Notice of Privacy Practices

Obtain an electronic or paper copy of your medical record

You may ask to inspect or receive an electronic or paper copy of your medical record and other PHI maintained in Forge’s designated record set. Forge will generally provide access or a copy within 30 days and sooner when Florida law requires. If Forge denies access in a limited circumstance, Forge will explain the denial in writing and tell you whether it may be reviewed.

Florida law requires Forge to furnish copies of reports and records relating to your examination or treatment in a timely manner and without delay for legal review. Forge will not condition furnishing those records on payment of an unpaid fee for medical services. Forge may verify your identity, arrange a secure delivery method, and charge no more than a reasonable, cost-based fee or the amount permitted by the Florida Board of Medicine.

Ask Forge to amend or correct information

You may ask Forge to amend health information that you believe is incorrect or incomplete. You may also ask Forge to correct contact or other identifying information in your record that you believe is inaccurate or incomplete. Ask Forge how to submit the request and the reason for it.

Forge may deny an amendment request in limited circumstances. If Forge does, it will explain the decision in writing within the time required by law—generally 60 days, subject to a permitted extension—and describe any right to submit a statement of disagreement. To preserve the integrity of the record, the original entry may remain and a correction or addendum may be documented when appropriate.

Request confidential communications

You may ask Forge to contact you in a particular way or at a different address or telephone number. Forge will accommodate reasonable requests. Not every communication method is available or equally secure, so Forge may work with you to identify an appropriate method.

Ask Forge to limit uses or disclosures

You may ask Forge not to use or disclose certain PHI for treatment, payment, or health care operations, or not to disclose it to family members or other people involved in your care. Forge is generally not required to agree. If Forge agrees, it will honor the restriction except when the information is needed for emergency treatment or another law permits or requires disclosure.

If you or someone other than a health plan pays in full for a health care item or service, you may ask Forge not to disclose PHI about that item or service to a health plan for payment or health care operations. Forge will agree unless the disclosure is required by law. Forge does not submit claims to health plans for its services.

Receive an accounting of disclosures

You may ask for a list, called an accounting, of certain disclosures of your PHI made during the six years before your request. The accounting generally does not include disclosures for treatment, payment, or health care operations; disclosures to you; disclosures you authorized; and certain other disclosures excluded by law. Forge will provide one accounting in any 12-month period without charge and may charge a reasonable, cost-based fee for another after telling you the cost in advance. Forge also maintains records of third-party disclosures as Florida law requires.

Receive a copy of this Notice

You may ask for a paper copy of this Notice at any time, even if you agreed to receive it electronically. Forge will provide it promptly.

Choose someone to act for you

A person with lawful authority to act as your personal representative may exercise your privacy rights and make choices about your PHI after Forge verifies that authority.

Ask a question or make a complaint

You may contact Forge’s Privacy Officer using the information at the end of this Notice if you have a question or believe your privacy rights were violated.

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by visiting hhs.gov/hipaa/filing-a-complaint, calling 1-877-696-6775, or writing to 200 Independence Avenue, S.W., Washington, D.C. 20201. A complaint concerning a Florida-licensed practitioner may also be submitted through the Florida Department of Health, Division of Medical Quality Assurance, at complaint-portal.mqa.flhealthsource.gov or by calling 850-245-4339. Forge will not retaliate against you for making a good-faith complaint or exercising a privacy right.

Family, friends, caregivers, and disaster relief

You may tell Forge whether it may disclose relevant information to a family member, close friend, caregiver, or another person involved in your care or payment for your care. If you cannot state a preference, Forge may disclose information when professional judgment and applicable law permit it and the disclosure appears to be in your best interest. Forge may also disclose information for disaster-relief notification when permitted by law. Forge does not maintain a facility directory.

Uses and disclosures requiring written authorization

Forge will obtain your written authorization for uses or disclosures not described in this Notice when authorization is required. You may revoke an authorization in writing for future uses or disclosures, except to the extent Forge has already acted in reliance on it or applicable law provides otherwise.

Forge does not sell patient medical information. Forge does not use or disclose patient medical information to market goods or services without your written authorization. Written authorization is also generally required for most uses or disclosures of psychotherapy notes. Forge does not use or disclose PHI for fundraising communications.

The following sections describe the principal ways Forge may use or disclose PHI without a separate written authorization. Every use or disclosure remains subject to applicable conditions and any more protective Florida or federal law. The fact that HIPAA permits a disclosure does not eliminate a stricter Florida requirement.

Treatment and care coordination

Forge may use PHI to evaluate and treat you, communicate about your care, prescribe and monitor medication, order and review laboratory testing, coordinate with a pharmacy, arrange a referral, and communicate with health care practitioners and providers involved in your care. For example, Forge may send a prescription to your chosen pharmacy or share relevant information with a specialist to whom you are referred.

Direct payment

Forge may use PHI to collect patient-authorized payment, document charges, issue receipts or refunds, and coordinate an item or service billed by an outside laboratory, pharmacy, or other provider. Forge does not submit health-insurance claims, verify benefits, or seek prior authorization for Forge services.

Health care operations and service providers

Forge may use PHI to schedule and document care, communicate with patients, assess quality, review professional performance, obtain legal or compliance advice, maintain records, train its workforce, manage licensing and credentialing, prevent fraud or misuse, secure its systems, and conduct other lawful practice operations.

Forge may provide PHI to a records custodian or service provider that performs technology, secure communication, payment, laboratory-coordination, recordkeeping, or other practice-support work for Forge. Forge requires an appropriate business associate agreement whenever HIPAA requires one. Access is limited to the work performed for Forge and is subject to applicable confidentiality, security, contractual, and Florida-law requirements.

Uses and disclosures permitted or required by law

Forge may use or disclose PHI without written authorization only when all applicable legal requirements are met. Depending on the circumstances, this may include:

• public-health activities, including required disease, adverse-event, product-safety, or abuse, neglect, or exploitation reporting;
• health-oversight, licensing, audit, inspection, or professional-disciplinary activities authorized by law;
• a court or administrative order, subpoena, discovery request, or other legal process after applicable notice and procedural requirements are satisfied;
• law-enforcement requests, workers’ compensation matters, and special government functions when authorized by law;
• preventing or reducing a serious and imminent threat to health or safety when disclosure is permitted by law;
• organ and tissue donation requests and disclosures to a coroner, medical examiner, or funeral director when authorized by law;
• research when the information is de-identified as Florida law requires, you provide written permission, or another lawful basis and all applicable conditions are satisfied;
• disclosures to the U.S. Department of Health and Human Services for HIPAA compliance and another disclosure specifically required or permitted by applicable law.

Forge limits uses and disclosures to the minimum information reasonably necessary when that standard applies and maintains a record of disclosures to third parties as required by Florida law.

Florida law generally prohibits furnishing patient records or discussing a patient’s medical condition with anyone other than the patient, the patient’s legal representative, or health care practitioners and providers involved in the patient’s care without written authorization, unless a specific law permits or requires the disclosure. Florida law also prohibits using patient information to solicit or market goods or services without a specific written authorization and restricts further disclosure by a third-party recipient. Forge follows those requirements whenever they are more protective than HIPAA.

Certain mental-health, HIV, genetic, sexual-health, and substance-use information may be protected by laws that are more specific or restrictive. Forge follows those requirements when they apply, including restrictions on redisclosure that accompany records received from another source.

Substance-use-disorder records subject to 42 C.F.R. Part 2

To the extent Forge maintains substance-use-disorder patient records subject to 42 C.F.R. Part 2, Forge will not use or disclose those records in a civil, criminal, administrative, or legislative investigation or proceeding against you without your written consent or a qualifying court order and subpoena. Forge will obtain separate written permission when Part 2 requires it, including for protected substance-use-disorder counseling notes. Forge does not use Part 2 records for fundraising communications.

Forge is required by applicable law to maintain the privacy and security of your PHI, provide this Notice of its legal duties and privacy practices, and notify you following a breach of unsecured PHI when notice is required. Forge uses reasonable and appropriate administrative, technical, and physical safeguards; trains workforce members as required; and requires appropriate confidentiality and security obligations from service providers. No storage system or electronic transmission can be guaranteed to be completely secure.

Forge must follow the duties and privacy practices described in the current version of this Notice. Forge will not use or disclose your PHI other than as described here unless you authorize it in writing or applicable law permits or requires it. Forge retains medical records for the periods required by law and as reasonably necessary for clinical, legal, and operational purposes.

Forge may change the terms of this Notice and apply the revised terms to PHI that Forge already maintains as well as information received or created in the future. The current Notice will be available on Forge’s website and by request. The effective date above identifies the current version.

Contact the Privacy Officer below. Do not send medical information by ordinary email; established patients should use Spruce. Forge may require identity verification and a secure process for records or privacy requests:

Privacy Officer
Forge Men’s Health PLLC
Email: info@forgemh.com