NOTICE OF PRIVACY PRACTICES
Effective Date: September 2013
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.
WHO WILL FOLLOW THIS NOTICE?
This Notice describes the practices of Statesboro Plastic Surgery and the practices that will be followed by all of Statesboro Plastic Surgery workforce members who handle your medical information.
OUR PLEDGE REGARDING YOUR PROTECTED HEALTH INFORMATION
Statesboro Plastic Surgery understands that medical information about you and your health is personal. We are committed to protecting medical information about you. We maintain our records and conduct our treatment environment with a goal of providing the highest level of protection for your medical information, while still providing you with the highest level of medical care. This Notice applies to all of the records of your medical care which are received or created by Statesboro Plastic Surgery.
Your other medical treatment providers (e.g., doctors, hospitals, home health agencies, etc.) may have different policies or notices regarding the use and disclosure of your medical information.
This Notice will tell you about the ways in which Statesboro Plastic Surgery may use and disclose medical information about you. Your medical information, also referred to as “protected health information,” is that information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health information and related health care services.
In this Notice, we also describe your rights and certain obligations Statesboro Plastic Surgery has regarding the use and disclosure of your protected health information. We are required by law to:
- make sure that medical and other information that identifies you (protected health information) is kept private;
- give you this Notice of our legal duties and privacy practices with respect to protected health information about you; and
- follow the terms of the Notice that is currently in effect.
USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
By becoming a patient of Statesboro Plastic Surgery, you are giving consent for Statesboro Plastic Surgery to use your protected health information for certain activities, including treatment, payment and other health care operations. Sometimes, you may hear these three activities referred to as “TPO.”
First of all, we may use and disclose protected health information about you so that Statesboro Plastic Surgery and its medical professionals can treat you. For example, we may use your past medical information in order to diagnose your present condition or we may provide information regarding your medical condition to another doctor to whom we refer you for additional care. We may also use and disclose protected health information about you so that we may be paid for the medical treatment we provide you. For example, we will submit protected health information about you to your insurance company in order to receive payment for services we have provided to you. We may also use and disclose protected health information about you for Statesboro Plastic Surgery’s health care operations, in other words, those other tasks that we need to perform to make sure that you are provided the highest quality of medical care. For example, we may use your protected health information to evaluate how we can better meet your needs or we may provide protected health information about you to an auditor who reviews our books so that we can keep our license to provide medical services in GA.
OTHER USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
The following uses of your protected health information may be made without any additional authorization from you. (Not every use or disclosure is listed, but be assured that all uses and disclosures made by Statesboro Plastic Surgery are only those which are permitted under the law):
USES AND DISCLOSURES FOR APPOINTMENT REMINDERS
We may use and disclose your medical information to contact you as a reminder that you have an appointment at the office. If you request that such communications be made confidentially, please contact our office in writing at 1402 Brampton Ave, Statesboro GA 30458. We will accommodate all reasonable requests.
USES AND DISCLOSURES TO OTHERS INVOLVED IN YOUR HEALTH CARE
We may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person’s involvement in your medical care. If you are unable to agree or object to this disclosure, we may disclose such information as necessary if we determine that it is in your best interests based on our professional judgment. We may also use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
USES AND DISCLOSURES IN EMERGENCY SITUATIONS
We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician will attempt to obtain your acknowledgment of this Notice as soon as reasonably practicable after the delivery of treatment.
USES AND DISCLOSURES FOR HEALTH-RELATED BENEFITS OR SERVICES
From time to time, Statesboro Plastic Surgery may use and disclose protected health information to tell you about certain health-related benefits or services that may be of interest to you.
USES AND DISCLOSURES REQUIRED BY LAW
We will use or disclose protected health information about you when required to do so by federal, state, or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if the law requires us to do so, of any such uses or disclosures. We must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the law.
USES AND DISCLOSURES FOR PUBLIC HEALTH ACTIVITIES
We may disclose your protected health information for public health activities and disclosure for such purposes will be to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for purposes such as controlling disease, injury or disability. Disclosures to public health authorities may include disclosure to a foreign authority that is working with the public health authority.
USES AND DISCLOSURES RELATED TO COMMUNICABLE DISEASES
We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
DISCLOSURES FOR HEALTH OVERSIGHT ACTIVITIES
We may disclose protected health information to a health oversight agency for activities authorized by law. These activities include, for example, audits, investigations, and inspections. These activities are necessary for the government to monitor the health care system, the delivery of health care, government benefit programs, other government regulatory programs and civil rights laws.
DISCLOSURES OF ABUSE OR NEGLECT
We may disclose your protected health information to a public health authority authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to a governmental entity or agency authorized to receive such information. In such cases, the disclosure will only be made in accordance with GA law.
DISCLOSURES TO THE FOOD AND DRUG ADMINISTRATION
We may disclose your protected health information to a person or company required by the Food and Drug Administration (FDA) to report adverse events, product defects or other problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements; or to conduct post-market surveillance, as required.
DISCLOSURES FOR LAWSUITS AND DISPUTES
If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court order or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
DISCLOSURES TO LAW ENFORCEMENT
We may release protected health information if asked to do so by a law enforcement official, in response to a court order, subpoena, warrant, summons, or similar process. Other related disclosures may include disclosures relating to individuals who are Armed Forces personnel, to national security and intelligence agencies, as well as disclosures to authorized federal officials for the protection of the President of the United States or other authorized persons or foreign heads of state.
DISCLOSURES TO CORONERS, FUNERAL DIRECTORS, AND ORGAN DONATION
We may disclose protected health information about you to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties required by law. We may also disclose protected health information about you to a funeral director in order to permit the funeral director to carry out legal duties, and may do so if death is reasonably anticipated. Your protected health information may also be disclosed for certain organ donations to which you may have agreed.
DISCLOSURES FOR RESEARCH
Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.
DISCLOSURES RELATED TO CRIMINAL ACTIVITY
We may disclose your protected health information, consistent with federal and GA laws, if we believe that the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public, or if it is necessary for law enforcement authorities to identify or apprehend an individual.
DISCLOSURES FOR WORKERS’ COMPENSATION
We may release protected health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
DISCLOSURES TO BUSINESS ASSOCIATES
We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
DISCLOSURE HEALTH INFORMATION AFTER DEATH
The health care provider may use or disclose information without your authorization 50 years after the date of death. Statesboro Plastic Surgery may disclose decedent’s PHI to family members and others who were involved in care/payment for care of decedent prior to death, unless inconsistent with prior expressed preference.
DISCLOSURE STUDENT IMMUNIZATION RECORDS
Statesboro Plastic Surgery may disclose proof of immunization of a child to schools in Georgia. In such cases, the disclosure will only be made in accordance with GA law.
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT
Individuals Involved in Your Care or Payment for Your Care
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
Disaster Relief
We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.
Fundraising
If Statesboro Plastic Surgery uses and disclose PHI for fundraising communications. We may contact you for fundraising efforts, but you can tell us not to contact you again. Statesboro Plastic Surgery will honor your decision to opt out.
When Statesboro Plastic Surgery is Required to Obtain an Authorization to Use or Disclose Your Health Information
The following uses and disclosures of your Protected Health Information will be made only with your written authorization:
- Uses and disclosures of Protected Health Information for marketing purposes; and
- Disclosures that constitute a sale of your Protected Health Information
Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
1. Right to Inspect and Copy
You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to Statesboro Plastic Surgery 1402 Brampton Ave Statesboro, GA 30458. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.
2. Right to an Electronic Copy of Electronic Medical Records
If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
3. Right to Request Restrictions
You have the right to request that we restrict the use and disclosure of your protected health information for treatment, payment and health care operations. For example, if you are an employee in a clinic and you receive health care services in that clinic, you may request that your medical record not be stored with the other clinic records. However, we are not required to agree in all circumstances to your requested restrictions, except in the case of a disclosure restricted to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and the protected health information pertains solely to a health care item or service for which you, or the person other than the health plan on your behalf, has paid the covered entity in full. If you would like to make a request for restrictions, you must submit your request in writing to Statesboro Plastic Surgery 1402 Brampton Ave, Statesboro GA 30458. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. 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.
4. Right to Confidential Communications
You also have the right to request to receive private health information communications (cell phone, e-mail) by alternative means or at alternative locations. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to 1402 Brampton Ave Statesboro, GA 30458. 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.
5. Right to Amend
If you feel that the protected health information we have about you is incorrect or incomplete, you have the right to request that your protected health information be amended. Only the health care entity (e.g., doctor, hospital, clinic, etc.) that created your protected health information is responsible for amending it. For more information regarding the procedures for submitting such a request, contact 1402 Brampton Ave Statesboro, GA 30458
6. Right to an Accounting of Disclosures
You have a right to an accounting of disclosures of your protected health information, for purposes other than treatment, payment or health care operations by Statesboro Plastic Surgery or any of the people or companies who perform treatment, payment or health care operations on our behalf. To request this list of disclosures we made of protected health information about you, you must submit a request in writing to 1402 Brampton Ave Statesboro, GA 30458. Your request must state a time period which may not be longer than six (6) years prior to the date of your request and may not include dates before April 16, 2003. Your request should indicate the form in which you want the list (for example, on paper or electronically). We must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request such list more than once per year.
7. 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.
- You may obtain a copy of this Notice at our website: www.statesboroplasticsurgery.com
- To obtain a paper copy of this Notice, contact 681.3330.
8. Change to this Notice
Statesboro Plastic Surgery reserves the right to change this notice. We reserve the right to make the revised or changed Notice effective for protected health information we already have about you, as well as any information we create or receive in the future. We will post a copy of the current Notice on Statesboro Plastic Surgery website. The Notice will contain, in the top right-hand corner, the effective date.
9. Notified of a Breach
Your provider is required by law to maintain the privacy of protected health information and provide you with notice of its legal duties and privacy practices with respect to protected health information and to notify you following a breach of unsecured protected health information.
10. Complaint
If you believe your privacy rights have been violated and/or that Statesboro Plastic Surgery has not followed this policy, you may file a complaint with Statesboro Plastic Surgery or with the Secretary of the Department of Health and Human Services. To file a complaint with Statesboro Plastic Surgery contact Statesboro Plastic Surgery 1402 Brampton Ave Statesboro, GA 30458 912.681.3330. We request that you file your complaint in writing so that we may better assist in the investigation of your complaint. You will not be penalized for filing a complaint.
11. Out-of-Pocket-Payments
If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
12. Minimum Necessary
For routine or recurring request and disclosures, Statesboro Plastic Surgery has standard protocols to limit your PHI.
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 Statesboro Plastic Surgery will be made only with your written permission (“authorization”). If you provide us permission to use or disclose protected health information about you, 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 authorization. You 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 medical treatment or other services that we have provided to you.
QUESTIONS?
If you have any questions regarding this notice, please contact Statesboro Plastic Surgery @ 912.681.3330 or mail your request to 1402 Brampton Ave Statesboro, GA 30458