There is also some pertinent information regarding your privacy and your rights following the forms... Please read that information and if there are any questions, contact us.  You may 'right click' on you mouse, select 'print' and print this entire page.

For our Medicare patients: We accept Medicare assignment.  If you have a secondary insurance with which we participate, we will bill this for you.  If we do not participate with your secondary insurance, the co-payment would be due at the time of service.  We will submit your secondary insurance as a courtesy for you.  Please be advised that you are also responsible for any deductible amounts.

For our HMO patients: Please obtain the required referral PRIOR to your appointment.  If you come for you appointment without a referral, it will be necessary to reschedule your visit for a time when you will have an authorization.  Please be advised that all co-payments amounts are also due at the time of service.

We have a waiting list for new patient appointments, so if for any reason you are unable to keep your scheduled appointment, please contact our office 24 hours in advance.  There may be a $20.00 charge for blocked time if you do not advise us of your cancellation. 

We look forward to seeing you for your office visit.  If there are any questions, please do not hesitate to contact us.

Directions to our office
Patient Information
Medical Release & Consent Forms
Sleepiness Questions
Overnight Stay

Disclosures
Dr. Kohler has a financial interest in the Florida Sleep Institute.  If sleep studies are recommended you have the right to select another facility such as Hernando Sleep Disorder Center or Oak Hill Hospital.

Family and Friends
We may use or disclose health information about you to your family members or friends if we obtain your verbal agreement to do so of if we give you an opportunity to object to such a disclosure and you do not raise objection.  We may also disclose health information to your family and friends if we can infer from the circumstances, based on our professional judgment, that you would not object.  For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room during treatment or while treatment is discussed.

In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest.  In that situation, we will disclose only health information relevant to the person's involvement in your care.  For example, we may inform the person who accompanied you to the emergency room that you suffered a heart attack and provide updates on your progress and prognosis.  We may also use our professional judgment and experience to make reasonable inferences that it is your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies, or X-rays.

You have the following rights regarding health information we maintain about you

Right to inspect and copy
You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care.  You must submit a written request to the Florida Sleep Institute in order to inspect and/or copy your health information.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies.  We may deny your request to inspect and /or copy in certain limited circumstances.  If you are denied access to your health information, you may ask that the denial be reviewed.  If such a review is required by law, we will select a licensed health care professional to review your request and our denial.  The person conducting the review will not be the person who denied your request and we will comply with the outcome of the review.

Right to amend
If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment as long as the information is kept by the office.  To request an amendment, submit a completed Medical Record Amendment/ Correction form to the Florida Sleep Institute.  We may deny your request for an amendment if it is not in writing or doesn't not include a reason to support the request.  In addition, we may deny your request if you ask us to amend information that:

1. we did not create, unless the person or entity that created the information is no longer available to make the amendment.
2. is not part of the health information we keep.
3. you would not be permitted to inspect and copy
4. is accurate and complete

Right to an accounting of disclosures
You have the right to request an "accounting of disclosures."  This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and health care operations.  To obtain this list, you must submit your request in writing to the Florida Sleep Institute.  It must state a time period, which may not be longer than six (6) years and may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (for example, on paper, electronically...)  We may charge you for the cost of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request at the time before any costs are incurred.

Right to request restrictions
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations.  You also have the right to request a limit in the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend.  For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request
If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.   *To request restrictions, you may complete and submit the Request for Restriction on Use/Disclosure of Medical Information form to the Florida Sleep Institute.

Right to request confidential communications
You have the right to request that we communicate with your about medical matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail.   *To request confidential communications, you may complete and submit the Request For Restriction On Use/Disclosure of Medical Information And/Or Confidential Communication to the Florida Sleep Institute.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted.

Right to a paper copy of this notice
You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time.  Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact the Florida Sleep Institute.

You may revoke your consent at any time by giving us written notice.  Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures which occurred before that time.
If you do revoke your consent, we will not be permitted to use or disclose information for purposes of treatment, payment or health care operations, and we may therefore choose to discontinue providing you with health care treatment and services.

Changes to this notice
We reserve the right to change this notice and to make ther revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective day in the top right hand corner. You are entitled to a copy of the  notice currently in effect.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services.  To file a complaint with our office, contact us at 4075 Mariner Blvd., Spring Hill, FL 34609.  You will not be penalized for filing a complaint.