Facial Plastic Surgery of Privacy Practices
Effective August 1, 2005
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 Facial Plastic Surgery and the practices that will be followed by all of Facial Plastic Surgery workforce members who handle your medical information.
OUR PLEDGE REGARDING YOUR PROTECTED HEALTH INFORMATION
Facial 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 notices applies to all of the records of your medical care which are received or created by Facial 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 Facial 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 Facial Plastic Surgery has regarding the use and disclosure of your protected health information. We are required by name to:
- Make sure that medical and other information that identifies you (protected health information) is kept private.
- Give your this notice of our legal duties and privacy practices with respect to protected health information about you.
- 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 at Facial Plastic Surgery, you are giving consent for Facial 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 Facial 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 Facial 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 .
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 Facial Plastic Surgery are only those which are permitted under the law).
Licensure proceedings by the American Board of Plastic Surgery.
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 1608 Walnut Street 9th Floor Suite 902B Philadelphia PA 19103. We will accommodate all reasonable requests.
Uses and disclosures to others involved in your healthcare
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, Facial Plastic Surgery may use and disclosure 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 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 Statename 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
We may disclose your protected health information to researchers when their research has been approved and protocols have been established to ensure the privacy of your information. We may also disclose a limited set of your information, as allowed under the law, for research purposes.
Disclosures related to criminal activity
We may disclose your protected health information, consistent with federal and Statename 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 illnesses.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
Right to inspect and copy
You have the right to inspect and copy protected health information that may be used to make decisions about your medical care. Usually this right includes both medical and billing records. 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, mailing or other supplies associated with your request. Your request to inspect and copy your information may only be denied in very limited circumstances and you have a right to request that any such denial be reviewed.
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. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to 1608 Walnut Street 9th Floor Suite 902B Philadelphia PA 19103. In your request, you must tell us:
- What information you want to limit.
- Whether you want to limit our use, disclosure, or both.
- To whom you want the limits to apply.
Right to confidential communications
You also have the right to request to receive private health information communications (such as appointment confirmations) 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 1608 Walnut Street 9th Floor Suite 902B Philadelphia PA 19103. 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.
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 1608 Walnut Street 9th Floor Suite 902B Philadelphia PA 19103.
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 Facial 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 1608 Walnut Street 9th Floor Suite 902B Philadelphia PA 19103. 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 August 1, 2005. Your request should indicate the form in which you want the list (for example, on paper or electronically). You will be charged for photocopying.
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: http://www.beckerentcenter.com
To obtain a paper copy of this Notice, contact 856-772-1617
To learn more about these procedures, or to make any of these requests, you should contact our Office Manager at 856-772-1617.
Changes to this notice
Facial 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 Facial Plastic Surgery website: http://www.beckerentcenter.com. The Notice will contain, in the top right-hand corner, the effective date.
Complaints
If you believe your privacy rights have been violated and/or that Facial Plastic Surgery or Dr. Dan Becker has not followed this policy, you may file a complaint with Dr. Dan Becker Office Manager or with the Secretary of the Department of Health and Human Services.
To file a complaint with Dr. Dan Becker contact Office Manager, 1608 Walnut Street 9th Floor Suite 902B Philadelphia PA 19103. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
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 Dr. Dan Becker 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 the Office Manager at Facial Plastic Surgery.
Pledge Regarding Privacy
This page describes the type of information we gather about you, with whom that information may be shared and the safeguards we have in place to protect it. You have the right to the confidentiality of your medical information and the right to approve or refuse the release of specific information except when the release is required by law. If the practices described in this brochure meet your expectations, please sign at the bottom of the page indicating your agreement. If you prefer that we not share information we may honor your written request in certain circumstances described below. If you have any questions about this notice, please contact our Privacy Officer at the address below.
WHO WILL FOLLOW THIS NOTICE
This notice describes the Becker Nose and Sinus Centerðs practices regarding the use of your medical information and that of: Any health care professional authorized to enter information into your Clinic chart or medical record employees, staff and other personnel who may need access to your information All entities, sites and locations of Becker Nose and Sinus Center follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or health care purposes described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal. Protecting medical information about you is important. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the Becker Nose and Sinus Center, whether made by health care professionals or other personnel. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to:
keep medical information that identifies you privately
give you this notice of 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.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we may use and disclose medical information. Not every use or disclosure in a category will be listed.
For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, training doctors, or other health care professionals who are involved in taking care of you. Different health care professionals also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the Clinic who may be involved in your medical care after you leave the Clinic or that provide services that are part of your care.
For Paymen:t We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, your insurance company may need to know about surgery you received so they will pay us or reimburse you for the surgery. We may also use and disclose medical information about you to obtain prior approval or to determine whether your insurance will cover the treatment.
For Health Care Purposes: We may use and disclose medical information about you for health care purposes. This is necessary to make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, nurses, technicians, and training doctors, for review and learning purposes. If we do disclose this information, we will remove or omit any information which identifies you specifically.
Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.
Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and disclose medical information to tell 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 medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also update your family or friends regarding your condition Research Medical information about you will NOT be used or disclosed for research purpose unless all specific identifying information about you is removed from the information. (i.e. the information will only be used anonymously).
As Required By Law We will disclose medical information about you when required to do so by federal, state or local law.
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 to your 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.
SPECIAL SITUATIONS
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.
Public Health Risks:
We may disclose medical information about you for public health activities. These activities generally include the following:
to prevent or control disease, injury or disability;
to report births and deaths;
to report child abuse or neglect;
to report reactions to medications or problems with products;
to notify people of recalls of products they may be using;
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;
to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence.
Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes: We may disclose medical information about you in response to a subpoena, discovery request, or other lawful order from a court.
Law Enforcement: We may release medical information if asked to do so by a law enforcement official as part of law enforcement activities; in investigations of criminal conduct or of victims of crime; in response to court orders; in emergency circumstances; or when required to do so by law.
Coroners, Medical Examiners and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
Protective Services for the President, National Security and Intelligence Activities: We may release medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations, or for intelligence, counterintelligence, and other national security activities authorized by law.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer at the address on the last page.
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 Becker Nose and Sinus Center will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept.
To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, 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. In addition, we may deny your request if you ask us to amend information that:
Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
– Is not part of the medical information kept by the Becker Nose and Sinus Center;
– Is not part of the information which you would be permitted to inspect and copy; or
– Is innaccurate and incomplete.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical information about you. To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer.
Right to Request Restrictions
You have the right to request a restriction or limitation on the medical 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 medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to our Privacy Officer at the address below. 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.
Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. 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 our Privacy Officer. 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.
Right to a Paper Copy of This Notice
You have the right to a paper 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.
You may obtain a copy of this notice at our website,
To obtain a paper copy of this notice, please request one in writing from our Privacy Officer at the address below.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice. The notice will contain on the first page, in the top right-hand corner, the effective date.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Becker Nose and Sinus Center or with the Secretary of the Department of Health and Human Services. To file a complaint with the Becker Nose and Sinus Center, contact our Privacy Officer at the address and phone number listed below. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
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. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, thereafter 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.
PRIVACY OFFICER:
1-215-948-2881
