Effective Date: April 14, 2003

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.

If you have any questions about this Notice, please contact the Director of your regional Florida Poison Information Center.

Jacksonville 904-244-4465

Miami 305-585-5250

Tampa 813-844-7044

OUR LEGAL DUTY TO PROTECT MEDICAL INFORMATION ABOUT YOU:

We understand your medical information is personal and we are committed to protecting your medical information. We create a record of the care and services you receive from the Florida Poison Information Center Network to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated the Florida Poison Information Center Network, whether made by poison center personnel, faculty, staff, or students. This Notice describes how we may use and disclose your medical information, and provides examples where necessary. This Notice also describes your rights regarding our use and disclosure of your medical information.

We are required by law to make sure that medical information that identifies you is kept private; provide you access to this Notice of our legal duties and privacy practices with respect to your medical information; and follow the terms of the Notice currently in effect. We reserve the right to change our privacy practices and this Notice at any time.

NOTICE OF ORGANIZED HEALTH CARE ARRANGEMENT

The Florida Poison Information Center Network and other affiliated health care providers, including all employees, volunteers, staff of other health care providers have agreed as permitted by law, to share your health information among themselves for purposes of treatment, payment or health care operation.

1) WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION WITHOUT YOUR WRITTEN PERMISSION IN THE FOLLOWING CIRCUMSTANCES.

· We may use and disclose your medical information to provide medical treatment to you, and to coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others. For example, we may use and disclose your medical information when referring you to another health care provider.

· We may use and disclose your medical information for health care operations. We will use your health information for regular operations of the poison center to ensure that all of our patients receive quality care. For example: Members of the medical staff, the risk management team or the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used to continually improve the quality and effectiveness of the healthcare and service we provide. We may also disclose information to other personnel for review and learning purposes.

· We may use and disclose your medical information to recommend treatment alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

· We may use and disclose your contact information for fundraising activities to raise money for the Florida Poison Information Center Network. If you do not want to be contacted for fundraising efforts, you must notify your poison center in writing at the addresses listed below.

Florida Poison Information Center –Jacksonville

655 W. 8^th Street

Jacksonville, Florida 32209

Florida Poison Information Center-Miami

            University of Miami School of Medicine
            Department of Pediatrics
            P.O. Box 016960 (R-131)
            Miami, Florida 33101

Florida Poison Information Center-Tampa

                                                Tampa General Hospital
                                                P.O. Box 1289
                                                Tampa, Florida 33601

· We may disclose your medical information to our Business Associates to carry out treatment, or health care operations.

· We may disclose medical information for research or collect information in databases used for research. Research projects are reviewed and approved by a Review Board to protect the privacy of your health information.

· We will disclose medical information about you when required by federal, state, or local law. We may release medical information about you to authorized federal officials for national security and intelligence activities.

· We may use and disclose your medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

· We may disclose your health information as required by law, for public health activities, which may include preventing or controlling disease, injury, or disability, reporting births and deaths, reporting medication reactions or problems, and reporting abuse, neglect or domestic violence.

· We may disclose your medical information to health oversight agencies as required by agencies who enforce compliance with licensure or accreditation requirements. Such activities include, for example, audits, investigations, inspections, and licensure.

· We may disclose your medical information 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. We may disclose your medical information for law enforcement purposes as required by law.

· We may disclose your medical information to coroners, medical examiners or funeral directors consistent with applicable law to carry out their duties.

2) SPECIAL CIRCUMSTANCES.

Alcohol, Drug Abuse, and Psychiatric Treatment Information may have special privacy protections. We will not disclose any information identifying an individual as being a patient or provide any medical information relating to the patient’s substance abuse or psychiatric treatment unless: 1. The patient consents in writing or 2. A court order requires disclosure of the information or 3. Medical personnel need information to meet a medical emergency or 4.Qualified personnel use the information for the purpose of conducting scientific research, management audits, financial audits or program evaluation or 5. it is necessary to report a crime or a threat to commit a crime, or 6.to report abuse or neglect as required by law .

3) YOU MAY OBJECT TO CERTAIN USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION. Unless you object, we may use or disclose your medical information in the following circumstances:

· Individuals Involved in Your Care: We may use or disclose information to notify or assist in notifying a family member, legal representative, or another person responsible for your care.

· Emergency Circumstances and Disaster Relief. We may disclose information about you to an entity assisting in a disaster relief effort so that your family can be notified of your location and general condition. Even if you object, we may still share the medical information about you, if necessary for the emergency circumstances.

4) OTHER USES OF MEDICAL INFORMATION. Other uses and disclosures of medical information not covered by this notice or law that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your revocation. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

5) YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. You have the following rights regarding medical information we maintain about you:

· Right to See and Obtain Copies of your Medical Information. You have the right to see and obtain copies of medical information that may be used to make decisions about your care. Usually, this includes medical records. To inspect and copy your medical information, you must submit your request in writing to the Director of the appropriate poison center. If you request a copy of the medical 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 see and obtain copies of your medical information in certain very limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed. The person conducting the review will not be the person who denied your request.

· Right to Amend. If you think that medical information we have about you is incorrect or incomplete, you may ask us to correct or add to the information. You have the right to request that we make amendments to clinical, billing and other records used to make decisions about you. Your request must be in writing and must explain your reason(s) for the amendment.

We may deny your request if: 1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record); 2) the information is not part of the records used to make decisions about you; 3) we believe the information is correct and complete; or 4) you would not have the right to see and copy the record as described above.

We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received information about you and who need the amendment. To request an amendment, your request must be made in writing and submitted to the Director of the appropriate poison center.

· Right to an Accounting of Disclosures. You have the right to request an Accounting of Disclosures. This is a list of the disclosures we have made of medical information about you. This Accounting of Disclosures does not include disclosures made for your treatment, health care operations, made to or requested by you, or that you authorized, occurring as a byproduct of permitted uses and disclosures, made to individuals involved in your care, or for other purposes described in the above subsections.

To request this list or accounting of disclosures, you must submit your request in writing to the Director at your regional poison information center. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first accounting you request within a 12 month period will be free of charge. For additional accountings, we may charge you for the costs of providing the accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

· 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 or health care operations. We are not required to agree to your request. If we do agree with your request, we will comply with your request unless the information is needed to provide you emergency treatment or the disclosure is required by the Secretary of the Department of Health and Human Services, and/or the uses and other disclosures listed in this notice.

To request restrictions, you must make your request in writing to the Director of the appropriate poison center. 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.

· Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may print a copy at our website: www.fpicn.org or contact the Poison Center administrative office serving your area for a mailed or faxed copy.

CHANGES TO THIS NOTICE

· 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 on our website (www.fpicn.org).The effective date of this notice will be listed on the first page, in the top right-hand corner of the document.

COMPLAINTS

· If you believe your privacy rights have been violated, you may file a complaint with us. You will not be penalized for filing a complaint.

To file a complaint, contact the Director of your regional poison information center. All complaints must be submitted in writing.

To file a complaint with the Secretary of the Department of Health and Human Services, contact the Office of Civil Rights, Medical Privacy, Compliant Division, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, HHH Building, Room 509H, Washington, DC 20201, Phone: 866/627-7748 TTY: 886-788-4989 Email through the internet: www.hhs.gov/ocr.