Privacy Policy

/Privacy Policy
Privacy Policy 2018-02-28T12:07:57+00:00

HIPAA Acknowledgement

Alternative Communications Request:

Protected Health Information Restriction:

Other than you or your insurance company, whom may we talk to about your health care information?

Privacy Notice Acknowledgement:

The patient identified above was provided with a copy of Surgery Center of Southwest Florida’s Privacy Notice and Summary Form.

  • I acknowledge that I have been given the opportunity to request alternative means of communication of my protected health information.
  • I acknowledge that I have been given the opportunity to request restrictions on use and/or disclosure of my protected health information. I also understand that my protected health information may still be used contrary to my request in the event of an emergency.
  • I acknowledge that I have received a copy of the Privacy Notice for Surgery Center of Southwest Florida Privacy Notice Revision Date:July 1, 2014

Privacy Notice – Summary


2. How we may use and disclose your health information. We use health information about you for your treatment, to get paid for treatment, for administrative purposes, and to evaluate the quality of care that you receive. For example, your health information may be shared with other providers to whom you are referred. Information may be shared by paper, mail, electronic mail, fax, or other methods. We may use or disclose your health information without your written authorization for several reasons. But beyond those situations, we will ask for your written authorization before using or disclosing your health information. If you sign any authorization to disclose information, you can later revoke it to stop any further uses or disclosures.

3. Your rights. In most cases, you have the right to look at or get a copy of your health information that we use to make decisions about you. If you request copies, we may charge you a cost-based fee. You also have the right to request a list of certain types of disclosures of your information that we have made. If you believe your health information is incorrect or information is missing, you have the right to request that we correct the existing information or add the missing information.

4. Our legal duty. We are required by law to protect the privacy of your health information, provide this notice about our privacy practices, follow the privacy practices that are described in this notice, and seek your acknowledgement of receipt of this notice. We may change our privacy polices any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time. For more information on our privacy policies, contact the person listed

5. Privacy Complaints. If you are concerned that we have violated your privacy rights, our privacy policies, or if you disagree with a decision we made about access to your health information, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide
you with the appropriate address on request.

If you have any questions or complaints, please contact:
Privacy Officer/Contact
12631 Whitehall Drive
Fort Myers, Florida 33907

Phone Number (239) 337-787