THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of your health information. We also are required by law to tell you how we may use and disclose your health information; your privacy rights in your health information, and our obligations concerning the use and disclosure of your health information
The terms of this notice apply to all records containing your health information that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location and on our website, www.indyplasticsurgery.com, and you may request a paper copy of our current Notice at any time.
Throughout this Notice of Privacy Practices, you may be instructed to contact our Privacy Officer, either by phone or in writing. Written requests or instructions may be mailed to: Privacy Officer, The Gillian Institute, 8455 Clearvista Place, Indianapolis, IN 46256, or by e-mail to firstname.lastname@example.org. Questions or concerns may be communicated in writing or by telephoning the Privacy Officer at (317) 913-3260.
WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR SPECIFIC WRITTEN AUTHORIZATION IN THE FOLLOWING CIRCUMSTANCES:
Treatment: Our practice may use your health information to treat you. For example, we might use your health information to order laboratory or other diagnostic tests, schedule surgery, or to write or phone in a prescription for you. Many of the people who work for our practice—including, but not limited to, Dr. Kimberly Short and our nurses—may use or disclose your health information in order to treat you or to assist others in your treatment, including providing your health information to a physician to whom we have referred you for further care. Additionally, we may disclose your health information to others who may assist in your care, such as your spouse, children, or parents.
Payment: Our practice may use and disclose your health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your health information to obtain payment from third parties that may be responsible for such costs, such as family members.
Health Care Operations: Our practice may use and disclose your health information in the business operations of our practice. These activities include, but are not limited to, quality assessment reviews, employee reviews, and the preparation and recording of your treatment in our practice. An example of the use of your health information for operations is that our practice may contact you and remind you of an appointment.
Other Services: We may use your health information to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may use your name and address to send you a newsletter about our practice and the services we offer. You may write our Privacy Officer to request that these materials not be sent to you.
Special Circumstances: The following categories describe unique scenarios in which we may use or disclose your health information:
- * To public health authorities and health oversight agencies that are authorized by law to collect information.
* Lawsuits and similar proceedings in response to a court or administrative order.
* If required to do so by a law enforcement official.
* When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
* If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
* To federal officials for intelligence and national security activities authorized by law.
* To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
* For Workers Compensation and similar programs.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
Right to Provide an Authorization for Other Uses and Disclosures: Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization.
Confidential Communications: You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. Unless you instruct us to the contrary, we may leave messages reminding you of an appointment at your home with a relative or on your answering machine and allow your spouse, parent, or child to schedule or change your appointments. To request a type of confidential communication, write the Privacy Officer, specifying the requested method of contact, or the location where you wish to be contacted. We will accommodate reasonable requests.
Requesting Restrictions: You have the right to request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. To request a restriction in our use or disclosure of your health information, write our Privacy Officer and describe in a clear and concise fashion the information you wish restricted; whether you are requesting to limit our practice’s use, disclosure, or both; and to whom you want the limits to apply.
Inspection and Copies: You have the right to inspect and obtain a copy of the health information we maintain on you, including patient medical records and billing records. Write the Privacy Officer in order to inspect and/or obtain a copy of your health information. We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
Amendment: You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, write the Privacy Officer. You must provide us with a reason that supports your request for amendment. We may deny your request if it is not in writing or if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the health information kept by or for the practice; or (c) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
Accounting of Disclosures: All of our patients have the right to request a list of any disclosures our practice has made of your health information for reasons other than treatment, payment, or operations or which were not authorized by you. In order to obtain an accounting of disclosures, you must submit your request in writing to the Privacy Officer and state a time period for which you are requesting the accounting, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with our practice, with the Secretary of the Department of Health and Human Services, or with the Office of Civil Rights. To file a complaint with our practice, write our Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.