Patient Information

Medical History

The Patient hereby consents to the use or disclosure of his/her individually identifiable health information (“protected health information”) and patient medical record information by Fabio Echavarria, M.D., PA (the “Practice”) in order to carry out treatment, payment, or health care operations.  The Patient should review the Practice’s Notice of Privacy Practices for a more complete description of the potential uses and disclosures of such information, and the Patient has the right to review such Notice prior to signing this Consent Form.

The Practice reserves for itself the right to change the terms of its Notice of Privacy Practices at any time.  If the Practice does change the terms of its Notice of Privacy Practices, Patient may obtain a copy of the revised Notice.

Patient retains the right to request that the Practice further restrict how his/her protected health information is used or disclosed to carry out treatment, payment, or health care operations.  The Practice is not required to agree to such requested restrictions; however, if the Practice does agree to Patient’s requested restriction(s), such restrictions are then binding on the Practice.

Patient acknowledges and agrees that the Practice may disclose Patient’s protected health information and patient medical record information to individuals who are either the Patient’s family members, legal representatives, guardians, health care surrogates, or have power of attorney on behalf of the Patient. 

At all times, Patient retains the right to revoke this Consent.  Such revocation must be submitted to the Practice in writing.  The revocation shall be effective exceptto the extent that the Practice has already taken action in reliance on the Consent.

The Practice may refuse to treat Patient if he/she (or an authorized representative) does not sign this Consent Form.  If Patient (or authorized representative) signs this Consent and then revokes it, the Practice has the right to refuse to provide further treatment to Patient as of the time of revocation (except to the extent that the Practice is required by law to treat individuals).

I HAVE READ AND UNDERSTAND THE INFORMATION IN THIS CONSENT.  I HAVE RECEIVED A COPY OF THIS CONSENT, AND I AM THE PATIENT OR AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS SEALED DOCUMENT VERIFYING CONSENT TO THE ABOVE STATED TERMS.

PATIENT NAME: {patientName3}               DATE: {date310} 

Upon check-in, we will collect your deductible, copay, uncovered services, or percent of your responsibility.  Please be prepared to pay before you are seen by the doctor.

Please be thorough with your insurance information if you expect us to file for you.  Bring your insurance card with you and a driver’s license without these we will be unable to see you!

If you do not show up for your scheduled appointment or do not cancel at least 24 hours prior to the appointment, we reserved the right to charge you a fee of $35.00.

As a courtesy, we will file your insurance.  It is your responsibility to make sure we receive prompt payment from them.  It is useful to maintain frequent contact with your insurance carrier to make sure they are paying as they should.

If your insurance denies payment on your account you will be asked to pay by check, cash, or charge.  If you do not pay in a timely fashion, your account may be turned over to a collection agency. Collection fee charges will apply.  If you do not agree with the denial it is your responsibility to pay services and take it up with your insurance.

TO ALL MEDICARE PATIENTS:  We will continue to participate as Medicare providers.  We will bill Medicare as well as secondary insurance, but if payment is not received from your secondary insurance within 45 days you will be notified and must pay our office the balance due.  You must then contact your secondary insurance to pay you for the balance you paid our office.

SELF PAY PATIENTS:  This category includes those people with no insurance and patients who have an indemnity plan and wish to file their own insurance.  Payment for medical services is expected on the day the services are rendered.  We accept Visa, Mastercard, checks, and money orders.  If you will not be able to pay for our services in full, you must contact the office to make a payment agreement before coming to see the doctor.

If your insurance is out of state (except PPO insurance), you must pay for your visit at the time of service.  95% of out of state insurance companies pay the patient and will not pay us directly (even if they tell you they will).

THERE WILL BE A $25.00 CHARGE TO COMPLETE ANY AND ALL FORMS AND LETTER (ie: FMLA, PHYSICAL FORMS, TRAVELING LETTER, PARKING PERMIT) UNLESS YOU SCHEDULE AN APPOINTMENT SPECIFICALLY FOR THE FORM TO BE FILL OUT. ALL FORMS WILL TAKE 7-10 BUSSINES DAYS TO BE FILLED.

PLEASE NOTE: FOR ANY EXPEDITED FORMS THERE WILL BE A $50.00 FEE. THANK YOU.

If you have any questions regarding this policy please ask prior to being seen by the physician.

PATIENT NAME: {patientName3}               DATE: {date310} 

Consent of Treatment

PATIENT NAME: {patientName3}

NAME OF GUARDIAN OR LEGALLY AUTHORIZED REPRESENTATIVE: {nameOf313} 

I, the aformentioned Patient or Guardian, am authorized and hereby give consent for the medical staff of Fabio Echavarria, MD, PA to examine and render care to {patientName3}.

This consent will remain in effect until revoked in writing.

By signing this document I acknowledge that I have read and understand the Consent of Treatment information outlined above. This consent form is also giving  Fabio Echavarria, M.D. PA permission to collect, give your pharmacy and your health plan permission to disclosure, information about your prescriptions that have been filled at any pharmacy or covered by any health plan. This includes prescription medicines to treat/ AIDS/HIV and medicines used to treat mental health conditions, such as depression.

DATE: {date310}

Patient Centered Medical Home

It is the policy of the practice to provide all patients with comprehensive information about our role of the patient centered medical home.

Our Goal: Our goal is to be your partner in healthcare by serving as your medical home. We are committed to make available to you a personal physician who provides for all of your healthcare needs and coordinates your care across all settings, including the medical office, hospital, clinics, testing facilities, and other places where you receive healthcare.

Access: You may request care and advice by calling (352) 243-7495 during our office hours, which are Mon-Fri (8AM -5PM).

If you need care or advice for non-urgent matters after office hours, please contact (352) 243-7495 or refer to your “call me” cards for further guidance. Please also refer to the patient portal to communicate with our practice.

Expectations: We expect you to provide us with your medical history, as well as information about any care you obtain outside of our practice, to include your current medications, recent test results, visits to other doctors and healthcare providers, hospitalizations, and emergency department visits.

*For further information on patient centered medical home visit us on our website at www.drfabioechavarriamd.com.

PATIENT NAME: {patientName3}

NAME OF GUARDIAN OR LEGALLY AUTHORIZED REPRESENTATIVE: {nameOf313} 

I, the aformentioned Patient or Guardian, acknowledge that I have received Fabio Echavarria, M.D., PA Notice of Patient Centered Medical Home. I have had full opportunity to read and consider the contents of this notice.

DATE: {date310}

1. Persons/organizations authorized to use or disclose the information:

• Fabio Echavarria, M.D., PA

2. Persons/organizations authorized to receive the information:

• Fabio Echavarria, M.D., PA
• Primary Partners
• WellMed
• Aledade
• Aegis
• HMO - Advantage Plans Management Entities

3. All records will be disclosed including: HIV/AIDS Information, Mental Health Information, Substance Abuse Information, Sexually Transmitted Diseases Information, If Patient is under the age of (18), pregnancy information

Electronic medical records for care improvement coordination

Items 4-5 only apply if the practice is requesting the information for its own uses and disclosures.

4. I understand that this Authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign or my revocation of this Authorization will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law.

5. The person/organization authorized to use/disclose the information will receive compensation for doing so:  Yes ____    No    X      

6. I understand that I may inspect or copy the information used or disclosed.

7. I understand that I may revoke this Authorization at any time by notifying the person/organization providing the information in writing, except to the extent that:

• action has been taken in reliance on this authorization; or
• if this authorization is obtained as a condition for obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy.

8. This authorization expires on  December 3, 2034 

PATIENT NAME: {patientName3}

NAME OF GUARDIAN OR LEGALLY AUTHORIZED REPRESENTATIVE: {nameOf313} 

DATE: {date310}

Effective Date: October 28, 2014
 
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 of Privacy Practices (‘Notice’), please contact:

Privacy Officer Fabio Echavarria
Phone Number: 352-243-7495
Access the practice secure portal: Click here to login  

Section A: Who Will Follow This Notice?

This Notice describes Fabio Echavarria, M.D., P.A. (hereafter referred to as ‘Provider’) Privacy Practices and that of:
 
Any workforce member authorized to create medical information referred to as Protected Health Information (PHI) which may be used for purposes such as Treatment, Payment and Healthcare Operations. These workforce members may include:

• All departments and units of the Provider.
• Any member of a volunteer group.
• All employees, staff and other Provider personnel.
• Any entity providing services under the Provider's direction and control will follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for Treatment, Payment or Healthcare Operational purposes described in this Notice

Section B: Our Pledge Regarding Medical Information

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the Provider. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all the records of your care generated or maintained by the Provider, whether made by Provider personnel or your personal doctor.  

This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:
 

• Make sure that medical information that identifies you is kept private.
• Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the Notice that is currently in effect.
   

Section C: How We May Use and Disclose Medical Information About You

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
 
Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, health care students, or other Provider personnel who are involved in taking care of you at the Provider. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the Provider also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the Provider who may be involved in your medical care after you leave the Provider, such as family members, clergy or others we use to provide services that are part of your care.
 
Payment. We may use and disclose medical information about you so that the treatment and services you receive at the Provider may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the Provider so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
 
Healthcare Operations. We may use and disclose medical information about you for Provider operations. These uses and disclosures are necessary to run the Provider and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many Provider patients to decide what additional services the Provider should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, health care students, and other Provider personnel for review and learning purposes. We may also combine the medical information we have with medical information from other Providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning a patient's identity.
 
Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the Provider.
 
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.
 
Health & Related Benefits and Services. We may use and disclose medical information to tell you about health & related benefits or services that may be of interest to you.
 
Fundraising Activities. If we intend to use your medical information for fund-raising purposes, we will inform you of such intent and that you have a right to opt out of receiving fundraising communications. We may use information about you to contact you in an effort to raise money for the Provider and its operations. We may disclose information to a foundation related to the Provider so that the foundation may contact you into raising money for the Provider. We only would release only contact information, such as your name, address and phone number and the dates you received treatment or services at the Provider. If you do not want the Provider to contact you for fundraising efforts, you must notify us in writing and you will be given the opportunity to ‘opt-out’ of these communications.
 
Authorizations Required. We will not use your protected health information for any purposes not specifically allowed by Federal or State laws or regulations without your written authorization; Specifically the following types of uses and disclosures of your medical information require an authorization; 1) disclosure of psychotherapy notes; 2) disclosures for marketing purposes; and 3) disclosures that constitute a sale of protected health information. Other uses and disclosures not described in the NPP will not be made unless an individual provides an authorization and that authorizations may be revoked prospectively at any time by written revocation.
 
Emergencies. We may use or disclose your medical information if you need emergency treatment or if we are required by law to treat you but are unable to obtain your consent. If this happens, we will try to obtain your consent as soon as we reasonably can after we treat you.
 
Communication Barriers. We may use and disclose your health information if we are unable to obtain your consent because of substantial communication barriers, and we believe you would want us to treat you if we could communicate with you.
 
Provider Directory. We may include certain limited information about you in the Provider directory while you are a patient at the Provider. This information may include your name, location in the Provider, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. This is so your family, friends and clergy can visit you in the Provider and generally know how you are doing.
 
Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care and we may also give information to someone who helps pay for your care, unless you object and ask us not to provide this information to specific individuals, in writing. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
 
Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the Provider. We will almost always generally ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the Provider.
 
As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law.
 
To Avert a Serious Threat to Health or Safety. We may use and disclose 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. Any disclosure, however, would only be to someone able to help prevent the threat.
 
E-mail Use. E-mail will only be used for communications with you following this organization’s current policies and practices and with your permission. The use of secured, encrypted e-mail is encouraged.
The practice also use via mail and telephone for communications with you with your permission.
 
Section D: Special Situations
 
Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
 
Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
 
Workers' Compensation. We may release medical information about you for workers' compensation or similar programs.
 
Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:

• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child abuse or neglect;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
  to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
 
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you 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 by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
 
Law Enforcement. We may release medical information if asked to do so by a law enforcement official:

• in response to a court order, subpoena, warrant, summons or similar process;
• to identify or locate a suspect, fugitive, material witness, or missing person;
• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• about a death we believe may be the result of criminal conduct;
• about criminal conduct at the Provider; and
• in emergency circumstances, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the Provider to funeral directors as necessary to carry out their duties.
 
National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
 
Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
 
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution.
 
Section E: Your Rights Regarding Medical Information About You

You have the following rights regarding medical information we maintain about you:
 
Right to Access, Inspect and Copy. You have the right to access, inspect and copy the medical information that may be used to make decisions about your care, with a few exceptions. Usually, this includes medical and billing records, but may not include psychotherapy notes.
 
If we maintain your information electronically you may request a copy of your records via a mutually agreed upon electronic format. If we fail to agree upon an electronic format for delivery of electronic copies we will provide you with a paper copy for your records. If you request a copy of the information in either paper or electronic format, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
 
We may deny your request to inspect and copy medical information in certain very limited circumstances. If you are denied access to medical information, in some cases, you may request that the denial be reviewed. Another licensed health care professional chosen by the Provider will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
 
Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may request us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Provider. In addition, you must provide a reason that supports your request.
 
We may deny your request for an amendment if; it is not in writing or does not include a reason to support the request or for other reasons. Typical reasons for denial of an amendment request include if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for the Provider;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete. 

Right to an Accounting of Disclosures. You have the right to request an ‘Accounting of Disclosures’. This is a list of the disclosures we made of medical information about you. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically, if available). The first list you request within a 12 month period will be complimentary. For additional lists, we may charge you for the costs of providing the list. 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 payment or healthcare operations. We require that any requests for use or disclosure of medical information be made in writing. In some cases we will not we are not required to agree to these types of request, however if we do agree to them we will abide by these restrictions. We will always notify you of our decisions regarding restriction requests in writing. We will not comply with any requests to restrict use or access of your medical information for treatment purposes.
 
You have the right to request, in writing, a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. In your request, you must tell us what information you want to limit, whether you want to limit our use, disclosure or both, and to whom you want the limits to apply, for example, disclosures to your spouse.
 
You also have the right, which we may not refuse,  to restrict use and disclosure of your medical information about a service or item for which you have paid completely out of pocket, for payment (i.e. your insurance company) and operational (but not treatment) purposes, if you have completely paid your bill for this item or service. We are not required to accept your request for this type of restriction until you have completely paid your bill (zero balance) for this item or service. We are not required to notify other healthcare providers of these types of restrictions, that is your responsibility.
 
Right to Receive Notice of a Breach. We are required to notify you by first class mail or by e-mail (if we offered and you have indicated a preference to receive information by e-mail), of any breaches of unsecured Protected Health Information as soon as possible, but in any event, no later than 30 days following the discovery of the breach. “unsecured Protected Health Information” is information that is not secured through the use of a technology or methodology identified by the Secretary of the U.S. Department of Health and Human Services to render the Protected Health Information unusable, unreadable, and undecipherable to unauthorized users. The notice is required to include the following information:
 

• a brief description of the breach, including the date of the breach and the date of its discovery, if known;
• a description of the type of Unsecured Protected Health Information involved in the breach;
• steps you should take to protect yourself from potential harm resulting from the breach;
• a brief description of actions we are taking to investigate the breach, mitigate losses, and protect against further breaches;
• contact information, including a toll-free telephone number, e-mail address, Web site or postal address to permit you to ask questions or obtain additional information.

In the event the breach involves 10 or more patients whose contact information is out of date we will post a notice of the breach on the home page of our Web site or in a major print or broadcast media. If the breach involves more than 500 patients in the state or jurisdiction, we will send notices to prominent media outlets. If the breach involves more than 500 patients, we are required to immediately notify the Secretary of HHS. We also are required to submit an annual report to the Secretary of HHS of a breach that involved less than 500 patients during the year and will maintain a written log of breaches involving less than 500 patients.
 
Florida Information Protection Act (FIPA). The Provider also complies with the Florida Information Protection Act. Breaches of ‘personal information’ for 500 or more patients, who are Florida residents, will result in notification to the Department of Legal Affairs in Tallahassee. Breaches involving over 1000 patients, who are Florida residents, will result in notification to credit reporting agencies. Patient notification will conform to FIPA by meeting the standards discussed above, as required by HIPAA.
 
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or hard copy or e-mail. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
 
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain an electronic copy of this notice at our website:  www.doctorfabioechavarria.com
 
To exercise the above rights, please contact Fabio Echavarria, M.D. to obtain a copy of the relevant form you will need to complete to make your request.

Section F: Changes To This Notice

We reserve the right to change this Notice. 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. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the Provider for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current Notice in effect.

Section G: Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Provider or with the Secretary of the Department of Health and Human Services; http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html 
 
To file a complaint with the Provider, contact the individual listed on the first page of this Notice. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Section H: Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this Notice or the laws 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 written authorization. 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.

Section I: Organized Healthcare Arrangement (OHCA)

The Provider, the independent contractor members of its Medical Staff (including your physician), and other healthcare providers affiliated with the Provider have agreed, as permitted by law, to share your health information among themselves for purposes of treatment, payment or health care operations, enabling us to better address your healthcare needs. Providers participating in an Organized Healthcare Arrangement may share the same Notice of Privacy Practices.
If You are a Medicare patient notice:

• The practice works with Aledade in care improvement coordination activities; see Aledade website for additional information at www.aledade.com
• We also work with Aegis, Wellmed, in reference to our Managed Care Plans.

Original Effective Date: April 14, 2003
 
Revised Date: August 16, 2013. Compliant with HIPAA Omnibus Privacy Rules

Revised: April 27, 2020.

I acknowledge that I have received Fabio Echavarria, M.D., PA, Notice of Privacy Practices.  I have had full opportunity to read and consider the contents of this Notice of Privacy Practices.

PATIENT NAME: {patientName3}

NAME OF GUARDIAN OR LEGALLY AUTHORIZED REPRESENTATIVE: {nameOf313} 

DATE: {date310}