Trinity Medical Associates


HIPPA Notice

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.

If you consent, the office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected Health Information (PHI) is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes are:

  • A nurse obtains information about you and records it in your medical record.
  • During the course of your treatment, the physician determines that he will need to consult with another specialist in the area. He will share the information with such specialist and obtain his or her input.

Examples of use of your health information for payment purposes:

  • We submit requests for payment to your insurance company. The insurance company or business associate helping us obtain payment requests information from us regarding your medical care. We will provide information to them about you and the care that was given.

Example of use of your health information for Healthcare Operations:

  • We may obtain services from business associates such as credentialing, medical review, legal services, and insurance. We will share information about you with such business associates as necessary to obtain these services.

Your Health Information Rights

The health and billing records we maintain are the physical property of the Doctors/Practice. You have the following rights with respect to your Protected Health Information.

  1. Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office.
  2. Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information (“Notice”) by submitting a request at our office.
  3. Right to inspect and copy your health record and billing record. You may exercise this right by submitting a request in writing by using a form that we provide to you upon your request. You have the right to appeal a denial of a request for access to your Protected Health Information except in certain circumstances.
  4. Right to request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request. (The physician or other health care provider is not required to make such amendments); you may file a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.
  5. Right to receive an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form provided by this office upon your request. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you at your request or disclosures made to family members at your request during the course of providing care.
  6. Right to confidential communication by requesting that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office using the form that we provide upon your request.

If you want to exercise any of the above rights, please contact Selena Nicholson, our Privacy Officer at (727)375-2222, in person, or in writing, during normal business hours. She will provide you with assistance on the steps to take to exercise your rights.

You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and healthcare operations purposes.

Our Responsibilities

The office is required to:

  • Maintain the privacy of your health information as required by law
  • Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you
  • Abide by the terms of this notice
  • Notify you if we cannot accommodate a requested restriction or request
  • Accommodate your reasonable requests regarding methods to communicate health information with you
  • Accommodate your request for an accounting of disclosures.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and requesting a copy in person.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Selena Nicholson Privacy Officer at (727)375-2222, or in person during normal business hours.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written request to Ms. Nicholson.

  • We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services as a condition of receiving treatment at this office.
  • We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Following is a List of Other Uses and Disclosures Allowed by the Privacy Rule

Patient Contact:
We may contact you to provide you with appointment reminders, with information about treatment alternatives, or information about health related benefits and services that may be of interest to you.

Notification – Opportunity to Agree or Object:
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, general condition, or death.

Communication with family:
Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person that you identify, health information relevant to that person’s involvement in your care or in payment of such care if you do not object or in an emergency.

Opportunity to object or agree is Not Required

Controlling Disease
As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Child Abuse and Neglect
We may disclose protected health information to public authorities as allowed by law to report child abuse or neglect.

Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs or replacement.

Victims of Abuse, Neglect, or Domestic Violence
We can disclose protected health information to governmental authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment the doctor believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.

Oversight Agencies
Federal law allows us to relate your protected health information to appropriate health oversight agencies or for health oversight activities to include audits, civil, administrative or criminal investigations, inspections, licenses or disciplinary actions, and for similar reasons related to the administration of healthcare.

Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order or administrative tribunal, provided that only the protected health information released is expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process.

Law Enforcement
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, including laws that require reporting certain types of wounds or other physical injury.

Coroners, Medical Examiners, And Funeral Directors
We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Threat to Health and Safety
To avert a serious threat to health and safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution or it’s agents the protected health information necessary for your health and the health and safety of other individuals.

Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Other Uses and Disclosures

  • Other uses and disclosures besides those identified in this notice will be made only as otherwise authorized by law or with your written authorization which you may revoke except to the extent information or action has already been taken.


  • We maintain a website that provides information about our practice. This notice will also be published on that website.


Printable HIPPA Notice