THE FOLLOWING NOTICE DESCRIBES 1-IOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED,
A N D H O W Y O U C A N G E T A C C E S S T O T H I S I N F O R M A T I O N . P L E A S E R E V I E W T H E I N F O R M A T I O N C A R E F U L L Y .
٠Your confidential healthcare information may be released to other healthcare professionals within the organization for the
purpose
of providing you with quality healthcare.
٠Your confidential healthcare information may be released to your insurance provider for the purpose of the organization
receiving
payment for providing you with needed healthcare services.
٠Your confidential healthcare information may be released to public or law enforcement officials in the event of an investigation
which you are avictim of abuse, acrime or domestic violence.
٠Your confidential healthcare information may be I'eleased to other healthcare providers in the event you need emergency care.
٠Your confidential healthcare information may be released to apublic health organization or federal organization in the event of
a
communicable disease or to report adefective device or untow'ard event to abiological product (food or medication).
٠Your confidential healthcare information may not be released for any other purpose than that which is identified in this notice.
٠Your confidential healthcare information may be released only after I'eceiving written authorization ftom you. This provision
includes but is not limited to and psychotherapy notes, foi' marketing purposes and any disclosures that may constitute asale of
your protected healthcare information. Any other uses or disclosures not described in this notice can only be made with your
expressed authorization. You may revoke your permission to release confidential healtlrcare information at any time.
٠You may restrict the disclosure of your protected health information for any services provided whereby your or somebody else
pays
“out of pocket", in full, for the services.
٠You may be contacted by the organization to remind you of any appointments, healthcare treatment options or other health
services that may be of interest to you.
٠You may be contacted by the organization for the purposes of raising funds to support the organization's operations. It is your
express right to opt out of any fund raising communications.
٠You have the right to restrict the use of your confidential healthcare infoimation. However, the organization may chose to
refuse
your restriction if it is in conflict of providing you with quality healthcare or in the event of an emergency situation.
٠You have the right to receive confidential communication about your health status.
٠You have the right to review and photocopy any/all portions of your healthcare information.
٠You have the right to make cIt anges to your healthcare infomation.
٠You have the right to know who has accessed your confidential healthcare information and for what purpose.
"You have the right to possess acopy of this Privacy Notice upon request. This copy can be In the form of an electronic
transmission or on paper.
٠The organization is required by law to protect the privacy of its patients. It will keep confidential any and all patient healthcare
information and will provide patients with alist of duties or practices that protect confidential healthcare information.
٠The organization will promptly contact you should there be any breach of your protected health information.
٠The organization will abide by the terms of this notice. The organization reserves the right to make changes to this notice and
continue to maintain the confidentiality of all Iiealthcare information. Patients will receive amailed copy of any changes to this
notice within 60 days of making the changes.
٠You have the right to complain to the organization if you believe your rights to privacy have been violated. If you feel your
privacy
rights have been violated, please mail your complaint to the organization:
ATTN:
٠All complaints will be investigated. No personal issue will be raised for filing acomplaint with the organization.
٠For further information about this Privacy Notice, please contact:
Administrator:
٠This notice is effective as of
printed or published
.This date must not be earlier than the date on which the notice is
This form provided courtesy of fjniversal Healthcare Consulting, Inc. rev 7/2013
Physicians that have a financial interest in this facility:
D R O B I N N A N W O B I
l o o o e x e c u t i v e D r i v e - s u i t e 8
P A T I E N T R I G H T S :
The patient has the right to:
be informed of his/her rights in advance of, receiving care.
The patient may appoint arepresentative to receive this
information should he/she so desire.
Exercise these rights without regard to sex, cultural,
economic, education, religious background, physical handicap, 01'
the source of payment for care.
Considerate, respectful and dignified care, provided in asafe
environment, with protection of privacy, free from all foi'ms of
abuse, neglect, harassment and/or exploitation.
Access protective and advocacy services or have these
accessed on the patient's
Appropriate assessment and management of pain.
Knowledge of the name of the physician who has primary
responsibility for coordinating his/her care and the names and
professional relationships of other physicians and healthcare
providers who will see them. The patient has aright to request a
change in providers if other qualified providers are available.
Be advised if the physician has afinancial interest in the
s u r g e r y c e n t e r.
Be advised as to the absence of malpractice coverage if
applicable.
Receive complete information from his/her physician about
his/her illness, course of treatment, alternative treatments,
outcomes of care (including unanticipated outcomes), and
prospects for recovery in terms that he/she can understand.
Receive as much information about any proposed treatment
or procedure as he/she may need in order to give informed
consent or to refuse the course oftreatment. Except in
emergencies, this information shall include adescription of the
procedure or treatment, the medically significant risks involved
in the treatment, alternate courses of treatment or non-
treatment and the risks involved in each and the name of the
person who will carry out the procedure or treatment.
Participate in the development and implementation of
his/her plan of care and actively participate in decisions
regarding his/her medical care. To the extent permitted by law,
this includes the right to request and/or refuse treatment.
Be informed of the facility's policy and state regulations
regarding advance directives and be provided advance directive
forms if requested.
Receive acopy of aclear and understandable itemized bill
and receive and explanation of his/her bill regardless of source
of payment.
Receive upon request, full information and necessary
counseling on the availability of known financial resource for
his/her care, including information regarding facilities discount
and charity policies.
Know which facility rules and policies apply to his/her
conduct while apatient.
Have all patient rights apply to the person who may have
legal responsibihty to make decisions regarding medical care on
Receive treatment for any emergency medical condition that will
detei'iorate from failure to provide treatment.
Full consideration of privacy concerning his/her medical care.
Case discussion, consultation, examination and treatment are
confidential and should be conducted discreetly. The patient has the
right to be advised as to the reason for the presence of any
individual involved in his/her health care.
C o n fi d e n t i a l t r e a t m e n t o f a l l c o m m u n i c a t i o n s a n d r e c o r d s
pertaining to his/her care and his/her stay at the facility. His/her
written permission will be obtained before medical records can be
made available to anyone not directly concerned with their care.
Receive information in amanner that he/she understands.
Communications with the patient will be effective and provided in a
manner that facilitates understanding by the patient. Written
information provided will be appropriate to the age, understanding
and, as appropriate, the language of the patient. As appropriate,
communications specific to vision, speech, hearing cognitive and
language-impaired patient will be appropriate to the impairment.
Access information contained in his/her medical record within a
r e a s o n a b l e t i m e f r a m e .
Be advised of the facility's grievance process, should he/she wish
to communicate aconcern regarding the quality of the care they
received. Notification of the grievance process includes: whom to
contact to file agrievance, and that he/she will be provided with a
written notice of the grievance determination that concerns the
name of the facility's contact person, the steps taken on his/her
behalf to investigate the grievance, the results of the grievance and
grievance completion date.
Be advised of contact information for the state agency to which
complaints can be reported, as well as contact information for the
office of the Medicare Beneficiary Ombudsman.
Be advised if the facility/personal physician proposes to engage in
or perform human experimentation affecting their care or
treatment. The patient has the right to refuse to participate in such
research projects. Refusal to participate or discontinuation of
participation will not compromise the patient's rights to access care,
t r e a t m e n t o r s e r v i c e s .
Full support and respect of all patient rights should the patient
choose to participate in research, investigation and/or clinical trials.
This includes the patient's right to afull informed consent process
as it relates to the research, investigation and/or clinical trial. All
information provided it subjects will be contained in the medial
record or research file, along with the consent formfs).
Be informed by his/her physician or adelegate of thereof of the
continuing healthcare requirement following their discharge from
the facility.
Be informed if Medicare eligible, upon request and in advance of
treatment, whether the health care provider or healthcare facility
accepts the Medicare assignment rate.
Receive upon request, prior to treatment, areasonable estimate of
P A T I E N T R E S P O N S I B I L I T I E S
The patient has the responsibility to provide accurate and
complete information concerning his/her present complaints, past
illnesses, hospitalizations, medications (including over the counter
products and dietary supplements), allergies and sensitivities and
other matters relating to his/her health.
The patient is responsible for keeping appointments and for
notifying the facility or physician when he/she is unable to do so.
The patient and family are responsible for asking questions when
they do not understand what they have been told about the patient's
care or what they are expected to do.
!f you wish to complete an Advance Directive, copies of the official forms are available at our front desk or online at:
The patient is responsible for following the treatment plan established by his/her professionals as they carry out the physician's orders.
The patient is responsible for repotting to the health care
provider any unexpected changes in his/her condition.
Provide aresponsible adult to transport him/her home from the facility and remain with him/her for 24 hrs unless exempted from that requirement by the attending physician.
In the case of pediatric patients, aparent or guardian is to
remain in the facility for the duration of the patient's stay in the facility.
The patient is responsible for his/her actions should you
refuse treatment or not follow your physician's orders.
The patient is responsible for assuring that the financial
obligations 0his/her care are fulfilled as promptly as possible.
The patient is responsible for following facility policies and procedures.
The patient is responsible to inform the facility about the
a d v a n c e d i r e c t i v e s .
The patient is responsible for being considerate of the rights of other patients and facility personnel.
The patient is responsible for being respectful of his/her
personal property and that of other persons in the facility.
If you do not agree with this facility's policy, we will be pleased to assist you in rescheduling your procedure.
If apatient is adjudged incompetent under the states laws, the rights of the patient are exercised by the person appointed and/or legal representative designated by the patient under Florida law to act on the patient's behalf. The center will accept aCourt Appointed Guardian, Dual Power of Attorney, or a Health Care Surrogate.
P A T I E N T C O M P L A I N T O R G R I E V A N C E
If you have aproblem or complaint, please speak to the receptionist or your caregiver, we will address your concern؛s) promptly.
If necessary, your problem or complaint will be advanced to the Administrator and/or Quality Assurance coordinator for resolution. You will receive aletter or phone call to inform you of the actions take to address your complaint.
If you are not satisfied with the response of the Surgery Center, y o u m a y c o n t a c t :
A D VA N C E D I R E C T I V E N O T I F I C AT I O N :
In the state of Florida, all patients have the right to participate in their own health care decisions and to make Advance
Directives or to execute Power of Attorney that authorize
others to make decisions on their behalf based on the patient's expressed wishes when the patient is unable to make decisions or unable to communicate decisions. Keyhole Surgery Center
O b i n n a N w o b i - A d m i n i s t r a t o r
؛863)-223-3856)
Patient comp!alnts or grievances may be filed through the state of Florida Consumer
Services Unit at 1-888-419-3456 [press 2) or write to the address below:
Complaints against an ambulatory surgical center may be filed with the state ofFlorida by calling the Consumer Assistance Unit a1-888-419-3456 or write to: However, unlike in an acute care hospital setting, the Surgery
Center does not routinely perform "high risk" procedures. Most procedures performed in this facility are considered to be of minimal risk. Of course, no surgery is without risk. You will discuss the specifics of your procedure with your physician who can answer your questions as to its risks, your expected recovery, and care after surgery.
Agency for Health Care Administration
C o n s u m e r A s s i s t a n c e U n i t
2727 Mahan Drive/BLDG. 1
Ta l l a h a s s e e , F l o r i d a 3 2 3 0 8
Ifyou have acomplaint against ahealth care professional and want to receive a complaint form, call Consumer Services Unit at l-888-419-3456(press 2] or write to the
address below: Therefore, it is our policy, regardless of the contents of an
Advance Directive or instructions from ahealth care surrogate or attorney-in-fact, that if an adverse even occurs during your
treatment at this facility, we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital
for further evaluation. At the acute care hospital, further
treatments or withdrawal of treatment measure already begun will be ordered in accordance with your wishes. Advance
Directive, or Healthcare Power of Attorney.
Department of Health
C o n s u m e r S e r v i c e s H n i t
4052 Bald Cypress Way, Bin C75
Ta l l a h a s s e e , F l o r i d a 3 2 3 9 9
You may also Contact AAAHC by mail at:
A c c r e d i t a t i o n A s s o c i a t i o n f o r
Ambulatory Health Care, INC.
5250 Old Orchard Road, Suite 200
S k o k i e , I l l i n o i s 6 0 0 7 7
All Medicare beneficiaries may also file acomplaint or grievance with the Medicare
Beneficiary Ombudsman.
Visit the Ombudsman's webpage on the web at: To listen to the Patient's Bill of Rights via phone, call toll-free @
866-969-6532. Press 1for English or 2for Spanish.
https://floridadep.gov/comm/ombudsman-public-services