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Notice of Privacy Practices


Cancer Foundation of the Florida Keys


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.

Personally identifiable information about your health, your health care, and your payment for health care is called Protected Health Information.  We must safeguard your Protected Health Information and give you this Notice about our privacy practices that explains how, when and why we may use or disclose your Protected Health Information.  Except in the situations set out in the Notice, we must use or disclose only the minimum necessary Protected Health Information to carry out the use or disclosure. 

We must follow the practices described in this Notice, but we can change our privacy practices and the terms of this Notice at any time.

If we revise the Notice, you may read the new version of the Notice of Privacy Practices on our website at [insert web address of Covered Department].  You also may ask for a copy of the Notice by calling us at [insert phone number of Covered Department] and asking us to mail you a copy or by asking for a copy at your next appointment.

Uses and Disclosures of Your Protected Health Information That Do Not Require Your Consent

We may use and disclose your Protected Health Information as follows without your permission:


Uses and Disclosures of Your Protected Health Information That Offer You an Opportunity to Object

In the following situations, we may disclose some of your Protected Health Information if we first inform you about the disclosure and you do not object:


Uses and Disclosures of Your Protected Health Information That Require Your Consent


The following uses and disclosures of your Protected Health Information will be made only with your written permission, which you may withdraw at any time:


Your Rights Regarding Your Protected Health Information

You have the following rights related to your Protected Health Information:



If you have any questions about these rights, please contact us.


How to Complain about Our Privacy Practices

If you think we may have violated your privacy rights, or if you disagree with a decision we made about your Protected Health Information, you may file a complaint with our Privacy Officer by writing to [contact information].

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services by writing to 200 Independence Avenue SW, Washington, D.C. 20201 or by calling 1-877-696-6775.

We will take no action against you if you make a complaint to either or both of these persons.


How to Receive More Information About our Privacy Practices

If you have questions about this Notice or about our privacy practices, please contact our Privacy Officer, [contact information for Privacy Officer of Covered Department].


This Notice is Effective on 
(Enter Today's Date):


We are required by law to maintain the privacy of and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information.  If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.


This signature is only an acknowledgment that you have received this notice of our Privacy Practices.

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