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HIPAA Notice of Privacy Practice

This Notice describes how medical information about your medical history may be used and disclosed by Tampa Rejuvenation (“Company”) in its capacity as a Business Associate to the Company’s affiliated practitioners who takes care of you (“Practitioner”), and how you can get access to this information. Please review this Notice carefully.

What is your medical information? All the health care related information your Practitioner and the Company have in your file, including your medical history, current condition, diagnosis, examination notes, test results, and prescriptions.

Why are you getting this Notice? The Company is a Business Associate to your Practitioner and, as such, performs certain administrative functions for your Practitioner which requires access to your medical record. As a Business Associate, the Company must comply with the HIPAA Privacy Rule that requires Company to protect the confidentiality of your medical information. As a medical services provider, your Practitioner must also comply with the HIPAA Privacy Rule. The Privacy Rule also gives you certain rights with respect to your medical information. This Notice explains both our obligations and your rights under the Privacy Rule.

Your rights:Although your physical medical file belongs to your Practitioner, the information in your file belongs to you. You therefore have the right to:

Company’s obligations: We are required to do the following:

Please note that the Company reserves the right to change its privacy practices and apply the changes to your medical information. If we do change our privacy practices, we will mail you a revised Notice to the address you have provided to us.

Uses and disclosures: These are some examples of the uses and disclosures of your medical information that the Company will make:

Complaints: If you think your privacy rights have been violated, you may complain to the Compliance Director at Company and/or to the Secretary of Health and Human Services. In order to file a complaint with Company, please speak with the Company’s Privacy Officer, Brittany Gomez (see below), and s/he will complete a written complaint form with you and follow up on your complaint. The Company will not retaliate against you for filing a complaint.

Contact: If you have any questions or complaints regarding your medical information or anything contained in this Notice, please contact the Privacy Officer, Brittany Gomez at 813.558.9500

Effective date: This Notice is effective as of April 14, 2003 until revised or revoked.


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