Ponte Vedra Vein Institute’s Privacy Policy is below. Questions concerning this policy may be submitted to info@pontevedavein.com.

Privacy Policy

Notice of Privacy Practices

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. The 

privacy of your health information is important to us.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to provide treatment, obtain payment, and conduct 

health care operations and for other purposes permitted or required by law. It also describes your rights concerning your PHI. “Protected health information” is 

information about you, including demographic information that may identify you and that relates to your past, present, or future physical or mental health or 

condition and related health care services.

We are required by law to follow the practices described in this notice. We may change the terms of this notice at any time. The new notice will be effective for all 

PHI we maintain at that time, including health information we created or received before we made changes.

Uses and Disclosures of Protected Health Information

Treatment: We will use and disclose your PHI to provide, coordinate, and manage health care and related services for you. For example, we will disclose information 

to a specialist to whom you have been referred to ensure the provider has enough information to diagnose and/or treat you. We may also disclose information to a 

laboratory that, at our request, becomes involved in your treatment.

Payment: We may use and disclose your information to obtain payment for services we provided to you. For example, we will send the necessary information to 

your health insurance company for the treatment provided. 

Healthcare Operations: We will use and disclose your health information to conduct the business activities of this office. These activities include, but are not limited 

to, quality assessment and improvement activities, review of the performance and qualifications of employees, evaluating practitioner or provider performance, 

conducting training programs, accreditation, certification, licensing, or credentialing activities. We may use a sign-in sheet at the registration desk where you will be 

asked to sign your name. We may also call you by name in the waiting room when we are ready to begin your treatment. 

We will share your PHI with business associates that perform specific functions for our practice, such as billing. When a business arrangement of this type requires the 

use of your information, we will have a written contract with the third party to protect the privacy of your PHI.

Others Involved in Your Health Care: We must disclose your health information to you as described in the Patient Rights sections of this notice. We may disclose your 

health information to a family member or other person to the extent necessary to help with your health care or with payment for your health care, but only if you 

agree. If we determine it is in your best interest based on our professional judgment or experience with common practices, we may allow another person to pick up 

filler prescriptions, medical supplies, x-rays or other forms of health information.

We may use or disclose PHI to notify or assist in notifying a family member, a professional representative or any other person responsible for your care of your 

location, your general condition, or death. If you are present prior to the use or disclosure of your PHI, we will provide you with the opportunity to object to such uses 

or disclosures. Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and 

disclosures to family members or others involved in your health care.

Emergencies: In the event of your incapacity or in emergency circumstances, we may use or disclose your PHI to treat you. 

Uses and Disclosures of PHI Bases Upon Your Written Authorization: Other uses and disclosures of your PHI will be made only with your written authorization, 

unless otherwise permitted or required by law as described below. You may revoke this authorization at any time, in writing, except to the extent that an action has 

already been taken in reliance on the authorization.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object: We may use or disclose 

your PHI in the following situations without your consent or authorization. These situations include:

Required by Law: We may use or disclose your PHI to the extent that law requires the use or disclosure.

We must make disclosures to you and, when required, to the Secretary of the Department of Health and Human Services to investigate or determine our compliance 

with the requirements of the Privacy Rule, Section 164.500 et. Seq.

Public Health: We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the 

information. The disclose will be made for the purpose of controlling disease, injury or disability. Additionally, we may disclose your PHI, if authorized by law, to a 

person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

We may disclose PHI to a health oversight agency for activities authorized by law, such as adults, and inspections. Oversight agencies seeking this information include

government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may 

disclose your PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such 

information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Legal Proceedings: We may disclose PHI during any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent 

such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose PHI, if applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1)

legal processes and otherwise required by law, (2) limited information requested for identification and location purposes, (3) pertaining to victims of a crime, (4) 

medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.

Military Activity and National Security: When the appropriate conditions apply, we may disclose, to military authorities, PHI of individuals who are Armed Forces 

personnel. We may also disclose your PHI to authorized federal officials for conduction national security and intelligence activities, including for the provision of 

protective services to the President or others legally authorized.

Worker’s Compensation: We may disclose your PHI as authorized to comply with workers’ compensation laws and other similar legally established programs.

Inmates: We may use or disclose your PHI if you are an inmate of a correctional facility and your physician created or received your PHI in the course of providing 

care to you.

Your Rights

Your rights with respect to your PHI and how you may exercise those rights are outlined below.

You have the right to obtain a copy and/or inspect your health information. Health information includes treatment records, billing records and any other records 

used by us to make decisions about your treatment. You may obtain a form from our office to request access. A reasonable cost-based fee will be charged for 

expenses such as staff time, copies, and postage. Contact us an indicated at the end of this Notice to obtain information about our fees or if you have any questions 

about your access.

You have the right to request a restriction on the use and disclosure of your PHI. You may ask us not to use or disclose some part of your PHI for the purposes of 

treatment, payment or operations. You may also request that we not disclose some part of your information to family and others who may be involved in your care 

or for notification purposes as otherwise described in this Notice. We are not required to agree to the restrictions but if we do, we are obligated to abide by the 

agreement except in cases of emergency. You may request a restriction by sending your request in writing to our Privacy Contact.

You have the right to request confidential communications by alternative means or at an alternative location. We will accommodate reasonable requests. We may 

also condition this accommodation by asking you for your information as to how payment will be handled or specification of an alternative address or other method 

of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.

You may have the right to request an amendment to your PHI. You may request that we amend PHI about you. Your request must be in writing with an explanation 

as to why the information should be amended. In certain cases, we may deny your request for amendment; you have the right to file a statement of disagreement 

with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. This right applies to disclosures made by our Business 

Associates or us.

It excludes disclosures for treatment, payment or healthcare operations as described in this Notice of Privacy Practices, to you, to family members or friends involved 

in your care, for notification purposes or because of any authorization signed by you. You can the right to receive specific information regarding these disclosures that 

occurred after April 14, 2003, for up to the previous 6 years. You may request a shorter timeframe. The right to receive this information is subject to certain 

exceptions, restrictions and limitations. If you request an accounting more than once in a 12-month period, we will charge you a reasonable cost-based fee for 

responding to the additional request.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

No mobile information or personally identifiable information will be shared with third parties/affiliates for marketing/promotional purposes.

Questions and Complaints

If you have any questions, concerns or want more information about our privacy practices, please contact us using the information below.

If you are concerned that we may have violated your privacy rights or disagree with a decision we have made regarding your access to your health information or any 

other request you have made in the exercise of your rights, you may send your complaint to us using the information below. You may also submit a written complaint 

to the Secretary of Health and Human Services. Contact us for the address of the Department of Health and Human Services.

We support your right to the privacy of your health information, and we will not retaliate against you in any way for filing a complaint.

Contact our office:

Contact office or official: Ponte Vedra Vein Institute

Phone: 904-280-0600 Fax: 904-280-0601 Email: info@pontevedravein.com

Address: 330 A1A N, STE 321, Ponte Vedra Beach, FL 32082

7741 Point Meadows Drive, STE 104, Jacksonville, FL 32256

This notice was published and becomes effective on March 1, 2015