Privacy Policy

During your Service at FourSquare we may gather information about your medical history and your current health. This notice explains how that information may be used and shared with others. It also explains your privacy rights regarding this kind of information. The terms of this notice apply to health information created or received by FourSquare.

1. When We May Use and Disclose Your Medical Information with Your Written Authorization

With your authorization – For any purpose other than the ones described below, we may use or disclose your health information only when you have given us your written authorization.

Marketing – We will obtain your written authorization before using your health information to send marketing materials.

Highly confidential information – There are additional protections for certain confidential health information. For example: psychotherapy notes, diagnosis, prognosis or treatment for alcohol or drug dependency, HIV testing or results, may require a special authorization.

Selling your information – We will not sell your medical information without your written authorization.

1. When We May Use And Disclose Your Medical Information Without Your Written Authorization

Payment – We may use or disclose your information to obtain payment for services provided to you.

Treatment – We may disclose your information to another health care provider so they can treat you; to provide appointment reminders; or to provide information about treatment alternatives.

Health care operations – This includes using your information for certain activities that are necessary to operate the practice and ensure that patients receive quality care. For example, we may use your information to review the performance of staff.

Reminders – To remind you of appointments or other information about new or alternative treatments or other health care services for the purposes of care coordination.

As required by law – We will disclose your medical information if we are required to do so by federal, state, or local law.

Business Associates – We may disclose information about you to our business associates so they can perform the services that we have contracted them to do for us. For example we may disclose your information to attorneys, collection and accreditation organizations.

Public health activities – We may use and disclose your medical information when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person.

Research – We may use and disclose your medical information for research purposes either with your specific, written authorization or if the research has been approved and reviewed for privacy by our Institutional Review Board. Researchers may review your health information in a limited manner to determine if the study or participants are appropriate.

FourSquare is committed to protecting patient privacy. We are required by law to provide you with this Notice of Privacy Practices and to make sure that medical information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to medical information about you; follow the terms of the notice that is currently in effect; and notify you in the event there is a breach of any unsecured protected health information about you.

Special Circumstances – We may use and disclose your medical information in these special circumstances:

• Organ and tissue donation
• Health oversight activities (as required or allowed by law)
• Judicial and administrative proceedings
• Workers compensation
• Coroners, medical examiners and funeral directors
• National security and intelligence activities
• Law enforcement

III. Disclosures We Make Unless You Object

To others involved in your care – We may provide information to family, friends, or other people involved in your health care or payment for your health care (if permitted under state law).

To maintain our facility directory – We may include limited information about you in our directory while you are a patient. This could include your name, location in the facility and your religious affiliation if you provide this information to us. This directory information, except for your religious affiliation and condition, may be released to people who ask for you by name. This is so your family, friends, and clergy can know your location. If you do not want to release such information Please notify us with written request to our maining address below.

FourSquare
PO Box 600047,
Jacksonville, FL, 32260

Fundraising– you may be contacted to raise funds for foundations, charity, special organizations. You may opt out of these communications at any time by notifying the Privacy Officer identified below or following the instructions in the fundraising communication.

1. Your Rights Regarding Your Medical Information

Right to inspect and copy your health information – You may request access to your health information to review or request copies of the information. This usually includes medical and billing records maintained by FourSquare.

Right to receive an electronic copy of your electronic medical record – You have the right to request an electronic copy of your medical information. If the form and format are not readily producible, we will work with you to create a reasonable electronic form or format. You can request a copy of your record by Notifying us in writing at our mailing address.

Right to request restrictions on the use or disclosure of your health information – You have the right to request restrictions on the use or disclosure of your medical record to your health plan for payment or health care operations if you have paid in full for the treatment out-of-pocket. This request must be in writing and identify what information you want to limit, how you want to limit the use and/or disclosure, and to whom you want the limits to apply.

Right to request to correct or amend your health information – You may ask us to correct your health information. We will consider all requests and may deny your request for legitimate reasons, for example, if we determine that the record is accurate and complete. To request a correction, you must notify in detailed writing for the above mentioned address.

Right to request confidential communications – You can request that we communicate with you about medical matters in a certain way. Request can be made in writing or by phone call to the above address and phone number.

Right to be notified of a breach – We will notify you in the event of a breach of your protected health information.

Right to receive an accounting of disclosures of your record – You can request a list of certain disclosures we have made of your health information. This information will not include disclosures for treatment, payment, health care operations, disclosures you have authorized and certain other disclosures. To request this list of disclosures you must submit your request in writing to (Include instructions on how to request a list of disclosures) and must state the time period for which you would like the accounting. If you request more than one accounting in any 12-month period, we may charge you a reasonable fee.

Right to a paper copy of this notice – You have the right to receive a paper copy of this notice and may ask for a copy at any time.

Changes to this Notice

We reserve the right to change this notice and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. The updated notice can be found on our website.

1. Complaints or Questions

You can complain if you feel we have violated your rights by contacting us using the information mentioned above.

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/what-to-expect/index.html

• We will not retaliate against you for filing a complaint.