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This Notice Describes How Medical Information about You May Be Used
and Disclosed and How You Can Get Access to This Information
PLEASE REVIEW CAREFULLY.

If you have any questions about this notice, please contact the Facility Privacy Officer listed at the end of this Notice.

Our Pledge Regarding Medical Information: We understand that your medical information is personal. We are committed to protecting your medical information. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information in the doctor's office or clinic.
This Notice will tell about the ways in which the Facility may use your medical information and disclose your medical information to others outside the Facility. The law requires the Facility to:

Who Will Follow This Notice: The Facility and all of its sites and locations will follow the terms of this Notice. The following people will also follow the terms of this Notice:

How the Facility May Use and Disclose Your Medical Information: We may use your medical information or share it with others for the following purposes:

 

Your Rights Regarding Your Medical Information: You have the following rights regarding your medical information:
** NOTE: All Requests Must Be Submitted in Writing to the Facility Privacy Officer listed at the end of this Notice**

ADDITIONAL INFORMATION CONCERNING THIS NOTICE:

Please contact the Facility Privacy Officer by calling (727) 823-1234.
Effective Date: October 16, 2016

This provider complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call (727) 823-1234 (TTY: (800) 318-2596)

Notice of Non-Discrimination