NOTICE OF HEALTH INFORMATION POLICIES

This notice describes how Medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

 

Understanding Your Health Information

Each time you are provided service or receipt of equipment from Custom Mobility a record of this is made. Typically this record contains personal health and personal information. This information, often referred to as your medical record, serves as a:

  • Basis for planning the service provided
  • Means of communication among the many health professionals who contribute to your care
  • Legal document for describing the service your received
  • Means by which you or a third party payer can verify that equipment or services billed were actually provided
  • A tool with which we can assess and continually work to improve the service we render and the outcomes we achieve.

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    Understanding what is in your record and how your health information is used helps you to:

  • Ensure its accuracy
  • Better understand who, what, when and why others may access your health information
  • Make more informed decisions when authorizing disclosure to others.

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    Your Health Information Rights

    Although your health record is the physical property of Custom Mobility, Inc. this information belongs to you. You have the right to:

  • Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522
  • Obtain a copy of the notice of information practices upon request
  • Inspect and copy your health record as provided for in 45CFR 164.524
  • Amend you health record as provided in 45 CFR 164.528
  • Revoke a written authorization
  • Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
  • Request communications of your health information except to the extent that action has already been taken.

    • If you request a copy of your medical information, we may charge you a reasonable fee for the paper, labor, mailing, and/or retrieval costs involved in filling your requests. We will provide you with information concerning the cost of copying your health information prior to performing such service.

    The title, address and telephone number of the person to whom you may file your request is listed on the last page of this document. All requests, noted above, must be made in writing.

     

    Custom Mobility, Inc. Responsibilities

    This organization is required to:

  • Maintain the privacy of your health information
  • Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
  • Abide by the terms of this notice
  • Notify you if we are unable to agree to a requested restriction
  • Accommodate reasonable requests you may have to communicate health information by alterative means of at alternative locations.

    • Custom Mobility reserves the right to change our practices and to make the new provision effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have supplied us with.

    Custom Mobility will not use or disclose your health information without your written authorization, for purposes other than described in this notice.

    You may revoke such authorization in writing.

    Examples of Permissible Disclosures for Treatment, Payment and Health Operations:

  • Any request for Protected Health Information from a payment source for the purpose of making a determination to pay or approve a claim is permissible.
  • Any request for Protected Health Information to a Physician’s office, Therapist or other Professional for the purpose of providing appropriate Equipment or Service is a permissible request.
  • Any request for Protected Health Information to a Physician’s office, Therapist or other Professional for the purpose of securing payment for services is permissible.
  • A disclosure of Protected Health Information to a vendor in order to obtain the appropriate equipment is permissible.
  • Other disclosures of Protected Health Information are permissible for Treatment, Payment or Operational Function of Custom Mobility Inc.
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    From time to time Custom Mobility may disclose information to notify or assist in notifying a family member, personal representative or another person responsible for your care in order to schedule service or equipment delivery or provide appointment reminders.

    Minimum Necessary Rule:

    Custom Mobility will employ whenever possible the minimum amount of Protected Health Information (PHI) necessary to accomplish the intended purpose of the use or disclosure.

    Minimum necessary does not apply to Treatment, Payment or Operational disclosures.


    For More Information or to Report a Problem
    If you have questions and would like additional information you may contact the Privacy Compliance Officer at Custom Mobility Inc., 7199 Bryan Dairy Road Largo, FL 33777-1502. Phone (727) 539-8119.

    If you believe your privacy has been violated, you can file a complaint with the Director of Health Information Management or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

    Effective Date: April 14, 2003