PURPOSE
This Notice of Privacy Practices describes how we may use and disclose your “Protected Health Information” to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. Protected Health Information is information about you that may identify you and that relates to your past, present or future physical or mental health or conditions and related health care services. This Notice also describes your rights in regard to your Protected Health Information, including your rights to access and control of such information. This Notice describes our practices and those of all employees, staff and other Dalton Plastic Surgery personnel.
ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE
You will be asked to provide a signed acknowledgement of receipt of this notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care services will in no way be conditioned upon your signed acknowledgement. If you decline to provide a signed acknowledgement, we will continue to provide your treatment, and will use and disclose your protected health information for treatment, payment and healthcare operations when necessary.
WE ARE REQUIRED BY LAW TO:
- Make sure that your medical information is protected;
- Give you this Notice describing our legal duties and privacy practices with respect to medical information about you; and
- Follow the terms of the Notice that is currently in effect.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
The following headings describe different types of uses and disclosures of your Protected Health Information. For each category of use or disclosure, we will explain what it means and provide you with examples. Not every use or disclosure will be listed. All of the permitted uses and disclosures fall within one of the following categories:
Treatment
We may use and disclose your Protected Health Information to provide medical treatment or services. In the course of providing medical treatment or services, we may use or disclose your Protected Health Information to doctors, nurses, technicians or other individuals involved in your care. For example, we may refer you for laboratory tests of your blood or urine. We may use the results to help us reach a diagnosis. We may also disclose your Protected Health Information to another care provider upon referral.
Payment
We may use and disclose your Protected Health Information for billing or collection from you, an insurance company or other third party for treatment and services that we provide to you. For example, we may provide your insurance carrier with information related to a procedure in order for us to receive compensation or for you to receive reimbursement for that procedure. In some instances, your Protected Health Information will be disclosed in order to receive approval for a particular course of action. For example, we may need to disclose your Protected Health Information to a Health Maintenance Organization (HMO) or other entity in order to receive approval for a particular course of treatment.
Health Care Operations
We may use and disclose your Protected Health Information for health care operations. These uses and disclosures are necessary to support the business activities of our practice and ensure that our patients receive quality care. For example our practice manager may use your Protected Health Information to evaluate the quality of care you received from us or to conduct cost-management and business planning activities. We may also share your Protected Health Information with third party ‘‘business associates’ that perform various activities.
Other Uses and Disclosures
As part of treatment, payment and healthcare operations, we may use and disclose to you Protected Health Information for the following purposes:
- To remind you of an appointment through means such as voice mail messages, email messages, postcards and letters.
- To inform you of possible treatment options or alternatives.
- To inform you about health related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care
We may release Protected Health Information under the following circumstances:
- To a friend or family member who is involved in your medical care.
- To someone who helps pay for your care.
- To an entity assisting in disaster relief efforts so that your family is notified of your condition, status and location.
SPECIAL SITUATIONS
Required by Law
We will disclose your Protected Health Information when required to do so by federal, state or local law.
Public Health Activities
Protected Health Information maybe used or disclosed to a public health authority that is authorized by law to collect or receive such information to prevent or control disease, injury or disability; or to report births and deaths. Protected Health Information may be used or disclosed to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition when required or authorized by law.
Abuse, Neglect and Domestic Violence
We may disclose your Protected Health Information to a public health or other appropriate government authority authorized by law to receive reports of child abuse or neglect. Further, we may disclose Protected Health Information about an individual whom we believe to be a victim of abuse, neglect or domestic violence if you agree or when required or authorized by law’.
Food and Drug Administration
We may disclose your Protected Health Information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, or biologic product deviations. Additionally, your Protected Health Information may be used to track products, enable product recalls, make repairs or replacements, or to conduct post marketing surveillance.
Health Oversight Activities
We may disclose your Protected Health Information to a health oversight agency for activities authorized by Law and as necessary for the government to monitor the health care system, government programs and compliance with civil rights laws. These oversight activities may include audits, investigations, inspections and licensure evaluation.
Legal Proceedings
If you are involved in a lawsuit or a dispute, we may disclose your Protected Health Information in response to a court or administrative order. We may also disclose your Protected Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in a lawsuit or dispute.
Law Enforcement
We may release your Protected Health Information if asked to do so by a law enforcement official in situations including, but not limited to the following:
- As required by law for reporting of certain types of wounds or other physical injuries;
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- To provide information about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- To provide information about a death we believe may be the result of criminal conduct;
- To provide information about criminal conduct at our practice; and
- Under emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
To Avert a Serious Threat to Health or Safety
We may use and disclose your Protected Health Information when necessary to prevent or lessen a serious threat to the health and safety of a person or the public. Any disclosure would only be to someone able to prevent or lessen the threat.
Specialized Government Functions
We may disclose the Protected Health Information of Armed Forces personnel, veterans and foreign military personnel for authorized activities under the appropriate circumstances. Further, your Protected Health Information may be disclosed to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities and special investigations, including the provision of protective services to the President, other authorized persons or foreign heads of state, as authorized by law.
Workers’ Compensation
We may release Protected Health Information about you in connection with Workers’ Compensation proceedings or similar programs.
Inmates
We may release your Protected Health Information to a correctional institution or law enforcement official if you are an inmate of a correctional institution or under the custody of a law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others: or (3) for the safety and security of the correctional institution.
Research
We may disclose your protected health information to researchers when authorized by law, if an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved the research.
Parental Access
Some state Laws concerning minors permit or require disclosure of protected health information to parents, guardians, and persons acting in a similar legal status. We will act consistently with the law of the state where the treatment is provided and will make disclosures following such laws.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Right to Inspect and Copy
With certain limited exceptions, you have the right to inspect and copy designated record sets containing your Protected Health information for as long as we maintain the record. A ‘designated record set” includes medical, billing, and other records, with the exception of psychotherapy notes, used for making decisions about individuals. Should your request fall under an exception you will receive a response explaining the reason for our inability to allow you to inspect and copy the information you requested. In order to inspect or copy a designated record set, you must submit a written request to Cheri A. Riddle, Privacy Officer. If you request a copy of the information, we may charge a fee associated with the costs of your request. Your request to inspect and copy your Protected Health Information may be denied under limited circumstances. If your request is denied, you may request that the denial be reviewed.
Right to Amend
You may ask us to amend your Protected Health Information in a designated record set if you feel that the information is incomplete or inaccurate. You have the right to request an amendment for as long as the information is kept by or for our practice. To request an amendment, you must submit a written request to Cheri A. Riddle, Privacy Officer. You must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. If you are denied the ability to amend your Protected Health Information, you may request a review of the denial. Possible reasons for denying your request to amend include, but are not limited to:
- The information was not created by us, unless you provide a reasonable basis to believe that the person or entity that created the information is no longer available to make the amendment;
- The information is not part of the designated record set maintained by our practice;
- The information is not part of the designated record set which you would be permitted to inspect; or
- The request pertains to information that is accurate and complete.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures” listing the disclosures we made of your Protected Health Information. To request an accounting of disclosures, you must submit a written request to Cheri A. Riddle, Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first accounting will be provided without charge. We may charge you for the costs of providing subsequent accountings within a 12 month period. We will notify you of the costs involved and you may choose to withdraw or modify your request before action is taken.
Right to Request Restrictions
You have the right to request a restriction or limitation on certain parts of the Protected Health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the Protected Health Information we disclose about you for notification purposes or to individuals involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not disclose information about a condition you have to your spouse or children. We are not required to agree to your request. Under certain circumstances, we may terminate our agreement to a restriction. You may also terminate a restriction at a later date. Make your written request for restrictions to Cheri A. Riddle, Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. You may contact Cheri A. Riddle, Privacy Officer to terminate a restriction.
Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain manner or location. We will accommodate all reasonable requests. For example, you can ask that we only contact you at home or not to send certain items in the mail. To request confidential communications, you must make your request in writing to Cheri A. Riddle, Privacy Officer. You do not need to include a reason for your request; however, your request must be specific as to your requested accommodations.
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 this Notice electronically, you are still entitled to a paper copy of this Notice. To obtain a paper copy of this Notice, contact Cheri A. Riddle, Privacy Officer.
OTHER USES OF PROTECTED HEALTH INFORMATION
Other uses and disclosures of your Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us with permission to use or disclose your Protected Health information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose Protected Health Information about you for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.
THIS NOTICE MAY BE AMENDED AT ANY TIME
We may change the terms of this notice at any time. Any revised notice will be effective for all Protected Health Information that we maintain at the time the new version is adopted. The effective date of a revised notice will be noted on it’s first page. A copy of the current notice in effect will be posted. Each time you receive treatment or healthcare services, you may request a copy of the current notice. In addition, you may always request a copy of the current notice.
COMPLAINTS
If you believe your privacy rights have been violated or that our practice has otherwise not complied with the terms of this notice, 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:
Cheri A. Riddle, Privacy Officer
Dalton Plastic Surgery
1501 Broadrick Drive, Suite 1
Dalton, GA 30720
All complaints must be submitted in writing. You will not be penalized for filing a complaint.
