Gessler Clinic, P.A.
Notice of Privacy Practices
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Effective on September 23, 2013

If you have any questions about this Notice, please contact Our Privacy Officer at 863-294-0670.
635 First Street North, Winter Haven, FL 33881


This Notice explains our privacy practices. It describes how Gessler Clinic, P.A. may use and disclose your health information. It will explain:

✷ How Your Health Information Will Be Used and Disclosed
✷ Your Rights Related to Your Health Information
✷ How to Complain if You Believe Your Rights Have Been Violated

In this Notice, Gessler Clinic, P.A. may be referred to as “we,” “our,” or “us.” We will protect your health information. Health information is information about you that may identify you and medical information such as your symptoms, test results, diagnoses, treatment, and plans of care.

We are required by law to maintain the privacy of your health information, to provide you this Notice about our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We are required to abide by the terms of this Notice. However, we may change our Notice at any time. Any new notice will be effective for all health information maintained at the time of the change. Upon your request, we will provide you with a copy of any new notice and we will distribute the notice to our new patients. On or before its effective date, the new notice will also be posted at our business locations and on our website.


Your health information may be used and disclosed by your doctor, our support staff and others who are involved in your care. Your health information may be used and disclosed for a number of reasons. This Notice explains those reasons and gives some examples of the types of uses and disclosures. The examples are not meant as a total list, and they do not explain all of the ways we might use and/ or disclose information. As required by Florida law, we will obtain your consent for disclosures for payment, health care operations, disclosure of certain highly sensitive information, or other disclosures explained on this Notice where state law requires special permission for the disclosure.

Treatment: We will use and disclose your health information to provide and coordinate your healthcare and any related services you may require. This includes the coordination and management of your care with a third party such as a hospital or home health agency. We will also disclose health information to other doctors and their staff who may be caring for you. We may disclose your health information to a referring doctor or laboratory who may be involved in your care to assist your doctor with your diagnosis or treatment. We may exchange your protected health information electronically for treatment and other permissible purposes.

Payment: Your health information will be used, as needed, to obtain payment for the healthcare services you receive. This may include certain activities that your health insurance plan requires before it will approve or pay for services that we recommend, such as approving a hospital admission or certain medical equipment, like a wheelchair.

Healthcare Operations: We may use or disclose health information, as needed, to support our business activities as they relate to your health care. These activities may include, but are not limited to, quality assessment, employee and physician review, training students.

For example, we may disclose your health information to healthcare students working with patients within our offices. We may use a sign-in sheet at the registration desk, asking you to provide us with your name and the name of your doctor. We may call you by name when your doctor is ready to see you. We may also use or disclose your health information to remind you of an upcoming appointment. We may disclose medical information to our attorneys as necessary to conduct or arrange for legal services.

We may share your health information with third parties who provide services or functions that are essential to our business. These third parties are called “business associates,” and they may include, for example, billing agents, attorneys providing legal services to us, accountants, consultants, or transcription services. We may share your protected health information with our business associates and may allow our business associates to create, receive, maintain, or transmit your protected health information on our behalf, in order for the business associate to provide services to us, for the proper management and administration of the business associate. Additionally, our business associate may re-disclose your protected health information to business associates that are subcontractors in order for the subcontractors to provide services to the business associate. The subcontractors will be subject to the same restrictions and conditions that apply to the business associates. Whenever such an arrangement involves the use or disclosure of your protected health information, we will have a written contract with the business associate that contains terms designed to protect the privacy of your protected health information.

We may use or disclose your health information, as necessary, to provide you with information about treatment alternatives or other benefits that may be of interest to you.


To You and Others Involved in Your Health Care: We will disclose your health information to you or someone who has the legal right to act on your behalf (your personal representative). We may disclose your information to a family member, a close friend, or any other person you identify if you direct us to do so or if we exercise professional judgment and determine that they are involved in your care or payment for your treatment. This may include telling a family member about your location, general condition, or death. In the event of a disaster, we may provide information about you to a disaster relief organization so they can notify your family of your condition and location. We will not disclose this information to family or friends if we know that you object. If you are not present or able to object, then your doctor may use his or her professional judgment to decide whether the disclosure is in your best interest.

Emergencies: We may use or disclose your health information in an emergency situation. If this happens, your doctor will try to obtain your consent as soon as reasonably possible after the delivery of treatment. If your doctor or another doctor is required by law to treat you and the doctor was unable to get your consent, he or she may still use or disclose your health information to treat you.

Required by Law: We may use or disclose your health information to the extent that the disclosure is required by law. The use or disclosure will be made and limited in accordance with the law.

Public Health: We may disclose your health information to a public health authority that is permitted by law to collect or receive the information. This may include disclosures made for the purpose of controlling disease, injury, or disability. If permitted by law, we may also disclose your health information to any person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose your health information to a public health agency that monitors the healthcare system, such as for audits, investigations, and inspections.

Abuse or Neglect: We may disclose your health information when it is related to child abuse, neglect, or domestic violence. We will make this disclosure only in accordance with laws that require or allow such reporting, or with your permission.

Food and Drug Administration: We may disclose your health information to a company required by the Food and Drug Administration to report adverse events, to report product problems, or to track product recalls.

Legal Proceedings: We will make disclosures required by court orders, certain subpoenas, or other judicial or administrative processes.

Law Enforcement: We may disclose health information for law enforcement purposes, such as locating a suspect, fugitive, or missing person. We may also make disclosures in connection with suspected criminal activity and to federal agencies investigating our compliance with the federal privacy rules.

Coroners, Funeral Directors, and Organ Donation: We may disclose health information to a coroner or medical examiner for identification purposes or other duties as authorized by law. Health information may also be used and disclosed for organ, eye, or tissue donation purposes.

Research: We may disclose your health information to researchers when their research has been approved by an institutional review board that has reviewed the research purposes and established protocols to ensure the privacy of your information, or as otherwise permitted by state and federal law.

Military and National Security: We may disclose the health information of armed forces personnel if authorized by military command authorities or for the purpose of determination of veterans’ benefits. We may also disclose your health information to authorized federal officers for conducting national security and intelligence activities, including the provision of protective services to the President or others legally authorized to receive such government protection.

Workers’ Compensation: We may disclose your health information as permitted by workers’ compensation and similar laws.

Inmates: We may use or disclose your health information if you are an inmate of a government facility and your doctor created or received such information in the course of providing care to you.

To Avert a Serious Threat to Health and Safety: We may disclose your health information with some limitations, when necessary to prevent a serious threat to your health and safety or to the health and safety of the public or another person.

Limited Data Set and De-identified Information: We may use or disclose your health information to create a limited data set or de-identified information, and use and disclose such information as permitted by law.


The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes; (ii) uses and disclosures of protected health information for marketing purposes, including subsidized treatment communications (except for certain activities otherwise permitted by federal privacy law, such as face-to-face communications or promotional gifts of nominal value); (iii) disclosures that constitute the sale of protected health information that requires your authorization; and (iv) other uses and disclosures of your health information not described in this Notice. You may give, amend, or revoke your authorization at any time, in writing. You may not revoke to the extent that we have already taken action in reliance on it. For more information about authorizations, please talk to your doctor or contact the Privacy Officer. Unless otherwise permitted by law or by your written authorization, we will not directly or indirectly receive remuneration in exchange for your health information. When using or disclosing your health information or requesting it from another covered entity, we will make reasonable efforts to limit such use, disclosure, or request, to the extent practicable, to the minimum necessary to accomplish the intended purpose of such use, disclosure, or request.


Below are statements of your rights with respect to your health information and a description of how you may exercise these rights.

You have the right to inspect and obtain a copy of your health information. This means that you may inspect and obtain a copy of part or all of your health information that is contained in a designated record set for as long as we maintain that information. A “designated record set” contains medical and billing records. We will provide you with a copy of your protected health information in the form and format requested, if it is readily producible in such form and format, or if not, in a readable hard copy or electronic form or such other form and format as agreed to by Gessler Clinic, P.A. and you. You may request that we transmit the copy of your protected health information directly to another person, provided your request is in writing, signed by you, and you clearly identify the designated person and where to send the copy of the protected health information.

Under federal law, you may not have the right to inspect a copy the following records: (i) psychotherapy notes; (ii) information compiled for use in a civil, criminal, or administrative action or proceeding, and (iii) health information that is restricted by another law.

You may submit your written request to inspect or request a copy of particular information to our Medical Record Department.

If your written request is accepted, you may be charged a reasonable, cost-based fee. If your written request is denied, you have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about inspecting or obtaining a copy of your information.

You have the right to request a restriction on the release of your health information. You may ask us not to disclose part of your health information for the purposes of treatment, payment, or healthcare operations. You may also ask us not to disclose any part of your health information to family members or friends who may be involved in your care and who may ask for the information for notification purposes.

We are not required to agree to a restriction that you may request in all circumstances. We are required to agree to a request to restrict the disclosure of your health information to a health plan if you submit the request to us and: (A) the disclosure is for purposes of carrying out payment or health care operations and is not otherwise required by law; and (B) the health information pertains solely to a health care item or service for which you, or a person on your behalf other than the health plan, has paid the covered entity out of pocket in full. If we agree to a request, we will comply with the restriction unless your information is needed for emergency treatment. We cannot agree to restrict disclosures that are required by law. We encourage you to discuss requests for restrictions with your doctor.

You may request to restrict or revoke disclosure of PHI by signing a “Friends and Family” form from the Administrative Office. You must complete, sign and date the form. Your request must state who the restriction will apply to and it must specify the restriction requested.

You can ask us to communicate with you by an alternate means or at an alternate location. We will agree to all reasonable requests. We may evaluate the reasonableness of your request by asking you for information about payments, alternative addresses, or other methods of contacting you. We may condition your request. Please make this request in writing to our Privacy Officer at the address on the front of this Notice.

You have the right to request that your doctor amend your health information. You may request an amendment of your health information in a designated record set if you believe it is incorrect or incomplete. All requests must be in writing. In certain cases, we may deny your request for an amendment. For example, we may deny your request if we did not create the information, if the information is something you would not be permitted to inspect or request a copy of, or if it is complete and accurate. If we deny your request, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement. Please contact the Privacy Officer if you have any questions about amending your information.

You have the right to receive an accounting or list of certain disclosures we have made. You have the right to receive information about disclosures that occurred during the past six years (three years for disclosures from an electronic health record relating to treatment, payment, or health care operations, as described below). You must request this information in writing. Your request should state a time frame for the disclosures. Your right to receive this information may be subject to certain exceptions, restrictions, and limitations. For example, although we do maintain a record of all disclosures as required by Florida law, the federal privacy standards do not require accounting for disclosures for certain purposes, including treatment, payment, or health care operations. Depending on the compliance date required by law for a particular record, an accounting of the disclosures from an electronic health record will include disclosures for treatment, payment or health care operations.

The first list you request within a 12-month period will be complimentary. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

You have the right to receive written notification of a breach. You have the right to receive written notification of a breach where your unsecured health information has been accessed, acquired, used, or disclosed to an unauthorized person as a result of such breach in a manner that compromises the security or privacy of the PHI. Unless specified by you to receive the notification by electronic mail, we will provide such written notification by first-class mail or, if necessary, by such other substituted forms of communication allowable under the law.

You have the right to obtain a copy of this Notice. You have the right to request and receive a copy of this Notice at any time. Upon request, we will send you a paper copy of this Notice even if you have agreed to accept this Notice electronically.


We encourage you to send any complaints about our privacy practices to our Privacy Officer. To submit a complaint or for further information about the complaint process, contact the Privacy Officer using the information found on the front of this Notice.
We will not retaliate against you for filing a complaint.

You may also complain to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us.