Notice of Privacy Practices

This summary of our privacy practices is a condensed version of our Notice of Privacy Practices.
Effective Date: 04-14-03
Date of Last Revision:  04-14-03

This information is made available on request by a patient.

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.

We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private.
How will we use or disclose your information? Here are a few examples (for more detail please refer to the Notice of Privacy Practices that follows this summary):

• For medical treatment

• For research

• To obtain payment for our services

• To avert a serious threat to health or safety

• In emergency situations

• For organ and tissue donation

• For appointment and patient recall reminders

• For workers compensation programs

• To run our Practice more efficiently and ensure all our patients receive quality care

• In response to certain requests arising out of lawsuits or other disputes
  

If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the practice, contact our office manager or privacy officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
You have certain rights regarding the information we maintain about you. These rights include:

The right to inspect and copy
The right to request restrictions
The right to amend
The right to a paper copy of this notice
The right to an accounting of Disclosures
The right to request confidential communications

For more information about these right please see the detailed Notice of Privacy Practices that follows this summary.
NOTICE OF PRIVACY PRACTICES FOR
SALEM PLASTIC SURGERY, INC.

Effective Date: 04-14-03

Date of Last Revision:

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 APPLIES TO ALL OF THE RECORDS OF YOUR CARE GENERATED BY THE PRACTICE, WHETHER MADE BY THE PRACTICE OR AN ASSOCIATED FACILITY.
If you have any questions about this notice, please contact _________________
at ______________________.

WHO WILL FOLLOW THIS NOTICE:
1. Any health care professional authorized to enter information into your chart (including physicians, PAs, RNs, etc.);
2. All areas of the practice (front desk, administration, billing and collection, etc.);
3. All employees, staff, volunteers, and other personnel that work for or with our practice; and
4. Our business associates (including a billing service, or facilities to which we refer patients), on-call physicians, and so on.

The practice provides this notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create paper and electronic medical records about your health, our care for you, and the services and/or items we provide to you as our patient. We need this record to provide for your care and to comply with certain legal requirements.
The practice is required by law to:
1. Make sure that the protected health information about you is kept private.
2. Provide you with a Notice of our Privacy Practices and your legal rights with respect to protected health information about you.
3. Follow the conditions of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose protected health information that we have and share with others. Each category of uses or disclosures provides a general explanation and provides some examples of uses. Not every use or disclosure in a category is either listed or actually in place. The explanation is provided for your general information only.

SUMMARY OF PRIVACY PRACTICES FOR
SALEM PLASTIC SURGERY, INC.

This summary of our privacy practices is a condensed version of our Notice of Privacy Practices.
Effective Date: 04-14-03
Date of Last Revision: ______
This information is made available on request by a patient.

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.
We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private.
How will we use or disclose your information? Here are a few examples (for more detail please refer to the Notice of Privacy Practices that follows this summary):
For medical treatment For research
To obtain payment for our services To avert a serious threat to health or safety
In emergency situations For organ and tissue donation
For appointment and patient recall reminders For workers compensation programs
To run our Practice more efficiently and ensure all our patients receive quality care In response to certain requests arising out of lawsuits or other disputes

If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the practice, contact our office manager or privacy officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
You have certain rights regarding the information we maintain about you. These rights include:
The right to inspect and copy The right to request restrictions
The right to amend The right to a paper copy of this notice
The right to an accounting of Disclosures The right to request confidential communications
For more information about these right please see the detailed Notice of Privacy Practices that follows this summary.
NOTICE OF PRIVACY PRACTICES FOR
SALEM PLASTIC SURGERY, INC.

Effective Date: 04-14-03

Date of Last Revision:

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 APPLIES TO ALL OF THE RECORDS OF YOUR CARE GENERATED BY THE PRACTICE, WHETHER MADE BY THE PRACTICE OR AN ASSOCIATED FACILITY.
If you have any questions about this notice, please contact _________________
at ______________________.

WHO WILL FOLLOW THIS NOTICE:
1. Any health care professional authorized to enter information into your chart (including physicians, PAs, RNs, etc.);
2. All areas of the practice (front desk, administration, billing and collection, etc.);
3. All employees, staff, volunteers, and other personnel that work for or with our practice; and
4. Our business associates (including a billing service, or facilities to which we refer patients), on-call physicians, and so on.

The practice provides this notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create paper and electronic medical records about your health, our care for you, and the services and/or items we provide to you as our patient. We need this record to provide for your care and to comply with certain legal requirements.
The practice is required by law to:
1. Make sure that the protected health information about you is kept private.
2. Provide you with a Notice of our Privacy Practices and your legal rights with respect to protected health information about you.
3. Follow the conditions of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose protected health information that we have and share with others. Each category of uses or disclosures provides a general explanation and provides some examples of uses. Not every use or disclosure in a category is either listed or actually in place. The explanation is provided for your general information only.

1. Medical Treatment: We use previously given medical information about you to provide you with current or prospective medical treatment or services. Therefore we may, and most likely will, disclose medical information about you to doctors, nurses, technicians, medical students, or hospital personnel who are involved in taking care of you. For example, a doctor to whom we refer you for ongoing or further care may need your medical record. Different areas of the practice also may share medical information about you including your record(s), prescriptions, requests of lab work and x-rays. We may also discuss your medical information with you to recommend possible treatment options or alternatives that may be of interest to you. We also may disclose medical information about you to people outside the practice who may be involved in your medical care after you leave the practice; this may include your family members, or other personal representatives authorized by you or by a legal mandate (a guardian or other person who has been named to handle your medical decisions, should you become incompetent).

2. Payment: We may use and disclose medical information about you for services and procedures so they may be billed and collected from you, an insurance company, or any other third party. For example, we may need to give your health care information, about treatment you received at the practice, to obtain payment or reimbursement for the care. We may also tell your health plan and/or referring physician about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment, to facilitate payment of a referring physician, or the like.

3. Health Care Operations: We may use and disclose medical information about you so that we can run our practice more efficiently and make sure that all of our patients receive quality care. These uses may include reviewing our treatment and services to evaluate the performance of our staff, deciding what additional services to offer and where, deciding what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other practices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

We may also use or disclose information about you for internal or external utilization review and/or quality assurance, to business associates for purposes of helping us to comply with our legal requirements, to auditors to verify our records, to billing companies to aid us in this process and the like. We shall endeavor, at all times when business associates are used, to advise them of their continued obligation to maintain the privacy of your medical records.

4. Appointment and Patient Recall Reminders: We may ask that you sign in writing at the Receptionists' Desk, a "Sign In" log on the day of your appointment with the practice. We may use and disclose medical information to contact you as a reminder that you have an appointment for medical care with the Practice or that you are due to receive periodic care from the Practice. This contact may be by phone, in writing, e-mail, or otherwise and may involve leaving an e-mail, a message on an answering machines, or otherwise which could (potentially) be received or intercepted by others.

5. Emergency Situations: In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort or in an emergency situation so that your family can be notified about your condition, status and location.

6. Research: Under certain circumstances, we may use and disclose medical information about you for research purposes regarding medications, efficiency of treatment protocols and the like. All research projects are subject to an approval process, which evaluates a proposed research project and its use of medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We will obtain an authorization from you before using or disclosing your individually identifiable health information unless the authorization requirement has been waived. If possible, we will make the information non-identifiable to a specific patient. If the information has been sufficiently de-identified, an authorization for the use or disclosure is not required.

7. Required By Law: We will disclose medical information about you when required to do so by federal, state or local law.

8. To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat either to your specific health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

9. Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

10. Workers' Compensation: We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

11. Public Health Risks: Law or public policy may require us to disclose medical information about you for public health activities. These activities generally include the following:
a. to prevent or control disease, injury or disability;
b. to report births and deaths;
c. to report child abuse or neglect;
d. to report reactions to medications or problems with products;
e. to notify people of recalls of products they may be using;
f. to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
g. to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

12. Investigation and Government Activities. We may disclose medical information to a local, state or federal agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.

13. Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical 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.

14. Law Enforcement: We may release medical information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process. Medical information may also be released to identify or locate a suspect, fugitive, material witness, or missing person. Information about the victim of a crime may be released under certain circumstances, if we are unable to obtain the person's agreement. The practice will also disclose information if we believe a death may be the result of criminal conduct. Information will also be released if criminal conduct at the office is suspected.

15. Coroners, Medical Examiners, and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. Medical information about patients may also be released to funeral directors as necessary to carry out their duties.

16. Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution.

17. Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. Medical information may be disclosed about you to the Department of Veterans Affairs upon your separation or discharge from military services.

Covered health care providers that maintain an office or other physical site where they provide health care directly to individuals are required to post their entire notice at the facility in a clear and prominent location.

PATIENT'S RIGHTS UNDER HIPAA

Under HIPAA, individuals have the following rights:
1. Right to inspect and copy PHI. This includes your medical and billing records, but does not include psychotherapy notes. To inspect and/or copy your medical record, you must submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of copying and mailing your information. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the practice will review your request and denial. The person conducting the review will not be the person who denied your request. The practice will comply with the outcome and recommendations from that review.

2. Right to amend. If your feel that the medical information about you in your record is incorrect or incomplete, then you may ask us to amend the information. Your request must be submitted in writing, along with your amendment and a reason that supports your request to amend. The amendment must be dated and signed by you. The practice may deny your request for an amendment is it is not in writing or does not include a reason to support the request. Your request may also be denied if your ask for information to be amended that:
a. Is not part of the medical information kept by or for the practice;
b. Is not part of the information, which you would be, permitted to inspect and copy;
c. The information is accurate and complete; or
d. We did not create the information, unless the person or entity that created the information is no longer available to make the amendment.

3. The right to request restrictions on the use and disclosure of PHI. This right may not necessarily be granted

4. The right to an accounting of certain disclosures of PHI. This request must be submitted in writing and must state a time period. The time period cannot go back further than six years and may not include dates before April 14, 2003. You will be notified of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission, unless those uses can be reasonably inferred from the intended uses above. If you have provided us with your permission to use or disclose medical 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 medical information about you for the reasons covered by your written 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 care that we provided to you.

The patient has the right to a copy of this notice. You may ask for a copy of this notice at any time.

CHANGES TO THIS NOTICE:
The practice reserves the right to change this notice. The revised or changed notice will become effective immediately upon the completion of the revision. We will post a copy of the current notice in the office. The notice will contain the effective date. Each time you register at or are seen at the office for treatment, we will offer you a copy of the current notice.

COMPLAINTS:
If you believe your privacy rights have been violated, you may file a complaint with the office or with the Secretary of the Department of Health and Human Services. To file a complaint with the office, contact ____________________
at _______________________. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.