Call Us (941) 552-4500
This notice describes how medical information about you, as a Brain Wave Center™client, may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions, please contact our HIPAA Privacy Office at the address or phone number located at the conclusion of this policy notice. This Notice is in accordance with the Health Insurance Portability & Accountability Act – HIPAA.
This Notice describes Practices of all Brain Wave Center workforce members including:
We understand that medical information about you is personal. We are committed to protecting your medical information. We create a record of care, as well as maintain your comprehensive health files to provide quality services. This notice applies to all records created at TheBrain Wave Center and all records we store and maintain on your behalf. We are required by law to:
The Brain Wave Center may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), for internal purposes of coordinating your care or making recommendations, as well as conducting health care operations. The Brain Wave Center has established a policy to guard against unnecessary disclosure of your health information. However, outside disclosures will be made only with your written authorization.Examples of disclosures that require your written authorization include, but are not limited to:
Page 1 of 4
Page 2 of 4
The Brain Wave Center may make changes to our privacy policy and practices. Changes may apply to medical information we already have and hold, as well as new information created or obtained after the policy change. Your questions and input regarding our policy and practices are always welcome. Please contact the Privacy Office for The Brain Wave Center as listed at the conclusion of this policy notice for a copy of the current Notice of Privacy Policy and Practices.
We at The Brain Wave Center continually strive to protect your privacy. If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made regarding access to your records, you may contact the Privacy Office for The Brain Wave Center listed below. If you are not satisfied with our response, you may contact the U.S. Department of Health and Human Services Office of Civil Rights. Instructions for filing a complaint are available at http://www.hhs.gov/ocr/hipaa/ or you can request the contact number from our Privacy Office. We will never penalize you or retaliate against you if you file a complaint.
Privacy Officer The Brain Wave Center™ Corporate Office 640 S. Washington Blvd. Sarasota, Florida 34236 Phone: (941) 552-4511
This Notice is effective January 1, 2011.
Page 3 of 4
I acknowledge that I have received a copy of The Brain Wave Center’s Notice of Privacy Practices.
Instructions to Client: The first three pages of this Notice of Privacy Practices are for your records. This page only should be signed and returned to The Brain Wave Center, as soon as possible.
Bring this signed form with you at your next appointment or Fax to (888) FAX-1HPi or mail to:
The Brain Wave Center™ 1 Health Place International® Privacy Office 640 S. Washington Blvd. Sarasota, Florida 34236
Page 4 of 4