HIPAA – Patient Consent for Use or Disclosure of Protected Health Information (PHI) — Acknowledgment of Receipt of Notice of Privacy Practices.
I acknowledge that I have been provided with ROJO BEST IV THERAPY L.L.C.'s "Notice of Privacy Practices," and I am giving my consent for the use and disclosure of Protected Health Information as required and/or permitted by law.
Effective Date: 02/16/2026 · Publication Date: 02/16/2026
This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully.
Protected health information (PHI) about you is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (name, address, phone, etc.), that may identify you and relate to your past, present or future physical or mental health condition and related healthcare services.
Our practice is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations, and for other purposes that are permitted or required by law.
Your Rights Under the Privacy Rule
Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff.
Right to a copy of this Notice
You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices. We are required to follow the terms of this notice. We reserve the right to change the terms of our notice at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and ask that a revised copy be sent to you in the mail or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous location within the practice and on our website.
Right to authorize other use and disclosure
You have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI. You may revoke an authorization at any time, in writing, except to the extent that your healthcare provider or our practice has taken action in reliance on the use or disclosure indicated in the authorization.
Right to request alternative confidential communication
You have the right to ask us to contact you about medical matters using an alternative method (e.g., email, telephone), and to a destination (e.g., cell phone number, alternative address) designated by you. You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/phone number we have on file. We will follow all reasonable requests.
Right to inspect and copy your PHI
You may inspect and obtain a copy of your complete health record. If your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state, or federal guidelines.
Right to request a restriction of your PHI
You may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.
Right to request an amendment to your PHI
You may request an amendment of your PHI for as long as we maintain this information. In certain cases, we may deny your request.
Right to request a disclosure accountability
You may request a listing of disclosures that we have made of your PHI to entities or persons outside of our office.
Right to receive a privacy breach notice
You have the right to receive written notification if the practice discovers a breach of your unsecured PHI and determines through a risk assessment that notification is required.
If you have questions regarding your privacy rights, please feel free to contact our Privacy Manager. Contact information is provided below under Privacy Complaints.
How We May Use or Disclose Protected Health Information
Following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe possible types of uses and disclosures.
Treatment
We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example, we would disclose your PHI as necessary to a pharmacy that would fill your prescriptions. We will also disclose PHI to other healthcare providers who may be involved in your care and treatment.
Special Notices
We may use or disclose your PHI as necessary to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health-related benefits and services offered by our office, for fund-raising activities, or with respect to a group health plan, to disclose information to the health plan sponsor. You have the right to opt out of such special notices, and each such notice will include instructions for opting out.
Payment
Your PHI will be used as needed to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits.
Healthcare Operations
We may use or disclose, as needed, your PHI in order to support the business activities of our practice. This includes, but is not limited to, business planning and development, quality assessment and improvement, medical review, legal services, auditing functions, and patient safety activities.
Health Information Organization
The practice may elect to use a health information organization, or other such organization, to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.
To Others Involved in Your Healthcare
Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person that you identify, your PHI that directly relates to that person's involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of the PHI, then your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed.
Other Permitted and Required Uses and Disclosures
We are also permitted to use or disclose your PHI without your written authorization for the following purposes: as required by law; for public health activities; health oversight activities; in cases of abuse or neglect; to comply with Food and Drug Administration requirements; research purposes; legal proceedings; law enforcement purposes; coroners; funeral directors; organ donation; criminal activity; military activity; national security; worker's compensation; when an inmate in a correctional facility; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.
Substance Use Disorder Records (42 CFR Part 2)
Records relating to substance use disorder treatment are protected under federal law (42 CFR Part 2). These records may not be used or disclosed without your specific written consent except as expressly permitted by law. Such records cannot be used in civil, criminal, administrative, or legislative proceedings without a valid court order.
Privacy Complaints
You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services, if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Privacy Manager at the address below. We will not retaliate against you for filing a complaint.
Rojo Best IV Therapy L.L.C.
3301 North University Dr, No. 100 #1135
Coral Springs, FL 33065