Hippa Privacy Rule

You Have the Following Rights Regarding Medical Information We Obtain About You  

Right to Inspect and Copy: You have the right to inspect and receive a copy of your medical information that is used to make decisions about your care. Usually, this includes medical and billing records maintained by Wellness Medical Clinic.

If you wish to inspect and copy medical information, you must submit your request in writing to Wellness Medical Clinic. (850) 518-4325 with questions. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request, to the extent permitted by state and federal law. If we maintain your health information electronically as part of a designated record set, you have the right to receive a copy of your health information in electronic format upon your request. You may also direct us to transmit your health information (whether in hard copy or electronic form) directly to an entity or person clearly and specifically designated by you in writing.

We may deny your request to inspect and copy your information in certain very limited circumstances. For example, we may deny access if your physician believes it will be harmful to your health, or could cause a threat to others. In these cases, we may supply the information to a third party who may release the information to you. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Wellness Medical Clinic will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Request Amendment: If you believe that medical infor- mation we have about you is incorrect or incomplete, you have the right to ask us to change the information. You have the right to request an amendment for as long as the information is kept by or for Wellness Medical Clinic.

To request a change to your information, your request must be made in writing and submitted to the [email protected]. In addition, you must provide a reason that supports your request.

Wellness Medical Clinic may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

  • Was not created by Wellness Medical Clinic, PLLC;, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for Wellness Medical Clinic, PLLC;
  • Is not part of the information which you would be permitted to inspect or copy; or
  • Is accurate and complete

Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. This list will not include disclosures for treatment, payment, and health care operations; disclosures that you have authorized or that have been made to you; disclosures for facility directories; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement with custody of you, and certain other disclosures.

To request this list of disclosures, you must submit your request in writing to the HIM Department. (850) 518-4325 with questions. Your request must state a time period for which you would like the accounting. The accounting period may not go back further than six years from the date of the request, and it may not include dates before March 18, 2022. You may receive one free accounting in any 12-month period. We will charge you for additional requests

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you. If you pay out-of-pocket in full for an item or service, then you may request that we not disclose information pertaining solely to such item or service to your health plan for purposes of payment or health care operations. We are required to agree with such a request, unless you request a restriction on the information we disclose to a health maintenance organization (“HMO”) and the law prohibits us from accepting payment from you above the cost-sharing amount for the item or service that is the subject of the requested restriction. However, we are not required to agree to any other request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or you request that we remove the restriction.

To request restrictions, you must make your request in writing to the [email protected]. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, if you want to prohibit disclosures to your spouse.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you only at work or only by mail.

To request confidential communications, you must make your request in writing to HIM Department. Contact (850) 518-4325 with questions. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted, and we may require you to provide information about how payment will be handled.

Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice any time. This notice is on our website, www.Wellness Medical Clinicmedical.org.

Changes to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. If the terms of this notice are changed, Wellness Medical Clinic will provide you with a revised notice upon request, and we will post the revised notice on our website, www.TallyClinics.com.

Complaints or Questions
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with Wellness Medical Clinic, or to ask a question about this Notice, contact the HIM Department (850) 518-4325. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses and Disclosures of Protected Health Information
We are required to obtain a written authorization from you for most uses and disclosures of psychotherapy notes, uses and disclosures of protected health information for marketing purposes and disclosures that constitute a sale of protected health information. Except as described in this Notice, Wellness medical Clinic, PLLC will not use or disclose your protected health information without a specific written authorization from you. If you provide us with this written authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except to the extent we have already relied on your authorization. We are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that we provided to you.

During your treatment at Wellness Medical Clinic, doctors, nurses and other care- givers may gather information about your medical history and your current health. This notice explains how that information may be used and shared with others. It also explains your privacy rights regarding this kind of information. The terms of this notice apply to health information created or received by Wellness Medical Clinic. We are required by law to: make sure that medical information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to medical information about you; follow the terms of the notice that is currently in effect; and notify you in the event there is a breach of any unsecured protected health information about you.

Notice of Privacy Practices



This notice applies to Wellness Medical Clinic, PLLC

Wellness Medical Clinic, PLLC



Effective date:
March 18, 2022

Your Medical Information May be Used and Disclosed for the Following Purposes:

Treatment: We may use your information to provide, coordinate and manage your care and treatment. For example, a Wellness Medical Clinic physician may share your medical information with another physician for a consultation or referral. We will get your written consent prior to making disclosures outside of Wellness Medical Clinic for treatment purposes, except in emergency circumstances when it is not possible to get your consent.

Payment: We may use and disclose medical information about you so that the treatment and services you receive may be billed to, and payment collected from, you, an insurance company or another third party. For example, we may need to give your health plan information about treatment you received at Wellness Medical Clinic so that your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval to determine whether your plan will cover the treatment, or for purposes of an independent review of a denial of a claim based on lack of medical necessity. We will get your written consent prior to making disclosures for payment purposes.

Health Care Operations: We may use and disclose medical information about you for Wellness Medical Clinic’s health care operations. Health care operations are the uses and disclosures of information that are necessary to run Wellness Medical Clinic and to make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff and physicians in caring for you. We will get your written consent before making disclosures to others outside of Wellness Medical Clinic for health care operations purposes.

Appointment Reminders and Other Health Information: We may use your medical information to send you reminders about future appointments. We may also send you refill reminders or other communications about your current medications. However, if we receive any financial remuneration for making such refill, or medication communications beyond our costs of making the communication, we must first obtain your written authorization to make such communications. We may contact you with information about new or alternative treatments, or of other health care services or for purposes of care coordination, unless we receive financial remuneration in exchange for making the communication; in that case, we will obtain your written authorization to make such communications. However, we are not required to obtain your written authorization for face-to-face communications.

To People Assisting in Your Care: Wellness Medical Clinic will only disclose medical information to those taking care of you, helping you to pay your bills, or other close family members or friends if these people need to know this information to help you, and then only to the extent permitted by law. We may, for example, provide limited medical information to allow a family member to pick up a prescription for you. We will get your consent prior to making disclosures about you to family or friends. If you are able to make your own health care decisions, Wellness Medical Clinic will ask your permission before using your medical information for these purposes. If you are unable to make health care decisions, Wellness Medical Clinic will disclose relevant medical information to family members or other responsible people if we feel it is in your best interest to do so, including in an emergency situation.

Research: Federal law permits Wellness Medical Clinic to use and disclose medical information about you for research purposes, either with your specific, written authorization or when the study has been reviewed for privacy protection by an Institutional Review Board or Privacy Board before the research begins. In some cases, researchers may be permitted to use information in a limited way to determine whether the study or the potential participants are appropriate. Florida law generally requires that we get your consent before we disclose your health information to an outside researcher. We will make a good faith effort to obtain your consent or refusal to participate in any research study, as required by law, prior to releasing any identifiable information about you to outside researchers.

As Required by Law: We will disclose medical information about you when we are required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the

public or another person. Any disclosure must be only to someone able to help prevent the threat. In addition, Florida law generally does not permit these disclosures unless we have your written con- sent, or when the disclosure is specifically required by law, including the limited circumstances in which Wellness Medical Clinic health care professionals have a “duty to warn.”

To Business Associates: Some services are provided by or to Wellness Medical Clinic through contracts with business associates. Examples include Wellness Medical Clinic’s, attorneys, consultants, collection agencies, and accreditation organizations. We may disclose information about you to our business associate so that they can perform the job we have contracted with them to do. To protect the information that is disclosed, each business associate is required to sign an agreement to appropriately safeguard the information and not to re-disclose the information unless specifically permitted by law.

Health Oversight Activities: Wellness Medical Clinic may disclose medical information to a health oversight agency for health oversight activities that are authorized by law. These oversight activities include, fo example, government audits, investigations, inspections, and licensure activities. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Florida law requires that patient identifying information (for example, your name, social security number, etc.) be removed from most disclosures for health oversight purposes, unless you have provided us with written consent for the disclosure.

Lawsuits and Disputes: We may disclose medical information about you in response to a valid court order or statutory authorization, or with your written consent.

Law Enforcement: We may release medical information if asked to do so by a law enforcement official in response to a valid court order, grand jury subpoena, or warrant, or with your written consent. In addition, we are required to report certain types of wounds, such as gunshot wounds and some burns. In most cases, reports will include only the fact of injury, and any additional disclosures would require your consent or a court order.

We may also release information to law enforcement that is not a part of the health record (in other words, non-medical information) for the following reasons:

  • To identify or locate a suspect, fugitive, material witness or missing person;
  • If you are the victim of a crime, if, under certain circumstances, we are unable to obtain your agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at our facility; and
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime

National Security and Intelligence Activities: We will release medical information about you to authorized federal officials for intelligence, counter-intelligence and other national security activities only as required by law or with your written consent.

Protective Services for the President and Others: We will disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or conduct special investigations only as required by law or with your written consent.