Our Lady of HealthMedical Group

Our Lady of Health Medical Group · Abraham Kalathoor, MD · Effective Date: January 1, 2025

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

Our Lady of Health Medical Group is committed to protecting your health information. We create a record of the care and services you receive from us. This 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.

How We May Use and Disclose Your Health Information

Treatment: We may use your health information to provide, coordinate, or manage your health care and any related services. For example, we may share your information with other physicians or health care providers who need it to treat you.

Payment: We may use and disclose your health information to bill for and receive payment for health care services we provide. Because our practice does not bill insurance for membership services, payment-related disclosures are limited.

Health Care Operations: We may use and disclose your health information for our internal operations, including quality assessment, training, licensing, business planning, and practice management.

Required by Law: We will disclose your health information when required to do so by federal, state, or local law, including mandatory reporting requirements.

Public Health Activities: We may disclose your information for public health reporting to authorized agencies, including disease reporting, vital statistics, and reporting of child or elder abuse or neglect.

Health Oversight Activities: We may disclose health information to government agencies for activities authorized by law, such as audits, investigations, and inspections.

Legal Proceedings: We may disclose your health information in response to a court or administrative order, subpoena, discovery request, or other lawful legal process.

Law Enforcement: Under certain conditions and as permitted by law, we may disclose health information to law enforcement officials.

Serious Threats to Health or Safety: We may use or disclose your health information when necessary to prevent a serious and imminent threat to your health or safety or the health or safety of the public.

Workers' Compensation: We may disclose your health information for workers' compensation or similar programs as authorized by law.

Uses and Disclosures That Require Your Authorization

Other uses and disclosures of your health information not described above will be made only with your written authorization. You may revoke that authorization in writing at any time; revocation will not affect any use or disclosure made prior to it. We will obtain your written authorization for:

• Marketing purposes
• Sale of your health information
• Most uses and disclosures of psychotherapy notes

Your Rights Regarding Your Health Information

Right to Inspect and Copy: You have the right to inspect and request a copy of your health information, including your medical record. We may charge a reasonable fee for copies. To request access, submit a written request to our Privacy Officer.

Right to Request Amendments: You have the right to request that we correct or add to your health information if you believe it is inaccurate or incomplete. We may deny your request in certain circumstances and will notify you in writing if we do.

Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures we have made of your health information, excluding disclosures for treatment, payment, operations, or certain other purposes.

Right to Request Restrictions: You have the right to request a restriction on uses and disclosures of your health information. We are not required to agree to your request, but if we do, we will comply unless the information is needed to provide emergency treatment.

Right to Request Confidential Communications: You have the right to request that we communicate with you in a specific way or at a specific location. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice at any time, including from our website.

Right to be Notified of a Breach: You have the right to be notified in the event of a breach of your unsecured protected health information.

Our Duties

We are required by law to maintain the privacy of your health information, provide you with this Notice, and abide by its terms. We reserve the right to change this Notice, and any changes will apply to information we already have about you as well as any information we receive in the future. The current Notice will be posted in our office and on our website.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be penalized for filing a complaint.

Privacy Officer: Abraham Kalathoor, MD
1032 E Brandon Blvd #1524, Brandon, FL 33511
Phone: (786) 610-6971  ·  Email: info@olhmedicalgroup.com

HHS Office for Civil Rights: 200 Independence Ave., S.W., Washington, D.C. 20201
Toll-free: 1-877-696-6775  ·  www.hhs.gov/ocr

Our Lady of Health Medical Group · Abraham Kalathoor, MD

At Our Lady of Health Medical Group, we are committed to providing compassionate, respectful, and high-quality care to every patient. The following describes your rights as a patient and the responsibilities we ask you to uphold.

Your Rights as a Patient

Right to Respectful Care: You have the right to receive care that is considerate, respectful, and delivered with dignity, regardless of age, race, ethnicity, national origin, religion, sex, gender identity, sexual orientation, disability, socioeconomic status, documentation status, or ability to pay.

Right to Informed Consent: You have the right to receive a clear explanation of your diagnosis, proposed treatments, potential risks and benefits, and available alternatives before consenting to any procedure or course of treatment. You have the right to ask questions and receive understandable answers.

Right to Refuse Treatment: You have the right to refuse any treatment, test, or procedure to the extent permitted by law. We will explain the potential consequences of your decision and document your refusal.

Right to Privacy & Confidentiality: You have the right to have your health information treated as private and confidential in accordance with HIPAA and applicable Florida law. Your records will not be shared without your authorization, except as required by law or for treatment purposes.

Right to Access Your Medical Records: You have the right to inspect, obtain copies of, and request amendments to your medical records in accordance with HIPAA. Requests should be submitted in writing to the Practice.

Right to a Second Opinion: You have the right to seek a second medical opinion from another qualified physician at any time.

Right to Know Your Care Team: You have the right to know the name and professional credentials of the physician and any clinical staff involved in your care.

Right to Continuity of Care: You have the right to receive information about your ongoing care and any necessary follow-up. If you are referred to another provider, we will coordinate that transition to the best of our ability.

Right to File a Complaint: You have the right to express concerns or file a complaint about the care or services you receive without fear of retaliation. Contact: info@olhmedicalgroup.com  ·  (786) 610-6971. You also have the right to file with the Florida Agency for Health Care Administration (AHCA): floridahealthfinder.gov, or the U.S. HHS Office for Civil Rights: hhs.gov/ocr.

Right to a Good Faith Estimate: If you do not have insurance or are not using insurance, you have the right to receive a Good Faith Estimate of expected costs before receiving services, in accordance with the No Surprises Act.

Your Responsibilities as a Patient

Provide Accurate Information: You are responsible for providing complete and accurate information about your health history, medications, allergies, and any changes in your condition. Inaccurate information may affect the quality of your care.

Follow Your Care Plan: You are responsible for following the treatment plan agreed upon with Dr. Kalathoor. If you are unable or unwilling to follow a recommended course of treatment, please communicate this so we can discuss alternatives.

Keep Your Appointments: You are responsible for attending scheduled appointments on time. If you need to cancel or reschedule, please provide as much advance notice as possible, and at least 24 hours when possible.

Communicate Changes: You are responsible for notifying the Practice if your health status, medications, contact information, or insurance status changes.

Financial Responsibilities: You are responsible for payment of membership fees and any non-covered services in accordance with the Financial Policy you have signed. You agree to maintain a valid payment method on file.

Respectful Conduct: You are responsible for treating Dr. Kalathoor and all Practice staff with courtesy and respect. Threatening, abusive, or disruptive behavior will not be tolerated and may result in termination of the care relationship.

Use of Communication Channels: Please use the urgent direct line for urgent medical matters, and the patient portal or email for non-urgent questions and administrative requests.

Emergency Situations: You are responsible for calling 911 or going to the nearest emergency room in the event of a life-threatening emergency. This practice is not an emergency service.

Our Lady of Health Medical Group · Abraham Kalathoor, MD

1. Membership Cancellation

Minimum Commitment: All memberships require a minimum initial term of three (3) consecutive months. The Patient may not cancel during this initial period except in the case of documented medical incapacity or at the Practice's discretion under extraordinary circumstances.

After the Minimum Period: Following the 3-month minimum, the Patient may cancel at any time by providing thirty (30) days' written notice via email to info@olhmedicalgroup.com. Membership benefits remain active through the end of the last paid billing period.

Effective Date of Cancellation: Cancellation takes effect 30 days after written notice is received. No further charges will be made after the effective cancellation date.

2. Refund Policy — Monthly Plans

Monthly membership fees are non-refundable. No partial-month refunds will be issued for mid-cycle cancellations. The Patient will retain access to membership benefits through the end of the last paid billing period.

3. Refund Policy — Annual Prepay Plans

Annual prepay fees are generally non-refundable. However, after the 3-month minimum, the Practice may issue a prorated refund for remaining full calendar months of unused membership, minus a $50 administrative fee, at the sole discretion of the Practice. Requests must be submitted in writing within 30 days of the cancellation request. If approved, refunds will be issued to the original payment method within 14 business days.

Exception — Practice Closure: In the event of permanent closure, a full prorated refund will be issued for any unused, prepaid membership period, with no administrative fee.

4. Cancellation by the Practice

The Practice reserves the right to cancel a membership with thirty (30) days' written notice for any reason, or immediately for cause, including:

• Non-payment of fees for more than 30 consecutive days
• Threatening, abusive, or harassing behavior toward the physician or staff
• Fraudulent use of membership benefits
• Behavior disruptive to the practice or harmful to other patients

In the event of cancellation by the Practice without cause, a prorated refund will be issued for any prepaid, unused membership period within 14 business days.

5. Appointment Cancellation

Telehealth & Office Visits: No fee is charged for cancellations made with at least 4 hours' notice. Late cancellations (less than 4 hours) or no-shows may result in a $50 fee at the Practice's discretion, which may be waived for documented emergencies.

House Visits (Premium Members): House visit cancellations require at least 24 hours' notice. Late cancellations or no-shows will result in a $50 cancellation fee.

6. Rescheduling

Patients are encouraged to reschedule rather than cancel whenever possible. Rescheduling can be done via the patient portal, by calling/texting (786) 610-6971, or by emailing info@olhmedicalgroup.com.

7. Individual (Non-Member) Visit Cancellation

Individual visit appointments canceled with less than 4 hours' notice or no-shows may result in a $50 cancellation fee. Payment for the visit is due at the time of service.

8. Medical Emergencies

Cancellation fees will always be waived in the event of a documented medical emergency. Please contact the Practice as soon as practicable.

9. Contact for Cancellations

Email: info@olhmedicalgroup.com (preferred for membership cancellations)
Phone/Text: (786) 610-6971 (for appointment rescheduling)

Our Lady of Health Medical Group · Abraham Kalathoor, MD · Under the No Surprises Act — Effective January 1, 2022

What Is a Good Faith Estimate?

Under Section 2799B-6 of the Public Health Service Act (the "No Surprises Act"), health care providers are required to provide uninsured and self-pay patients with a Good Faith Estimate of expected costs before or at the time of scheduling health care services.

Who Has This Right?

You have the right to receive a Good Faith Estimate if you:

• Do not have health insurance, or
• Are not planning to use your health insurance for the scheduled service.

What the Estimate Includes

Your Good Faith Estimate will include the expected charges for the primary service and any related items or services reasonably expected to be provided at the same time. The estimate is based on information known at the time of scheduling — actual charges may differ if your care changes.

When You Will Receive the Estimate

If your service is scheduled at least 10 business days in advance, you will receive your estimate within 3 business days of scheduling.

If your service is scheduled 3–9 business days in advance, you will receive your estimate within 1 business day of scheduling.

If Your Bill Is Higher Than the Estimate

If you receive a bill that is $400 or more above your Good Faith Estimate, you have the right to dispute the bill through the Patient-Provider Dispute Resolution process established under federal law.

For questions about the dispute process, visit: www.cms.gov/nosurprises

How to Request Your Good Faith Estimate

Contact us at least 3 business days before your scheduled appointment. We are happy to provide a written estimate upon request.

Email: info@olhmedicalgroup.com
Phone: (786) 610-6971

Contact Information

Our Lady of Health Medical Group
Abraham Kalathoor, MD
1032 E Brandon Blvd #1524, Brandon, FL 33511
Phone: (786) 610-6971  ·  Email: info@olhmedicalgroup.com