NOTICE OF PRIVACY PRACTICES
Global Neuro And Spine Institute
4243 NW Federal Hwy.
Jensen Beach, FL 34957]
 

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
 Global Neuro and Spine Institute at (800)735-1178
 

 

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.  It also describes your rights to access and control your protected health information.  “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

 

We are required to abide by the terms of this Notice of Privacy Practices.  We may change the terms of our notice, at any time.  The new notice will be effective for all protected health information that we maintain at that time.  Upon your request, we will provide you with any revised Notice of Privacy Practices.  You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

 

1.         Uses and Disclosures of Protected Health Information

 

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you.  Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.

 

Following are examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

 

Treatment:  We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you.  We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.  In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

 

Payment:  Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.  For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. 

 

Health Care Operations:  We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.

 

We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice.  Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

 

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.  You may contact Global Neuro and Spine Institure to request that these materials not be sent to you.

 

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office.  If you do not want to receive these materials, please contact Global Neuro and Spine Institure and request that these fundraising materials not be sent to you.

 

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object 

 

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object.  These situations include:

Public Health:  We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.  For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.
 

Communicable Diseases:  We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
 

Health Oversight:  We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. 
 

Abuse or Neglect:  We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect.  In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.  In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
 

Food and Drug Administration:  We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
 

Legal Proceedings:  We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process. 
 

Law Enforcement:  We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes.  These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred. 
 

Coroners, Funeral Directors, and Organ Donation:  We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.  We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.  We may disclose such information in reasonable anticipation of death.  Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
 

Research:  We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
 

Criminal Activity:  Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. 
 

Military Activity and National Security:  When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.  We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. 
 

Workers’ Compensation:  We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally established programs.
 

Inmates:  We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
 

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

 

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below.  You may revoke this authorization in writing at any time.  If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization.  Please understand that we are unable to take back any disclosures already made with your authorization.

 

Your prior written authorization is required for:

1) Most uses and disclosures of psychotherapy notes (if applicable).

2) Uses and disclosures of PHI for marketing purposes.

3) Disclosures of PHI that constitute a “sale”.

 

 

 

 

 

 

 

Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object

 

We may use and disclose your protected health information in the following instances.  You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information.  If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.

 

Others Involved in Your Health Care or Payment for your Care:  Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.  We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.  Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
 

 

2.         Your Rights

 

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

 

You have the right to receive electronic copies of your health information.

 

You have the right to opt out of any communication made to you for fundraising purposes . Each fundraising communication will specify the opt out option(s) available.

 

You have the right to inspect and copy your protected health information.  This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information.  You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.  As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. 

 

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable.  In some circumstances, you may have a right to have this decision reviewed.  Please contact Global Neuro and Spine Institure if you have questions about access to your medical record. 

 

You have the right to request a restriction of your protected health information.  This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must state the specific restriction requested and to whom you want the restriction to apply. 

 

Your physician is not required to agree to a restriction that you may request.  If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.  With this in mind, please discuss any restriction you wish to request with your physician. 

 

You have the right to restrict certain of disclosures of PHI to health plans when you have paid in full for the health care item or service.  We are required to comply with your request no to disclose health information to a health plan when you have paid in full out-of –pocket for the item or service.

 

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.  We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.

 

You may have the right to have your physician amend your protected health information.   This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.  Please contact our Privacy Officer if you have questions about amending your medical record.  

 

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.  This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure.  You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations. 

 

You have the right to receive a notification of a breach of your unsecured PHI in appropriate circumstances.  We have an obligation to notify you of a breach of our unsecured PHI.

 

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

 

3.         Complaints

 

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying Global Neuro and Spine Institure of your complaint at (800)735-1178.  We will not retaliate against you for filing a complaint.

 

 

Notice of Privacy Practices Acknowledgment

Global Neuro and Spine Institute

 

 

 

I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information.

I acknowledge that I have received or have

been given the opportunity to receive a copy of your Notice of Privacy Practices. I also understand that

this practice has the right to change its Notice of Privacy Practices and that I may contact the practice at

any time to obtain a current copy of the Notice of Privacy Practices.

 

This notice was published and becomes effective on

IMPORTANT DISCLOSURE, AUTHORIZATION,
ASSIGNMENT OF BENEFITS NOTICE AND BILL OF RIGHTS
By signing below, I acknowledge that I understand the following:
1. I hereby consent for treatment, consultation, or testing. I allow the provider, to release any
information as required, in accordance with HIPPA guidelines.
2. I hereby assign to Global Neuro and Spine Institute any benefits under any policy of insurance,
indemnity agreement or any other collateral source as defined by Florida statues, for any services
and /or charges provided by Global Neuro and Spine Institute It is the intent of the undersigned that
this assignment be deemed irrevocable unless both the patient and an unauthorized representative
for Global Neuro and Spine Institute execute a revocation of this Assignment of benefits prior to the
filing of any suit for insurance benefits. The Assignment of Benefits shall apply to any and all
causes of actions, suits, claims, counter-claims and demands.
3. I hereby authorize all parties involved to release any and all documentation related to my care to
Global Neuro and Spine Institute.
4. I hereby authorize my attorney to release my settlement disbursement to Global Neuro and Spine
Institute.
5. Under Florida Law, physicians are generally required to carry malpractice insurance. Otherwise,
they must demonstrate financial responsibility to cover potential claims for medical malpractice.
Your doctor may have decided not to carry medical malpractice insurance. This is permitted under
Florida law subject to certain conditions. Florida law imposes penalties against non-insured
physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This
notice is provided pursuant to Florida law.
6. I agree and hereby authorize Global Neuro and Spine Institute to retain legal counsel of its choice in
order to collect any and all outstanding balances as a result of treatment, services, or products
provided, and to proceed against any insurance company for refusal to pay benefits due and owning
under Florida law.
1. If you need a referral from your insurance company or your primary care physician to be seen in
our facility, the referral must be presented at the time of your visit. If it is not available, it will be
your responsibility to obtain one. Consequently, you will need to reschedule your visit should the
referral not be available. We encourage you to call your primary care physician and have your
referral faxed to us. Our fax numbers can be obtained from the front desk.
2. Many insurance companies require authorization or pre-authorization in order to have supplies
and/or services dispensed by a doctor’s office or facility. Due to the many changes in insurance
policies, it is no longer an easy task to interpret each individual policy. Although Global Neuro and
Spine Institute tries to stay aware of these changes, it is not always possible; therefore, we urge you,
the patient, to please check with your insurance company regarding your coverage. It is your
responsibility to know your individual coverage and is limitations.
Global Neuro and Spine Institute
3. By rendering services and/or leaving the office with supplies that are not authorized, you will be
financially responsible if your insurance company denies payment. In instances when your
insurance company gives approval for care or services and later reverses its position, for whatever
reason, you agree to be fully responsible for services rendered.
4. If you have a co-payment or any out-of-pocket expense, deductible, etc.., it must be paid at the time
services are rendered.
5. I understand that I am responsible for any deductible or copayments under my insurance and that I
am responsible for any charges should my insurance benefits become exhausted. I agree that in the
event that it becomes necessary to collect monies owed by me, I will be responsible for all cost
including, but not limited to, collection agency commissions, attorney fees and court costs. In
addition, I agree to pay an interest charge of one and one half percent (11/2 %) per month on any
balance after 45 days of service. Being carefully informed of these facts, I have decided to remain
in the care of my physician and his associates.
6. If for any reason you cannot keep your appointment, 24-hour notice must be given, otherwise
a $50.00 fee will be charged.
7. I HEREBY AUTHORIZE THE ASSIGNEE TO REQUEST ALL DOCUMENTS AND
INFORMATION PERMITTED BY FLORIDA STATUTE SECTION 627.4137, INCLUDING
BUT NOT LIMITED TO A COPY OF THE APPLICABLE INSURANCE POLICY,
DECLARATION PAGE REFLECTING COVERAGE ON THE DATE OF LOSS, AND THE
APPLICABLE PIP/LOG/LEDGER, ALL OF WHICH TO BE PROVIDED TO THE ASSIGNEE
UPON REQUEST. This request is authorized pursuant to the terms of my policy as well as Florida
Statutes 627.4137. I hereby authorize this assignee to request and receive a copy of my PIP
Log/Ledger periodically.
8. Be further advised that I AM HEREBY PLACING YOU ON NOTICE PERSUANT TO FLORIDA
CASE LAW THAT SHOULD YOU (THE INSURANCE COMPANY/CARRIER) DENY,
REDUCE, OR FAIL TO PAY ANY PART OF, OR AN ENTIRE BILL WHICH WAS
SUBMITTED ON MY BEHALF FROM THIS PROVIDER, I (THE ASSIGNOR) AS WELL AS
THE ASSIGNEE ARE REQUESTING IN ADVANCE THAT YOU RESERVE, OR “SETASIDE”, THE AMOUNT YOU
RECEIVED OR DENIED UNTIL THE DISPUTE IS
RESOLVED. Should you submit a check to assignee which is loss that the correct contractual
amount, and contains any language referring to “Full and Final Payment” I have instructed
Assignee to return the check to you (the carrier) and consider the bill still due and owing (i.e. A
late payment as defined in F.S.S 627.736). Additionally, SHOULD THE REMAING AMOUNT
OF MY BENEFITS APPROACH THE AMOUNT WHERE THERE WOULD BE
INSUFFICIENT FUNDS TO PAY THE AMOUNT YOU REDUCED, DENIED, OR FAILED
TO PAY, PLEASE NOTIFY ME (THE ASSIGNOR) AND THE ASSIGNEE OF THIS FACT.
Should my benefits exhaust; please notify me (the assignor) and assignee promptly.

 

Formulary Benefits Data Consent Form

Formulary Benefits data are maintained for health insurance providers by organizations
known as Pharmacy Benefits Manager (PBM). PBM's are third party administrators of
prescription drug programs whose primary responsibilities are processing and paying
prescription drug claims. They also develop and maintain formularies, which are lists of
dispensable drugs covered by a particular drug benefit plan.
By signing below, I give permission for Global Neuro and Spine Institute to access my
pharmacy benefits data, electronically through RxHub. This consent will enable Global
Neuro and Spine Institute to:
Determine the pharmacy benefits and drug co-pays for my health plan
Check whether a prescribed medication is covered (in formulary) under my plan
Display therapeutic alternatives with preference rank (if available) within a drug class for
non-formulary medications
Determine if my health plan allows electronic prescribing to Mail Order pharmacies, and
if so, e-prescribe to these pharmacies
Download a historic list of all medications prescribed for me by any provider

CANCELLATION AND NO SHOW POLICY

Please be advised that if you must cancel your appointment, kindly provide our office with 24
hours’ notice.
Patients that do not show up for their scheduled appointments without a call to cancel will be
considered a NO SHOW, and will be responsible for a$50.00 no show fee for the Office Visit
and $100 for a Procedure Visit (Injection or EMG). This fee will be due at the next scheduled
appointment.

CONSENT TO CALL

By selecting I accept below, the patient is giving permission for the practice to use the
information provided as part of the check in process to email and call the patient. This includes:
Entry of any telephone contact number constitutes written consent to receive any automated,
prerecorded, and artificial voice telephone calls initiated by the Practice. To alter or revoke this
consent, visit the Patient Portal “Contact Preferences".

CONSENT TO TEXT

By selecting I accept below, the patient is giving permission for Global Neuro and Spine
Institute to use the information provided as part of the check in process to text the
patient. This includes: Entry of any telephone contact number constitutes written
consent to receive on mobile phone any automated text alerts initiated by the Global
Neuro and Spine Institute. To alter or revoke this consent, visit the Patient Portal
“Contact Preferences". Text alerts may be about appointments, test results, and more.
Select "I accept" if the patient has agreed to receive automated text alerts. Select "I
decline" if the patient has declined

Super Confidentiality

I give consent for the release of medical record information for the purposes of reimbursement, arranging referrals or other medical care, including the release of super confidential information such as HIV/AIDS, STD’s, substance use, mental health, pregnant minor, and conditions reportable to the Department of Health. Your choice on whether to sign this form will not affect your ability to get medical treatment, payment for medical treatment or health insurance enrollment, or eligibility for benefits. This consent will stay in effect for the duration of your care at Global Neuro and Spine. You have the right to amend or revoke this consent at any time.

Zero Tolerance Agreement

At Global Neuro and Spine Institute, we pride ourselves on providing a high standard of
service to all our patients. In order for us to maximise the service we are able to give, we
request patients agree to a number of practical measures.
❏ I will keep (and be on time for) all my scheduled appointments with the provider.
❏ If I need to cancel, I will notify the office within 24 hours of my scheduled appointment
❏ I will treat all practice staff and doctors with courtesy and respect. We work as a 'ZERO
TOLERANCE' practice therefore any abrupt or rude behaviour exhibited either in the
office, over the phone, or via correspondence may result in causes for discharge.
❏ I will not be disrespectful or disruptive to the staff if I owe a balance that is requiring
payment either over the phone or at the time of appointment.
❏ I will keep the practice informed of up-to-date addresses and telephone numbers,
especially if I’ve recently moved.
❏ I will participate in all treatment plans recommended by the provider.
❏ I will authorize my provider to seek contact from any/or all providers that have
or are currently treating me.
❏ I will not allow another individual to contact the office on my behalf unless
authorized by me.
Your care is of our utmost concern. Should you have any complaint or suggestion to make
about the services provided by the practice, you may contact the practice manager via your
patient portal. If you do not have a patient portal, please request access from the medical
staff during your appointment or you may call 1-800-735-1178 and one of our staff
members can assist.

 

COVID-19 

Our goal is to continue to support patients and address their health care concerns during the COVID-19 pandemic. If you have an urgent need, please do not delay care, whether it is COVID-19 related or not. Our offices are taking extra precautions to ensure we can safely care for you. This includes robust patient screening, universal masking, and enhanced cleaning of patient, staff, and waiting areas.

 

 

Preparing for your clinic appointment

 Our entire organization and all of its facilities are taking extra measures to keep patients safe when it is necessary for them to have an in-person appointment.

 We ask all patients to please follow the below temporary measures and aid us in our effort of keeping you and your care team,  and all of our patients safe.

 

 

Prior to arriving

 We will continue to ask you a few questions when you schedule your appointment to help identify any symptoms or recent exposures you may have had to COVID-19.
If any concerns are identified, our medical staff will reach out and determine if we need to update your appointment.

During your appointment

 

 Patients in our clinics may have only ONE individual accompany them, with consideration for special exceptions determined by our care teams.
All patients, visitors and staff are required to wear a mask to decrease the risk of COVID-19 exposure. Please bring your own face mask or covering to wear while at our facilities. The Center for Disease Control and Prevention has details on appropriate face coverings.
Please do not bring children under the age of 13 unless they are actively receiving care in the clinic setting.
Due to additional screening activities, when entering our buildings, please allow extra time upon arrival (approximately 15 minutes).
 

 

 

 

 

 

THANK YOU

PLEASE NOTE ONCE YOU HIT SUBMIT YOU WILL BE REDIRECTED TO OUR PATIENT PORTAL.

1)PLEASE ENTER YOUR EMAIL FOR YOUR USERNAME

2)TEMPORARY PASSWORD IS: Password1(Case Sensitive)

3)PLEASE GO TO THE MY HEALTH SECTION AND FILL OUT YOUR MEDICAL HISTORY AS 

SEEN IN THE EXAMPLE BELOW.

 

If you have any issues please email info@globalneuroandspine.com

Thank you very much.