Orange Park Neurosurgery, P.L.
NOTICE OF PRIVACY PRACTICES
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS
PRACTICE ) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR
INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your individually identifiable health information
(IIHI). In conducting our business, we will create records regarding you and the treatment and
services we provide to you. We are required by law to maintain the confidentiality of health
information that identifies you. We also are required by law to provide you with this notice of our
legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By
federal and state law, we must follow the terms of the notice of privacy practices that we have in
effect at the time.
We realize that these laws are complicated, but we must provide you with the following important
information:
• How we may use and disclose your IIHI
• Your privacy rights in your IIHI
• Our obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your IIHI that are created or retained by our
practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or
amendment to this notice will be effective for all of your records that our practice has created or
maintained in the past, and for any of your records that we may create or maintain in the future. Our
practice will post a copy of our current Notice in our offices in a visible location at all times, and you
may request a copy of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
[insert name, or title, address and telephone number of a person or office to contact for further
information.]
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
(IIHI) IN THE FOLLOWING WAYS
The following categories describe the different ways in which we may use and disclose your IIHI.
1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have
laboratory tests (such as blood or urine tests), and we may use the results to help us reach a
diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your
IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our
practice – including, but not limited to, our doctors and nurses – may use or disclose your IIHI in
order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to
others who may assist in your care, such as your spouse, children or parents.
Finally, we may also disclose your IIHI to other health care providers for purposes related to your
treatment.
2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the
services and items you may receive from us. For example, we may contact your health insurer to
certify that you are eligible for benefits (and for what range of benefits), and we may provide your
insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your
treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be
responsible for such costs, such as family members. Also, we may use your IIHI to bill you directly
for services and items. We may disclose your IIHI to other health care providers and entities to
assist in their billing and collection efforts.
3. Health Care Operations. Our practice may use and disclose your IIHI to operate our business.
As examples of the ways in which we may use and disclose your information for our operations, our
practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-
management and business planning activities for our practice. We may disclose your IIHI to other
health care providers and entities to assist in their health care operations.
OPTIONAL:
4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind
you of an appointment.
OPTIONAL:
5. Treatment Options. Our practice may use and disclose your IIHI to inform you of potential
treatment options or alternatives.
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS
PRACTICE ) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR
INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your individually identifiable health information
(IIHI). In conducting our business, we will create records regarding you and the treatment and
services we provide to you. We are required by law to maintain the confidentiality of health
information that identifies you. We also are required by law to provide you with this notice of our
legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By
federal and state law, we must follow the terms of the notice of privacy practices that we have in
effect at the time.
We realize that these laws are complicated, but we must provide you with the following important
information:
• How we may use and disclose your IIHI
• Your privacy rights in your IIHI
• Our obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your IIHI that are created or retained by our
practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or
amendment to this notice will be effective for all of your records that our practice has created or
maintained in the past, and for any of your records that we may create or maintain in the future. Our
practice will post a copy of our current Notice in our offices in a visible location at all times, and you
may request a copy of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
[insert name, or title, address and telephone number of a person or office to contact for further
information.]
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
(IIHI) IN THE FOLLOWING WAYS
The following categories describe the different ways in which we may use and disclose your IIHI.
1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have
laboratory tests (such as blood or urine tests), and we may use the results to help us reach a
diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your
IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our
practice – including, but not limited to, our doctors and nurses – may use or disclose your IIHI in
order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to
others who may assist in your care, such as your spouse, children or parents.
Finally, we may also disclose your IIHI to other health care providers for purposes related to your
treatment.
2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the
services and items you may receive from us. For example, we may contact your health insurer to
certify that you are eligible for benefits (and for what range of benefits), and we may provide your
insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your
treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be
responsible for such costs, such as family members. Also, we may use your IIHI to bill you directly
for services and items. We may disclose your IIHI to other health care providers and entities to
assist in their billing and collection efforts.
3. Health Care Operations. Our practice may use and disclose your IIHI to operate our business.
As examples of the ways in which we may use and disclose your information for our operations, our
practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-
management and business planning activities for our practice. We may disclose your IIHI to other
health care providers and entities to assist in their health care operations.
OPTIONAL:
4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind
you of an appointment.
OPTIONAL:
5. Treatment Options. Our practice may use and disclose your IIHI to inform you of potential
treatment options or alternatives.
Billing Process
Dear Valued Patient:
Thank you for choosing Dr. Mark Spatola for your neurosurgical needs. The purpose of this letter is
to give you information about our billing process.
This is how our billing process usually works: A claim will be sent to your insurance company. After
your insurance company receives a claim, the insurance company may contact you for additional
information. Please respond to your insurance company’s questions as quickly as possible so
their payment is not delayed. It usually takes 30 – 45 days for your insurance company to pay your
claim. After your insurance company pays us, we will provide you with information about any
amount you may owe. Please keep in mind that your policy is a contract between you and your
insurance company. If you did not follow your insurance plan’s terms, they may not pay for all or part
of your care.
In the event Dr. Spatola orders testing on you, or performs surgery, you will receive bills from
physicians and/or other healthcare providers for services or tests that they provided. Those bills are
separate and apart from Dr. Spatola’s bill. If you have questions about those bills, please call the
number printed on their statements.
We are pleased to help you with your questions or to provide more information about our
procedures and charges. We can be reached at (904) 276-3376.
Thank you again for choosing Dr. Spatola for your neurosurgical needs.
Dear Valued Patient:
Thank you for choosing Dr. Mark Spatola for your neurosurgical needs. The purpose of this letter is
to give you information about our billing process.
This is how our billing process usually works: A claim will be sent to your insurance company. After
your insurance company receives a claim, the insurance company may contact you for additional
information. Please respond to your insurance company’s questions as quickly as possible so
their payment is not delayed. It usually takes 30 – 45 days for your insurance company to pay your
claim. After your insurance company pays us, we will provide you with information about any
amount you may owe. Please keep in mind that your policy is a contract between you and your
insurance company. If you did not follow your insurance plan’s terms, they may not pay for all or part
of your care.
In the event Dr. Spatola orders testing on you, or performs surgery, you will receive bills from
physicians and/or other healthcare providers for services or tests that they provided. Those bills are
separate and apart from Dr. Spatola’s bill. If you have questions about those bills, please call the
number printed on their statements.
We are pleased to help you with your questions or to provide more information about our
procedures and charges. We can be reached at (904) 276-3376.
Thank you again for choosing Dr. Spatola for your neurosurgical needs.
Appointments
Hours/referral
Our office is open Monday through Friday 9:00 am to 4:00 pm with referral by a
physician being necessary.
What to Bring
New patients should arrive at the office at least 15 minutes prior to their
appointment in order to complete New Patient History and Registration forms.
To minimize delays, these forms can be downloaded directly and completed
prior to your appointment. Also, make sure you have the following available:
Cancellations
Please call us at least 24 hours in advance if you need to reschedule or cancel
your appointment; this will allow another patient to see us in a timely fashion.
Hours/referral
Our office is open Monday through Friday 9:00 am to 4:00 pm with referral by a
physician being necessary.
What to Bring
New patients should arrive at the office at least 15 minutes prior to their
appointment in order to complete New Patient History and Registration forms.
To minimize delays, these forms can be downloaded directly and completed
prior to your appointment. Also, make sure you have the following available:
- MRI/CT films or X-rays
- Insurance card
- Photo ID
- Co-pay as expected (Please review your insurance policy)
Cancellations
Please call us at least 24 hours in advance if you need to reschedule or cancel
your appointment; this will allow another patient to see us in a timely fashion.
New Patient History Form
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