Presidential Women’s Center
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.
Presidential Women’s Center (PWC) is committed to protecting the privacy of your health record (chart) and the confidentiality of your visit. Your chart and the information it contains will not be disclosed to anyone or any agency outside of PWC without written authorization from you unless such a release is required by law. PWC will use your health information for the purpose of:
Information obtained by a healthcare provider or staff member will be recorded in your record and used to determine the best course of treatment for you.
Your information will be used, as needed to obtain payment for your healthcare services.
- Regular Healthcare Operations
Members of the staff may use information in your healthcare record to assess the care you received and the outcomes of your care. This information may be used in the training of staff in an effort to improve the quality of care provided at PWC.
- Business Associates
PWC provides some services through contracts with business associates. An example is our answering service. To protect your health information, we require the business associate to appropriately safeguard your information.
Any information collected for marketing purposes will be done only with you written consent.
If requested we are required by law to report:
- Food and Drug Administration (FDA)
As required by law, PWC may disclose to the FDA health information relative to adverse events with respect to product defects, product recalls, repairs or replacement.
- Public Health
PWC may disclose your health information, as required by law, to public health or legal authorities charged with preventing or controlling disease, injury or disability.
- Law Enforcement
PWC may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
Your Healthcare Rights
Although your health record is the physical property of PWC, the information it contains belongs to you. You have the right to:
- Request a restriction on certain uses and disclosures of your information. This includes you right to restrict information requested by your insurance company when you have paid for your services out of pocket.
- Obtain a paper copy of the notice of privacy practices on request
- Inspect and receive a copy of your health record
- Amend your health record. If we deny your request for amendment, you have the right to file a statement of disagreement with us.
- Obtain an accounting of disclosures of your health information
- Request communication of your health information by alternative means or at alternative locations.
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken
- Receive notice if a breach of PHI has occurred.
PWC is required to:
- Maintain the privacy of your health information
- Provide you with a notice as to PWC’s legal duties and privacy practices with respect to information PWC collects and maintains about you
- Abide by the terms of this notice
- Notify you if PWC is unable to agree to a requested restriction
- Make the appropriate notifications if there has been a breach of your personal information
- Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
For more information or to report a complaint
If you have questions or want to report a complaint, please contact PWC’s Privacy Officer at 561-686-3859. Complaints may also be filed with the Secretary of Health and Human Services. We will not retaliate against you for filing a complaint.
By signing below I authorize Presidential Women’s Center staff to leave voice messages that may contain my personal health information and/or financial information at the following phone number ( )_________________________. PWC will make every effort to maintain my confidentiality but that no guarantee can be made. I understand that by signing, I authorize that a voice message may be left at the telephone number above. These messages may contain but are not limited to laboratory test results, surgical outcomes and prescription/drug information.
I have read this privacy notice and I have been given ample time to ask questions regarding the information it contains. I understand Presidential Women’s Center will hold my record to the highest standard of privacy and confidentiality and will only release my personal health information when authorized by me in writing, or when required by law to do so. PWC reserves the right to change practices and to make new provisions effective for all protected health information PWC maintains. Should PWC’s information practices change, we will make a reasonable effort to notify you of this change during the course of your treatment.
Print Name: ______________________________________________