I. Financial

Thank you for choosing the Florida Lipid Institute. We are committed to the success of your medical treatment and care. Please understand that payment of your bill is part of this treatment and care. Also please understand that we currently do not accept credit or debit cards.

All patients are responsible for knowing the requirements of their insurance plans, including which labs they may use, what services are covered, etc. We will assist our patients, but we cannot be responsible for knowing or interpreting the benefits of each individual policy. You can direct particular questions to the customer service number usually found on the back of your insurance card.

You are personally responsible for payment for services provided if your insurance carrier does not pay all or a portion of each visit's charges. If your insurance company denies payment for any reason (e.g. non-covered services, failure to secure written referral from Primary Care Physician) you will pay for services upon written/verbal notice of refusal from Florida Lipid Institute. Failure to pay within 30 days of notification may result in dismissal from this office. In the event you do not pay for the medical services that were provided to me, you agree to pay the cost of collection, including attorney fees, whether or not a lawsuit commenced as part of the collection process.

II. FLI Privacy Practice Notice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY THE FLORIDA LIPID INSTITUTE AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are required by law to: (1) Make sure that medical information that identifies you is kept private; (2) Give you this notice of our legal duties and privacy practice (3) Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:

Treatment
We may use and disclose information about you to provide, coordinate or manage your medical care and any related services. We also may disclose medical information about you to professionals outside of FLI who may be involved in your medical care. For example, a doctor involved in treating your broken foot may need to know what medications you are on that might complicate the healing process.

Payment
We may use information to obtain payment for your medical services. For example, we may need to give your health plan information about a procedure you received at FLI so your health plan will pay us or reimburse you for the procedure.

Health Care Operations
We may use your information to support the business activities of FLI.  These activities include, but are not limited to, training of medical students, licensing, employee review activities.

We may use and disclose information: to contact you as a reminder that you have an appointment at FLI; to tell you about possible treatment options that may be of interest to you; to others involved in your medical care; for medical research purposes.

We may use or disclose your information in certain situation even without your consent or authorization: when required by law; to avert a serious threat to health or safety; as necessary to facilitate organ or tissue donation or transplantation if you are an organ donor; as required by military command authorities if you are a member of the armed forces; to report abuse or neglect; to report reactions to medications or problems with products; if requested to do so by a law enforcement official; if requested by a coroner, medical examiner or funeral director; or, to authorized federal officials for national security reasons.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU:

You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request 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 to a specific family member. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request.

You have the right to request that we communicate with you in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will accommodate reasonable requests.

You have the right to inspect and copy your protected health information. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances.

If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for FLI. To request an amendment, your request must be made in writing. In addition, you must provide a reason that supports your request. In certain cases we may deny your request.

You have the right to request an accounting of disclosures. This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment or healthcare operations. This request must be in writing.

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.
You can also view or download a printable copy of this form by clicking here.

We reserve the right to change this notice. We reserve the right to make the revised notice effective for medical information we already have about you as well as any information we receive in the future. We will make available a copy of the current notice at each practice site.

If you believe your privacy rights have been violated, you may file a complaint with FLI or with the Secretary of the Department of Health and Human Services. To file a complaint with FLI, contact the FLI Privacy Officer. All complaints must be submitted in writing.