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.

Your privacy is important to us.  We want you to understand:

• Who will follow this notice

• The common ways in which we may use and share your medical information

• Other ways in which we may use and share your medical information without your permission

• There will be no other use of your medical information without your permission

• Your rights concerning your medical information

• How to file a complaint about your privacy

Who will follow this notice?

This notice applies to the following areas of COPE, Inc.

• Any entity, site, or location where personnel share Private Health Information with each other for treatment, payment, or any other facility operations as described in this notice.

• Any health care professional authorized to enter Private Health Information into your financial and / or medical record.

• Any member of a volunteer group allowed to work in the above noted areas.

What are the common ways in which we may use and share your medical information?

• TREATMENT PURPOSES: We will share your information with those who are caring for you.  For example, if you come in for counseling services and are in need of medication, the doctor may share your information with your pharmacist.
• PAYMENT PURPOSES: We may share your medical information with the insurance company paying for your care.
• HEALTH CARE OPERATIONS: We may use your medical information to improve the way we provide care to you and others.  For example, a team of experts from our staff may review your medical information to insure quality of care.
• APPOINTMENT REMINDERS: We may call or send you a letter to remind you about your appointment.  Please tell us if you do not want your information used in this way.
• SIGN-IN SHEETS: We may use sign-in sheets in our offices and call your name when the doctor is ready to see you.
• RESEARCH: We may share your information for research.  If we do this, the law required us to take extra steps to protect your privacy and tell us why we will be using your information.
• FAMILY AND OTHERS IN YOUR PERSONAL LIFE: If you ask us in writing to share specific information with a specific person, then we may do so.  Otherwise, we will never share any information with these persons.
• SATISFACTION SURVEYS: We may send a survey to you in the mail.

In what other ways may we use and share your medical information without your permission?

• AS REQUIRED BY LAW:  We must contact the police if we suspect you are involved in child abuse or neglect.

• LAW ENFORCEMENT:  We may contact the police if we believe you are a victim of abuse.  We may also contact the police if you commit a crime at our facility.

• REVIEWS BY OUTSIDE AGENCIES:  We may share your medical information when being reviewed by outside agencies that have authority over us.  This includes state, federal and other licensing agencies.

• COURT ORDER:  We may share your medical information when responding to an order or when initiating involuntary court proceeding (Baker Act / Marchman Act ).

• CHILDREN:  In some cases we may not share your child’s medical information with you.  For example, there are times when your child can seek care without your permission.

• IN CASE OF DEATH:  We may share limited medical information with the medical examiner.

• INMATES:  If you are a prisoner, we may share your information as appropriate.

We will not use your medical information in any other way without your permission.  

• USE OF INFORMATION:  We will not share your medical information except in the ways indicated in the Notice unless you give us your written authorization.

• RIGHT TO REVOKE YOUR AUTHORIZATION:  You have the right to revoke your authorization at any time.

What are your rights concerning your medical information?

   Right to Request Restrictions:

• You can ask us not to share your medical information for treatment, payment an health care operations.  Usually, we will not agree to this request because it would make it difficult for us to care for you.
• This request must be in writing.
• Please note, if you need emergency treatment we may share your medical
• information even if you have asked us not to.

   Right To See And Get A Copy:

• You have the right to see and get a copy of your medical information for as long as we have it.
• Sometimes the law does not allow us to let you see all or parts of your medical information.  If this happens, you can appeal our decision.  Your appeal must be in writing.
• We may charge a fee for giving you a copy.

   Right To Request Confidential Communications:

• You can ask us to contact you in certain ways.  For example, you can ask that we not send your bills or appointment reminders to your home address or call you at your work number.
• This request must be made in writing and tell us how you would like to be contacted.
• We will agree to reasonable requests.

   Right To Change Information:

• You can ask us to change your medical information.  For example, you can ask us to correct errors such as your date of birth.
• This request must be made in writing.
• The law does not require us to agree to your request.
• If we deny your request to change your medical information you can appeal our decision.  Your appeal must be in writing.

   Right To An Accounting:

• You can ask us to give you a list of people we have shared your medical information with.
• This does not include information shared for treatment, payment and healthcare operations.
• This also does not include information shared at your request.
• This request must be made in writing.
• We are required to keep track of your shared information for six years.
• This right starts on April 14, 2003 and we will not have any information prior to that date.
• If you request more than one accounting in a twelve-month period, we may charge you a fee.
• How can you complain about our handling of your privacy?

You have the right to complain if you feel your privacy rights have been violated by anyone who works for COPE, Inc.  There will be no retaliation against you for filing a complaint.  The quality of the health care or services we provide will not be affected in any way because a complaint was filed.

We ask that you please give us the opportunity to resolve any issues you have concerning your privacy.  If you have any concerns about your privacy or feel any of your privacy rights have been violated, please file a written complaint with the COPE, Inc. Privacy officer at the address below.  If you prefer, we will be happy to assist you in completing a written complaint.  You can call us at 850-892-8045 for assistance.

Privacy Officer
HIPAA Program
COPE, Inc.
3686 US Hwy 331 South
DeFuniak Springs, FL  32435

You also have the right to file a complaint with the Secretary of the U. S. Department of Health and Human Services, but we ask that you first allow us the opportunity to correct any issues you may have concerning your privacy.