Mayra Alfonso Physiatry, PLLC
Effective Date: February 7, 2026
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.
Our Commitment to Your Privacy
Mayra Alfonso Physiatry, PLLC (“we,” “us,” “our”) is committed to protecting the privacy of your health information. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment, or health care operations, and for other purposes permitted or required by law. It also describes your rights regarding your health information.
We are required by law to:
- Maintain the privacy of your Protected Health Information (PHI)
- Provide you with this Notice of our legal duties and privacy practices
- Follow the terms of the Notice currently in effect
- Notify you if we are unable to agree to a requested restriction
- Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
How We May Use and Disclose Your Health Information
For Treatment
We may use and disclose your PHI to provide, coordinate, or manage your health care and related services. This includes consultation with other health care providers regarding your treatment and referral to other providers for services we do not provide.
Example: We may share your medical information with your primary care physician, specialists, physical therapists, or other health care providers involved in your care to coordinate treatment plans.
For Payment
We may use and disclose your PHI to obtain payment for services we provide. This includes billing you, your insurance company, Medicare, or other third-party payers.
Example: We may submit claims to Medicare or your insurance company that include information about your diagnosis, treatment, and services provided.
For Health Care Operations
We may use and disclose your PHI for our health care operations, including quality assessment, credentialing, business planning, and other administrative activities.
Example: We may use your health information to evaluate the quality of care you received or for training purposes.
Business Associates
We may disclose your PHI to third-party service providers (“business associates”) who perform services on our behalf, such as billing companies, IT vendors, or consultants. These business associates are required by contract to safeguard your information.
As Required by Law
We will disclose your PHI when required to do so by federal, state, or local law.
Public Health Activities
We may disclose your PHI for public health activities, such as reporting diseases, injuries, vital events, or suspected abuse or neglect to public health authorities.
Health Oversight Activities
We may disclose your PHI to health oversight agencies for activities authorized by law, such as audits, investigations, inspections, or licensure actions.
Judicial and Administrative Proceedings
We may disclose your PHI in response to a court order, subpoena, discovery request, or other lawful process, subject to legal requirements and your rights.
Law Enforcement
We may disclose limited PHI to law enforcement officials as required by law or in response to a valid request in specific circumstances, such as identifying or locating a suspect or reporting a crime.
To Avert a Serious Threat to Health or Safety
We may use or disclose your PHI if we believe it is necessary to prevent or lessen a serious and imminent threat to your health or safety or that of another person or the public.
Specialized Government Functions
We may disclose your PHI for specialized government functions, such as military and veterans’ activities, national security, or protective services for the President.
Workers’ Compensation
We may disclose your PHI as authorized by and to comply with workers’ compensation laws or similar programs.
Coroners, Medical Examiners, and Funeral Directors
We may disclose your PHI to coroners, medical examiners, or funeral directors as necessary to carry out their duties.
Uses and Disclosures That Require Your Written Authorization
Other uses and disclosures of your PHI not covered by this Notice or permitted by law will be made only with your written authorization. You may revoke your authorization in writing at any time, except to the extent that we have already taken action in reliance on your authorization.
Examples of uses requiring authorization:
- Most uses and disclosures of psychotherapy notes (if applicable)
- Marketing communications
- Sale of your PHI
- Other uses not described in this Notice
Your Rights Regarding Your Health Information
You have the following rights regarding your PHI:
Right to Request Restrictions
You have the right to request restrictions on certain uses and disclosures of your PHI for treatment, payment, or health care operations. We are not required to agree to your request except in one situation: if you pay out-of-pocket in full for a service and request that we not disclose PHI related solely to that service to your health plan for payment or health care operations, we must honor that request unless disclosure is required by law.
Right to Receive Confidential Communications
You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. For example, you may request that we contact you only at work or by mail. We will accommodate reasonable requests.
Right to Inspect and Copy
You have the right to inspect and obtain a copy of your PHI contained in a designated record set (such as medical and billing records) for as long as we maintain the information. We may charge a reasonable fee for copying and mailing. In limited circumstances, we may deny your request, and you may request a review of the denial.
Right to Amend
You have the right to request that we amend your PHI if you believe it is incorrect or incomplete. We may deny your request if the information was not created by us, is not part of the records we maintain, is not available for inspection, or is accurate and complete. If we deny your request, you may submit a written statement of disagreement.
Right to an Accounting of Disclosures
You have the right to request an accounting of certain disclosures of your PHI made by us during the six years prior to your request (or a shorter period if you specify). The accounting will not include disclosures made for treatment, payment, or health care operations, disclosures made to you, disclosures you authorized, and certain other disclosures. The first accounting in a 12-month period is free; we may charge a reasonable fee for additional requests.
Right to a Paper Copy of This Notice
You have the right to obtain a paper copy of this Notice upon request, even if you have agreed to receive the Notice electronically.
Right to Notification of a Breach
You have the right to be notified in the event of a breach of your unsecured PHI.
How to Exercise Your Rights
To exercise any of the rights described above, please submit a written request to:
Mayra Alfonso Physiatry, PLLC
Attn: Privacy Officer
PO Box 880004
Boca Raton, FL 33434
Email: privacy@drmayraalfonso.com
Changes to This Notice
We reserve the right to change this Notice at any time. Any revised Notice will apply to PHI we already have as well as any PHI we create or receive in the future. We will post the current Notice on our website at drmayraalfonso.com and make copies available upon request.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services (HHS).
To file a complaint with us:
Mayra Alfonso Physiatry, PLLC
Attn: Privacy Officer
PO Box 880004
Boca Raton, FL 33434
Email: privacy@drmayraalfonso.com
To file a complaint with HHS:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
Website: www.hhs.gov/ocr/privacy/hipaa/complaints/
You will not be retaliated against for filing a complaint.
Contact Information
If you have questions about this Notice or need more information, please contact:
Mayra Alfonso Physiatry, PLLC
Privacy Officer
PO Box 880004
Boca Raton, FL 33434
Phone: 954-574-2042
Email: privacy@drmayraalfonso.com
Effective Date: February 7, 2026
Acknowledgment: I acknowledge that I have received a copy of this Notice of Privacy Practices.
Patient/Legal Representative Signature: ___________________________
Print Name: ___________________________
Date: ___________________________
(If signed by legal representative, state relationship to patient: ___________________________)
