HIPAA Notice of Privacy Practices – RDM Magnolia Practice Care

Notice of Privacy Practices

Health Insurance Portability and Accountability Act (HIPAA)

Effective Date: March 19, 2025

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.

About This Notice

RDM Magnolia Practice Care, under the care of Dr. Rolando Dominguez, MD, is required by federal law — specifically the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164 — to maintain the privacy of your Protected Health Information (PHI) and to provide you with this Notice of our legal duties and privacy practices.

We are required to abide by the terms of this Notice currently in effect. We reserve the right to change our privacy practices and this Notice. If we make a material change, we will provide you with a revised Notice. You may request a copy of any current or revised Notice at our office at any time.

1. What Is Protected Health Information (PHI)?

PHI is individually identifiable health information that relates to your past, present, or future physical or mental health or condition; the provision of health care to you; or the past, present, or future payment for the provision of health care. PHI includes information in your medical record, conversations between your doctor and other healthcare providers regarding your treatment, and your billing information.

2. How We May Use and Disclose Your PHI

The following categories describe the ways we may use and disclose your PHI. Not every use or disclosure in a category will be listed, but all permitted uses and disclosures fall within one of these categories.

A. Treatment

We may use and disclose your PHI to provide, coordinate, or manage your medical care. For example, we may share your PHI with a specialist, hospital, laboratory, imaging center, rehabilitation facility, or home care agency involved in your treatment. As Chief of Staff and Board Member at HCA Florida Lake City Hospital and Medical Director for multiple rehabilitation and home care facilities, Dr. Rolando Dominguez, MD may share your information with those affiliated facilities as part of your coordinated care.

B. Payment

We may use and disclose your PHI so that the treatment and services you receive may be billed and payment collected from you, your insurance company, Medicare, Medicaid, or another third party. For example, we may share PHI with our billing company or your insurance carrier to obtain reimbursement for services rendered. Our billing company is a Business Associate under HIPAA and is contractually required to protect your PHI.

C. Health Care Operations

We may use and disclose your PHI for health care operations purposes. This includes quality assessment and improvement activities, training of medical students or residents, credentialing, legal services, auditing functions, and business planning. For example, we may review patient records to evaluate the quality of care provided.

D. Referring Physicians, Labs, and Imaging Centers

In connection with your treatment, we may share your PHI with referring physicians, laboratories, radiology or imaging centers, and other healthcare providers involved in your care. These disclosures are made solely for treatment purposes.

E. Required or Permitted by Law

We may use or disclose your PHI without your authorization when required or permitted by law, including:

Public health activities — reporting communicable diseases, vital statistics, or product recalls to public health authorities as required by Florida law or federal regulation.
Health oversight activities — audits, investigations, or inspections by government agencies such as the Florida Department of Health or the Centers for Medicare and Medicaid Services (CMS).
Judicial and administrative proceedings — in response to a court order, subpoena, or other lawful process, subject to applicable legal protections.
Law enforcement — under limited circumstances as required or permitted by law, including reporting certain injuries, crimes, or threats.
Serious threats to health or safety — to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, to appropriate persons capable of preventing or lessening the threat.
Workers’ compensation — as authorized by and to the extent necessary to comply with Florida workers’ compensation laws.
Military and veterans’ activities — if you are a member of the armed forces, as required by military authorities.
National security and intelligence activities — as required by law.

F. Medicare and Medicaid

Because this practice participates in Medicare and Medicaid, we may disclose your PHI to the Centers for Medicare and Medicaid Services (CMS), the Florida Agency for Health Care Administration (AHCA), and other applicable payers and oversight bodies as required to administer these programs, process claims, and comply with program requirements.

3. Special Protections for Certain Categories of PHI

Certain categories of PHI receive heightened protection under federal and Florida law. We apply additional safeguards to the following types of information:

A. Reproductive Health Information

This practice provides care that may include reproductive health services. Under the HIPAA Privacy Rule as amended (effective 2024) and consistent with applicable Florida law, we will not disclose your reproductive health information to law enforcement, employers, or other persons for the purpose of investigating or imposing criminal, civil, or administrative liability on you or another person for seeking, obtaining, providing, or facilitating lawful reproductive health care. We will obtain your written authorization before disclosing reproductive health information in circumstances not otherwise required by law.

B. Mental Health Information

To the extent mental health information is generated in connection with your care at this practice, it is treated with the same protections as all other PHI. Psychotherapy notes, if any, receive the highest level of protection under HIPAA and will not be disclosed without your specific written authorization, except as otherwise required by law.

C. HIV/AIDS-Related Information

Florida Statute § 381.004 imposes strict confidentiality requirements on HIV-related information. Disclosure of HIV test results or HIV status requires written informed consent except in limited circumstances specified by Florida law. We comply fully with these requirements.

D. Substance Abuse Treatment Records

If substance abuse treatment records are maintained in connection with your care, those records may be subject to additional federal protections under 42 C.F.R. Part 2, which generally prohibits disclosure without your written consent except in limited circumstances permitted by law.

4. Uses and Disclosures Requiring Your Written Authorization

We will obtain your written authorization before using or disclosing your PHI for purposes not described in this Notice, including:

Marketing communications (any use of PHI to encourage you to purchase a product or service, except face-to-face communications or promotional gifts of nominal value).
Sale of your PHI to any third party.
Disclosure of psychotherapy notes, except as permitted by law.
Disclosure of reproductive health information as described in Section 3(A) above.
Any other use or disclosure not described in this Notice or not otherwise required or permitted by applicable law.

You have the right to revoke any authorization you have given us at any time, in writing. The revocation will not apply to uses or disclosures already made in reliance on your prior authorization.

5. Your Rights Regarding Your PHI

A. Right to Access and Inspect Your Records

You have the right to inspect and obtain a copy of PHI that we maintain in a designated record set, which generally includes your medical and billing records. To request access, please contact our office by phone at 386-755-3300 or visit us in person at 777 W Duval St, Lake City, FL. We may charge a reasonable, cost-based fee as permitted by Florida Statute § 456.057 and applicable HIPAA regulations.

B. Right to Request Amendment

If you believe that PHI we have about you is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances. Any denial will be provided to you in writing with an explanation.

C. Right to an Accounting of Disclosures

You have the right to receive an accounting of certain disclosures of your PHI we have made during the six years prior to the date of your request. This right does not apply to disclosures made for treatment, payment, or healthcare operations, or to disclosures made with your authorization.

D. Right to Request Restrictions

You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or healthcare operations. We are not required to agree to your request except in one circumstance: if you request that we not disclose your PHI to a health plan for payment or healthcare operations purposes, and you have paid for the service in full out of pocket, we must agree to that restriction.

E. Right to Request Confidential Communications

You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. For example, you may request that we contact you only by telephone. We will accommodate reasonable requests.

F. Right to a Paper Copy of This Notice

You have the right to receive a paper copy of this Notice at any time, even if you have agreed to receive it electronically. Please ask at our front desk or call 386-755-3300.

G. Right to Be Notified of a Breach

If there is a breach of your unsecured PHI, we are required by law to notify you of that breach in accordance with HIPAA’s Breach Notification Rule (45 C.F.R. §§ 164.400–414).

6. Privacy Officer and Contact Information

We have designated a Privacy Officer who is responsible for ensuring compliance with this Notice and our privacy practices. If you have questions about this Notice, wish to exercise any of the rights described herein, or wish to file a complaint, please contact our Privacy Officer by phone or in person:

Privacy Officer: Evelyn Jayo

Practice: RDM Magnolia Practice Care

Address: 777 W Duval St, Lake City, FL 32055

Telephone: 386-755-3300

Fax: 386-382-4426

Requests to access or amend your records, and complaints, must be submitted by phone or in person at the address above.

7. Right to File a Complaint

If you believe your privacy rights have been violated, you have the right to file a complaint with us using the contact information above, or with the U.S. Department of Health and Human Services, Office for Civil Rights:

HHS Office for Civil Rights: 200 Independence Avenue, S.W., Washington, D.C. 20201

Toll-Free Hotline: 1-800-368-1019 | TDD: 1-800-537-7697

Website: www.hhs.gov/ocr/privacy

You will not be retaliated against in any way for filing a complaint with us or with the Secretary of HHS. We will not condition treatment, payment, or enrollment on whether you have filed a complaint.

8. Changes to This Notice

We reserve the right to change this Notice and to make the revised Notice effective for PHI we already hold about you as well as any PHI we receive in the future. We will post a copy of the current Notice in our office and make it available upon request. The Effective Date at the top of this Notice indicates when it was last revised.

9. Governing Law

This Notice is governed by the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (45 C.F.R. Parts 160 and 164), as amended, and the laws of the State of Florida, including but not limited to Florida Statute § 456.057 (confidentiality of patient records), Florida Statute § 381.004 (HIV confidentiality), and the Florida Digital Bill of Rights (Fla. Stat. § 501.701 et seq.).

Acknowledgment of Receipt

To obtain or sign an Acknowledgment of Receipt of this Notice, please ask at our front desk during your first visit. A paper copy of this Notice is available at our office upon request.

Note: Patient refusal to sign does not affect the provision of care.