 Get a list of those with whom we’ve shared information- Accounting of Disclosures

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.

Accounting of Disclosures- English

Accounting of Disclosures – Spanish

File a complaint if you feel your rights are violated – Privacy Complaint

You can file a complaint if you feel we have violated your rights by submitting below to Doctors HealthCare Plans or you can file a complaint directly with the U.S. Department of Health and Human Services Office for Civil Rights:

Privacy Complaint – English

Privacy Complaint – Spanish

U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775

www.hhs.gov/ocr/privacy/hipaa/ complaints/

We will not retaliate against you for filing a complaint.

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Last Updated:  03/14/2019

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