Privacy Notice

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Anne Hermann, M.D., P.A. d/b/a Hermann Aesthetics and Wellness (“Hermann Wellness,” “We,” or “Our”) is a cash-based practice that does accept insurance or process transactions governed by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). However, Hermann Wellness is dedicated to maintaining the privacy of your personal information, medical information, and complying with applicable state privacy laws. We will maintain the privacy of your health information and inform you about our privacy practices by providing you with this Notice. We will follow the privacy practices as described below. This Privacy Notice effective for all health information maintained, created and/or received by Hermann Wellness. You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer, whose contact information is provided at the end of this Privacy Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We may use or share your medical information in the following ways, without your prior authorization.

Treatment: We may use and disclose your medical information to provide you with treatment and professional services, which may include electronic disclosures. For example, we may use and disclose your medical information to assist other health care providers in their treatment of you, or to inform you of potential treatment alternatives or programs. We may also disclose your medical information to your family, friends and/or other persons you choose to involve in your care, if you agree that we may do so. To protect the privacy of your information while providing treatment services to you, we have established “minimum necessary” or “need to know” standards that limit staff members’ access to your medical information according to their primary job functions. All staff members are also required to sign a confidentiality statement.

Payment: We may use and disclose your medical information to bill and collect payment for the services and items provided by us, as described in the new patient paperwork signed by you. This may involve our business office staff and other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances. We obtain written assurances regarding the privacy of information from any third parties that assist us in billing and collection. We do not participate in insurance plans and our services are not covered by insurance.

Healthcare Operations: We will use and disclose your health information to operate our practice, improve your care, and contact you when necessary. For example, we may use or disclose your medical information to evaluate the quality of care you received from us or to conduct cost-management and business planning activities. In some circumstances and when permissible by law, we may also share health information with other health care providers for their health care operations.

OTHER USES & DISCLOSURES

Emergencies: In an emergency, we may use or disclose your medical information to notify, or assist in the notification of a family member or anyone responsible for your care, to inform them of your location, general condition or death. When possible, we will obtain your consent and/or the opportunity to object to such disclosure. You should maintain current contact information for your emergency contact on file with our practice. Under emergency conditions or if you are incapacitated, we will use our professional judgment to disclose only that information directly relevant to your care.

Required by Law: We may use or disclose your medical information when we are required to do so by law. Examples include court orders and subpoenas when proper notice has been provided.

Public Health and Safety: In accordance with applicable law and subject to certain conditions, we may share your medical information for the following purposes:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions
• Reporting suspected abuse or neglect
• Preventing or reducing a serious threat to health or safety

Compliance with Law: We will share your medical information if state or federal laws require it, which may include certain disclosures (when permissible and required) to determine our compliance with the law.

Workers’ Compensation: We may release your medical information for workers’ compensation and similar programs subject to the requirements of State Law.

Law Enforcement & Other Government Requests: We may share medical information for law enforcement purposes or with law enforcement officials when permitted by law. We may also share medical information with health oversight agencies for activities authorized by law, and for special government functions such as military, national security, and presidential protective services when permitted by law.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, or letters.

DISCLOSURES REQUIRING YOUR AUTHORIZATION

Other uses and disclosures that are not described in this Privacy Notice will be made only with your written authorization. We will never sell or use your medical information for marketing purposes without your authorization. Most uses and disclosures of psychotherapy notes require your prior authorization. Any authorization you provide to us regarding the use and disclosure of your medical information may be revoked at any time by notifying us in writing. After you revoke your authorization, we will no longer use or disclose your medical information based on the authorization. However, uses and disclosures made before we received your revocation will not be affected.

YOUR PRIVACY RIGHTS

When it comes to your medical information, you have certain rights. This section explains your rights and some of our responsibilities to help you exercise those rights.

Access or Inspect Records: Upon request we will provide you with an electronic or paper copy of your medical records. To obtain copies or request inspection of your medical information, you must submit your request in writing to our Privacy Officer, whose contact information is included at the end of this Privacy Notice. Limited exceptions may apply depending on the type of information we maintain about you.

Amendments: You can ask us to correct the medical information we maintain about you if you believe it is incorrect or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied (for example, if the record is accurate and complete). To request an amendment, your request must be made in writing and submitted to our Privacy Officer, whose contact information is provided at the end of this Privacy Notice. Please note that we cannot completely delete information contained in your record and the change requested by you will appear as an addendum to the existing record.

Accountings: You can ask for a list (an accounting) of the times we shared your medical information for six years prior to the date of your request, who we shared it with, and why. Please note the accounting will not include disclosures made for treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but may charge a reasonable, cost-based fee if you ask for another one within 12 months. To request an accounting, submit your request in writing to the Privacy Officer.

Restrictions: You can ask us not to use or share certain medical information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If we agree to your request, our agreement will be in writing, and we will comply with the restriction unless (i) the information is needed to provide you with emergency care or (ii) we are required or permitted by law to disclose it. We do not participate in insurance, but you can also ask us not to share information with your health insurer related to services and health care items for the purpose of payment or our operations if you have paid in full for the service or health care item. We will agree to this request unless a law requires us to share that information.

Breach Notification Requirements: In accordance with applicable law, we will notify you of a breach of your unsecured personal and/or medical information.

Personal Representatives: If you have given someone the legal authority to exercise your rights and choices covered by this Privacy Notice, we will honor such requests once we verify their authority. This Privacy Notice also applies to minors, disabled adults, or others that are not able to make health care decisions for themselves or who choose to designate someone to act on their behalf. Personal Representatives (including parents and legal guardians) can exercise the rights described in this Privacy Notice. There are, however, some limited situations under State Law where prior authorization of a minor patient is required before certain actions can be taken and where the minor would be treated as the individual for the purposes of this Privacy Notice. We comply with applicable State Laws in this regard.

Confidential Communications: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. To request confidential communications, you must make a written request to our Privacy Officer specifying the requested method of contact for billing purposes, or the location where you wish to be contacted. You do not need to give a reason for your request.

Paper Copy of this Privacy Notice.
We will provide you with a paper copy of this Privacy Notice upon
receipt of your request. To obtain a paper copy, please contact the Privacy Officer whose contact information is provided at the bottom of this Privacy Notice.

ELECTRONIC COMMUNICATIONS

Using any unsecure electronic communication (such as regular email) to communicate with us can present risks to the security of information. These risks include possible interception of the information by unauthorized parties, misdirected emails, shared accounts, message forwarding, or storage of the information on unsecured platforms and/or devices. We do not advise communicating with us via unsecured email or text message. By choosing to correspond with us via unsecure electronic communication platforms, you are acknowledging and accepting these risks.

QUESTIONS AND COMPLAINTS

If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us. Please submit your complaint in writing to the Privacy Officer whose information is provided at the bottom of this Privacy Notice. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with applicable regulators.

HOW TO CONTACT US

Practice Name: Anne Hermann MD PA

Privacy Officer: Anne Hermann, MD

Telephone: 813-902-9559 or 727-278-3992 Fax: 813-315-6611
Address: 1111 Assembly Dr, Tampa, FL 33607
Address: 6387 Central Avenue, St. Petersburg, FL 33710
Email: contact@doctorhermann.com