Mark A Spatola MD FAANS
Orange Park Neurosurgery, P.L.
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.
Mark A. Spatola, M.D.
Orange Park Neurosurgery P.L.
2021 KingsleyAvenue, Suite 101
Orange Park, FL 32073
(904) 276-3376 Fax (904) 276-5308
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
· 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
the office at (904) 276-3376.
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
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.
4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind
you of an appointment.
5. Treatment Options. Our practice may use and disclose your IIHI to inform you of potential
treatment options or alternatives.
6. Health-Related Benefits and Services. Our practice may use and disclose your IIHI to inform you
of health-related benefits or services that may be of interest to you.
7. Release of Information to Family/Friends. Our practice may release your IIHI to a friend or family
member that is involved in your care, or who assists in taking care of you. For example, a parent or
guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold.
In this example, the babysitter may have access to this child’s medical information.
8. Disclosures Required By Law. Our practice will use and disclose your IIHI when we are
required to do so by federal, state or local law.
D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your
identifiable health information:
1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are
authorized by law to collect information for the purpose of:
· maintaining vital records, such as births and deaths
· reporting child abuse or neglect
· preventing or controlling disease, injury or disability
· notifying a person regarding potential exposure to a communicable disease
· notifying a person regarding a potential risk for spreading or contracting a disease or condition
· reporting reactions to drugs or problems with products or devices
· notifying individuals if a product or device they may be using has been recalled
· notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse
or neglect of an adult patient (including domestic violence); however, we will only disclose this
information if the patient agrees or we are required or authorized by law to disclose this information
· notifying your employer under limited circumstances related primarily to workplace injury or
illness or medical surveillance.
2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for
activities authorized by law. Oversight activities can include, for example, investigations,
inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal
procedures or actions; or other activities necessary for the government to monitor government
programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to
a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may
disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another
party involved in the dispute, but only if we have made an effort to inform you of the request or to
obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:
· Regarding a crime victim in certain situations, if we are unable to obtain the person’s
· Concerning a death we believe has resulted from criminal conduct
· Regarding criminal conduct at our offices
· In response to a warrant, summons, court order, subpoena or similar legal process
· To identify/locate a suspect, material witness, fugitive or missing person
· In an emergency, to report a crime (including the location or victim(s) of the crime, or the
description, identity or location of the perpetrator)
5. Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a
deceased individual or to identify the cause of death. If necessary, we also may release
information in order for funeral directors to perform their jobs.
6. Organ and Tissue Donation. Our practice may release your IIHI to organizations that handle
organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary
to facilitate organ or tissue donation and transplantation if you are an organ donor.
7. Research. Our practice may use and disclose your IIHI for research purposes in certain limited
circumstances. We will obtain your written authorization to use your IIHI for research purposes
except when an IRB or Privacy Board has determined that the waiver of your authorization satisfies
the following: (i) the use or disclosure involves no more than a minimal risk to the individual’s
privacy based on the following: (A) an adequate plan to protect the identifiers from improper use
and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent
with the research (unless there is a health or research justification for retaining the identifiers or
such retention is otherwise required by law); and (C) adequate written assurances that the PHI will
not be re-used or disclosed to any other person or entity (except as required by law) for authorized
oversight of the research study, or for other research for which the use or disclosure would
otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and
(iii) the research could not practicably be conducted without access to and use of the PHI.
8. Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when
necessary to reduce or prevent a serious threat to your health and safety or the health and safety of
another individual or the public. Under these circumstances, we will only make disclosures to a
person or organization able to help prevent the threat.
9. Military. Our practice may disclose your IIHI if you are a member of U.S. or foreign military
forces (including veterans) and if required by the appropriate authorities.
10. National Security. Our practice may disclose your IIHI to federal officials for intelligence and
national security activities authorized by law. We also may disclose your IIHI to federal officials in
order to protect the President, other officials or foreign heads of state, or to conduct investigations.
11. Inmates. Our practice may disclose your IIHI to correctional institutions or law enforcement
officials if you are an inmate or under the custody of a law enforcement official. Disclosure for
these purposes would be necessary: (a) for the institution to provide health care services to you, (b)
for the safety and security of the institution, and/or (c) to protect your health and safety or the health
and safety of other individuals.
12. Workers’ Compensation. Our practice may release your IIHI for workers’ compensation and
E. YOUR RIGHTS REGARDING YOUR IIHI
You have the following rights regarding the IIHI that we maintain about you:
1. Confidential Communications. You have the right to request that our practice communicate with
you about your health and related issues in a particular manner or at a certain location. For
instance, you may ask that we contact you at home, rather than work. In order to request a type of
confidential communication, you must make a written request to [insert name, or title, and
telephone number of a person or office to contact for further information] specifying the requested
method of contact, or the location where you wish to be contacted. Our practice will accommodate
reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of
your IIHI for treatment, payment or health care operations. Additionally, you have the right to request
that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the
payment for your care, such as family members and friends. We are not required to agree to your
request; however, if we do agree, we are bound by our agreement except when otherwise required
by law, in emergencies, or when the information is necessary to treat you. In order to request a
restriction in our use or disclosure of your IIHI, you must make your request in writing to [insert
name, or title, and telephone number of a person or office to contact for further information]. Your
request must describe in a clear and concise fashion:
(a) the information you wish restricted;
(b) whether you are requesting to limit our practice’s use, disclosure or both; and
(c) to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be
used to make decisions about you, including patient medical records and billing records, but not
including psychotherapy notes. You must submit your request in writing to [insert name, or title,
and telephone number of a person or office to contact for further information] in order to inspect
and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying, mailing,
labor and supplies associated with your request. Our practice may deny your request to inspect
and/or copy in certain limited circumstances; however, you may request a review of our denial.
Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or
incomplete, and you may request an amendment for as long as the information is kept by or for our
practice. To request an amendment, your request must be made in writing and submitted to [insert
name, or title, and telephone number of a person or office to contact for further information]. You
must provide us with a reason that supports your request for amendment. Our practice will deny
your request if you fail to submit your request (and the reason supporting your request) in writing.
Also, we may deny your request if you ask us to amend information that is in our opinion: (a)
accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which
you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual
or entity that created the information is not available to amend the information.
5. Accounting of Disclosures. All of our patients have the right to request an “accounting of
disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice
has made of your IIHI for non-treatment or operations purposes. Use of your IIHI as part of the
routine patient care in our practice is not required to be documented. For example, the doctor
sharing information with the nurse; or the billing department using your information to file your
insurance claim. In order to obtain an accounting of disclosures, you must submit your request in
writing to [insert name, or title, and telephone number of a person or office to contact for further
information]. All requests for an “accounting of disclosures” must state a time period, which may
not be longer than six (6) years from the date of disclosure and may not include dates before April
14, 2003. The first list you request within a 12-month period is free of charge, but our practice may
charge you for additional lists within the same 12-month period. Our practice will notify you of the
costs involved with additional requests, and you may withdraw your request before you incur any
6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of
privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper
copy of this notice, contact [insert name, or title, and telephone number of a person or office to
contact for further information].
7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a
complaint with our practice or with the Secretary of the Department of Health and Human Services.
To file a complaint with our practice, contact [insert the name, title, and phone number of the contact
person or office responsible for handling complaints]. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your
written authorization for uses and disclosures that are not identified by this notice or permitted by
applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI
may be revoked at any time in writing. After you revoke your authorization, we will no longer use or
disclose your IIHI for the reasons described in the authorization. Please note, we are required to
retain records of your care.
Again, if you have any questions regarding this notice or our health information privacy policies,
please contact [insert name, or title, and telephone number of a person or office to contact for
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. Click below to print forms:
New Patient History and Registration forms.
Also, make sure you have the following available:
- MRI, CT, Xray CD/DVD
- Insurance card
- Photo ID
- Co-pay as expected (Please review your insurance policy)
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