June 1, 2015
NOTICE OF ADVANCED COSMETIC SURGERY PRIVACY PRACTICES
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.
This notice is intended to inform you about our practices related to the protection of the privacy of your medical records. Generally, we are required by law to ensure that medical information that identifies you is kept private. Further, we must give you this information related to our legal duties and privacy practices with respect to any medical information we create or receive about you. We are required by law to follow the terms of the notice that is currently in effect.
This notice will explain how we may use and disclose your medical information, our obligations related to the use and disclosure of your medical information and your rights related to any medical information that we have about you. This notice applies to the medical records that are generated in or by this Practice.
With a few exceptions, we are required to obtain your authorization for the use or disclosure of information for reasons other than for treatment, payment or health care operations. We have listed some of the reasons why we might use or disclose your medical information and some examples of the types of uses or disclosures below. Not every use or disclosure is covered, but all of the ways that we are allowed to use and disclose information will fall into one of the categories.
If you have any questions about the content of this Notice of Privacy Practices, or if you need to contact someone at the Practice about any of the information contained in this Notice of Privacy Practices, the contact person is:
Contact: Privacy Officer
Address: 14340 Metcalf Avenue Overland Park, KS 66223
Phone number: 913-341-2188
In addition to Practice departments, employees, staff and other Practice personnel, the following persons will also follow the practices described in this Notice of Privacy Practices:
- Any health care professional who is authorized to enter information in your medical record;
- Any member of a volunteer group that we allow to help you while you are receiving care at the Practice’s Office; and
Use and Disclosure of Medical Information for Treatment, Payment or Health Care Operations:
We can use or disclose medical information about you regarding your treatment, payment for services or for certain Practice operations.
For Treatment: To provide you with medical treatment or services, we may need to use or disclose information about you to doctors, nurses, technicians, students or other Practice personnel who are involved in your treatment. For example, a doctor may need to know what drugs you are allergic to before prescribing medications. Other doctors may share this medical information about you to coordinate your care. For instance, the laboratory may request information to complete lab work. We may also disclose medical information about you to people who may be involved in your medical care after you leave the Practice, such as home health agencies, your family and clergy members. We may also disclose information to other covered entities that are not affiliated with the Practice for your treatment (e.g. pharmacists, emergency medical providers, and unaffiliated physicians).
For Payment: We may use and disclose your medical information for the Practice to bill and receive payment for the treatment that you received here. For example, we may use or disclose your medical information to your insurance company about a service you received at the Practice so that your insurance company can pay us or reimburse you for the service. We may also ask your insurance company for prior authorization for a service to determine whether the insurance company will cover it. We may also disclose your information so that other covered entities may obtain payment for treatment that they have provided (e.g. ambulance service providers).
For Health Care Operations: We can use and disclose medical information about you for Practice operations. These include uses and disclosures that are necessary to run the Practice and make sure that our patients receive quality care. For example, we may use or disclose medical information about you to evaluate our staff’s performance in caring for you. Medical information about you and other Practice patients may also be combined to allow us to evaluate whether the Practice should offer additional services or discontinue other services and whether certain treatments are effective. We may also compare this information with other Practices to evaluate whether we can make improvements in the care and services that we offer.
Uses and Disclosures of Medical Information that do not Require Your Authorization:
We can use or disclose health information about you without your authorization when there is an emergency or when we are required by law to treat you, when we are required by law to use or disclose certain information, or when there are substantial communication barriers to obtaining consent from you.
Further, we may use or disclose your health information without your consent or authorization in any of the following circumstances:
When it is required by law;
When it involves use and disclosure for public health activities, such as mandated disease reporting, etc.;
When reporting information about victims of abuse, neglect or domestic violence as required by law;
When disclosing information for the purpose of health oversight activities, such as audits, investigations, licensure or disciplinary actions or legal proceedings or actions;
When disclosing information for judicial and administrative proceedings in accordance with state and/or federal law, for instance, in response to a court order, such as a court-ordered subpoena;
When disclosing information for law enforcement purposes, for instance, to locate or identify a suspect, fugitive, witness or missing person or regarding a victim of a crime who can not give consent or authorization because of incapacity;
When disclosing information about deceased persons to medical examiners, coroners and funeral directors;
When disclosing or using information for organ and tissue donation purposes;
When disclosing information related to a research project when a waiver of authorization has been approved by the Institutional Review Board [or the Privacy Board];
When we believe in good faith that the disclosure is necessary to avert a serious health or safety threat to you or to the public’s safety;
When disclosure is necessary for specialized government functions, such as military service, for the protection of the president or for national security and intelligence activities;
When required by military command authorities, if you are a member of the armed forces (or if foreign military personnel, to appropriate foreign military authorities);
In the case of a prison inmate, information can be released to the correctional facility in which he or she resides for the following purposes: (1) for the institution to provide the inmate with health care; (2) to protect the health and safety of the inmate or the health and safety of others; or (3) for the safety and security of the correctional facility; and
When disclosure is necessary to comply with worker’s compensation laws or purposes.
Planned Uses or Disclosures to Which You May Object
We will use or disclose your health information for any of the purposes described in this section unless you affirmatively and object to or otherwise restrict a particular release. You must direct your written objections or restrictions to: Privacy Officer, 14340 Metcalf Avenue Overland Park, KS 66223.
We may use or disclose your health information to contact you and remind that you have an appointment for treatment or medical care.
We may use or disclose your health information to provide you with information about or recommendations of possible treatment options or alternatives that may interest you.
We may use and disclose your health information to inform you about health benefits or services that may interest you.
We may use health information about you to contact you in an effort to raise money for the Practice. A Foundation related to the Practice may receive contact information, which includes your name, address and phone number and the dates that you received services from the Practice.
We may release health information about you to a friend and/or family member who is involved in your care. We can tell your family and/or friends of your condition and that you are in the Practice for treatment or services. We can also given this information to someone who will help or is helping to pay for your care.
We can disclose health information about you to a public or private entity that is authorized by law or its charter to assist in disaster relief efforts, i.e., the American Red Cross, for the purpose of notification of family and/or friends of your whereabouts and condition.
Other Uses or Disclosures
Uses or disclosures not covered in this Notice of Privacy Practices will not be made without your written authorization. If you provide us written authorization to use or disclose information, you can change your mind and revoke your authorization at any time, as long as it is in writing. If you revoke your authorization, we will no longer use or disclose the information. However, we will not be able to take back any disclosures that we have made pursuant to your previous authorization.
Your Rights with Respect to Health Information
Right to Request Restrictions: You have the right to request that we restrict any use or disclosure of your health information. We are not required to agree to any restriction that you request. If we do agree to adhere to your restrictions, we will comply with your request unless the information is needed to provide you treatment. Any request to restrict uses or disclosures must be made in writing to: Privacy Officer. Your request must indicate (1) what information you want limited; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.
Right to Receive Information in Certain Form and Location: You have the right to receive information about your health in a certain form and location. For instance, you can request that we not contact you at work. To request confidential communications, you must make your request in writing to: Privacy Officer. The request must tell us how and/or where you want to receive information. We will accommodate reasonable requests.
Right to Inspect and Copy PHI: You have the right to inspect and copy your health information that may be used to make decisions about your care, with the exception of any psychotherapy notes that we might have created. If you want to see or copy your medical information, you must submit your request in writing to: Privacy Officer. If you request copies of information, we may charge a fee for any costs associated with your request, including the cost of copies, mailing or other supplies.
In limited circumstances we can deny access to your health information. If access is denied, you can request that the denial be reviewed. Another licensed health care professional chosen by the Practice will review your request and the denial. We will adhere to the decision of the reviewer.
Right to Request Amendment to PHI: You have a right to request that your health information be changed if you believe that it is incorrect or incomplete. You have a right to request changes for as long as the information is kept by the Practice. To request a change in your information, you must submit it in writing to Privacy Officer. In addition, you must give the reason that you want the information changed, including why you think the information is incorrect or incomplete.
We can deny your request if it is not in writing and if it does not include a reason why the information should be changed. We can also deny your request for the following reasons: (1) the information was not created by the Practice, unless the person or entity that did create the information is no longer available; (2) the information is not part of the medical record kept by or for the Practice; (3) the information is not part of the information that you would be permitted to inspect and copy; or (4) we believe the information is accurate and complete.
Right to an Accounting of Disclosures: You have the right to receive an accounting of disclosures of medical information that we have made, with some exceptions. You must submit your request in writing to: Privacy Officer. Your request must state the time period that may not be longer than six (6) years and may not include dates before April 14, 2003. You should include how you want the information reported to you, i.e., by paper, electronically, etc. You have the right to receive a free accounting every twelve (12) months. If you request more than one (1) accounting in a twelve (12) month period, we may charge you a reasonable fee for the costs of providing that list. We will notify you of the charge for such a request and you can then choose to withdraw or change your request before any costs are incurred.
You have the right to a paper copy of this Notice of Privacy Practices. Even if you have agreed to receive this notice in another form, you can still have a paper copy of this notice. To obtain a paper copy of this notice, contact the Privacy Officer. [You can obtain a copy of this notice at our Web site, www.advancedcosmeticsurgerykc.com.]
If you believe that we have violated any of your privacy rights or have not adhered to the information contained in this Notice of Privacy Practices, you can file a complaint by putting it in writing and sending it to: Privacy Officer, 14340 Metcalf Avenue Overland Park, KS 66223 (913) 341-2188. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint with either the Practice or the U.S. Department of Health and Human Services.
Changes to This Notice of Privacy Practices
We reserve the right to change or modify the information contained in this Notice of Privacy Practices. Any changes that we make can be effective for any health information that we have about you and any information that we might obtain. Each time you receive services from the Practice, we will provide the most current copy of our Notice of Privacy Practices. The most recent version of Privacy Practices will be posted in our building. Also, you can call or write our contact person, whose information is included on the first page of this Notice of Privacy Practices, to obtain the most recent version of this Manual.