Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED TO OTHER PERSONS AND/OR ENTITIES, YOUR RIGHTS, AND HOW YOU MAY ACCESS THIS INFORMATION.
Uses and Disclosures: Dr. Steve Laverson and Plastic Surgery office staff use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care you receive. Continuity of care may be important to your treatment, and if necessary, your records may be shared with other providers to whom you are referred, or from whom you were referred. Dr. Laverson and/or Feel Beautiful staff may use or disclose your personally identifiable health information (including photographs) without your authorization in several routine situations, but beyond those circumstances, we will ask for your written authorization before using or disclosing any identifiable health information about you. Included in routine use is the sharing of your “before and after” pictures with others interested in the same procedure you had, including in online galleries of “before and after” results. Not included in routine use is the publishing of your pictures in print and/or electronic media for marketing/advertising. Please review the Feel Beautiful Photographic Consent for more information.
Your Rights: You have the right to inspect and obtain a copy of health information about you. Normal photocopy fees and/or photographic printing fees apply. You also have the right to receive a list of disclosures of your information. If you believe information in your record is incorrect, you may request correction of the record.
Our legal and professional duty: We are required by law and by professional plastic surgery standards to protect the privacy of your information, to provide this notice about our information management procedures, to follow the practices here enumerated, and to document your acknowledged receipt of this notice. Before changing our policies, our notice will be changed and posted in the waiting area. You will be provided a copy of this notice upon request. For more information about our privacy practices, contact Cherise Jacobs, Privacy Officer, at 858-295-4001, email email@example.com.
Complaints: If you believe your privacy rights may have been violated or you disagree with a disclosure we implemented, please contact the Privacy Officer above and/or submit a written complaint to the U.S. Department of Health and Human Services, Office for Civil Rights, Region IX, 90 7th Street, Suite 4-100, San Francisco, CA 94103, phone 415-437-8310 or 800-368-1019, or visit http://www.hhs.gov/ocr/.
Uses and Disclosures of Protected Health Information
Following are examples of the types of uses and disclosures of your protected health care information that Dr. Laverson is permitted. These are common types of uses and disclosures, but other routine disclosures may be permitted without your authorization.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and related services. For example, Dr. Laverson may refer you to another physician or specialist, and have a phone conversation about your condition with that other physician or specialist describing information about your history, examination, laboratory findings, radiographic findings, and/or past treatment. This information is provided to assist the other professional to diagnose or treat you.
Payment: Your protected health information will be used as needed to substantiate care for which third party payer(s) are billed. Pre-authorization for surgery and/or hospitalization may require disclosure of your protected health information to the payer or an agency of the payer.
Healthcare Operations: In scheduling surgery, your diagnosis and/or planned procedure will be disclosed to hospital or surgery center personnel.
Business Associates: Your protected health information may be shared with third party business associates such as our billing service, transcription service, and/or bilingual interpreter(s). All of our contracted business associates handling your protected information have agreed to written terms protecting the privacy and confidentiality of your record.
Marketing: We display potentially identifiable information about patients in the course of informing the interested public about expected results of procedures Dr. Laverson performs. Distribution of this information, generally photographs, is restricted by Dr. Laverson’s discretion. Please see photographic consent. Although we appreciate satisfied patients informing others of their treatment, we will never inform another individual, even a friend of yours or member of your family, about your diagnosis and treatment without your express written consent to do so. Only if this friend or family member is involved in your care will they receive protected health information about you, and then, only that information which must be disclosed to facilitate your care. All treatments you receive are strictly confidential and private, with the exceptions described.
Complaints: If you submit a complaint to any consumer protection agency or other entity, public or private, and we are asked to respond, your information may be disclosed in our response.
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke your authorization at any time in writing, but information disclosed prior to revoking authorization will not be affected.
Opportunity to Object
We may use and disclose your protected health information in the following instances. You may object to these uses and disclosures. If you are not present or unable to object, Dr. Laverson may exercise professional judgment to determine whether or not the disclosure is in your best interest.
Others involved in your healthcare: As mentioned above, we may disclose to a friend, family member, or any other person you identify, your protected health information if disclosure is necessary in your care and/or well-being.
Emergencies: In an emergency treatment situation, you will receive a Notice of Privacy Practices as soon as reasonably practical after your emergency care.
Communication Barriers: We may use and disclose your protected health information if we have attempted to obtain acknowledgement from you of our Notice of Privacy Practices but have been unable to do so due to communication barriers and we determine, in Dr. Laverson’s best professional judgment, that you would agree.
Without Opportunity to Object
We may use or disclose your protected health information in the following situations without your authorization or opportunity to object:
Public Health: For public health purposes to a public health authority or to a person who is at risk of contracting or spreading your disease.
Health Oversight/Regulation: Your information may be disclosed to a city, county, state, federal, public, or private agency in compliance with legal mandates and/or statutes, such as audits, investigations, and inspections.
Abuse or Neglect: To an appropriate authority to report child or elder abuse or neglect, and/or if we believe you may be a victim of abuse, neglect, or domestic violence.
Food and Drug Administration (FDA): As required by the FDA to track products.
Legal Proceedings: In the course of legal proceedings.
Law Enforcement: For law enforcement purposes, if you have been a vicim of crime, or to prevent a crime.
Research: To researchers when their research has been approved by an Institutional Review Board or Privacy Board.
Military Personnel, Inmates, National Security: To military supervisors of Armed Forces personnel or to custodians of inmates, as necessary. Preserving national security may also necessitate disclosure of protected health information. Fugutives of the law presenting for plastic surgery to alter physical characteristics may be subject to disclosure of protected health information.
Workers Compensation: To comply with workers’ compensation laws
Coroners, Funeral Directors, and Organ Donation: For the Coroner, Medical Examiner, or Funeral Director to perform duies authorized by law and for organ donation purposes.
Compliance: To the Department of Health and Human Services to monitor our compliance.
In summary, we respect your right to privacy and the privacy of your information very seriously. We will only use or disclose your protected health information as required by law, limited to the relevant requirements of the law, and in your best interest and the best interest of citizens of the United States of America.
You have the right to:
Inspect and copy your protected health information. Photocopy and printing charges apply. Access will be granted whether or not we were the source of the information. Exceptions to your access occur rarely, such as when disclosure of information may be dangerous. If we deny access, an explanation will be provided. If the denial is contested, a third party review will be commissioned. Access must be requested in writing. Reasonable time must be permitted to elapse, up to 30 days, to fulfill the request.
Request a restriction of your protected health information. You may ask us not to use or disclose part or all of your protected health information for treatment, payment, or healthcare operations. You may also request that information not be disclosed to family members or friends who may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you request, but we make every effort to agree with your request. If we do agree, then we must protect your information accordingly.
Request to receive confidential communications from us by alternative means or at an alternative location. We accommodate reasonable requests. We may condition this accommodation upon payment for services. We will not require an explanation from you about the basis of your request.
Ask for amendment of your protected health information. You may request an amendment of protected health information about you. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and your medical record will note the disputed information. It is improper to delete or alter portions of the medical record, but additional explanation and/or documentation is OK.
Receive an accounting of disclosures. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations. It excludes disclosures to you, to friends or family members involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures. Your right to receive this information is subject to certain exceptions, restrictions, and limitations.
Receive an accounting of disclosures. This right applies to disclosure for purposes other than treatment, payment, or healthcare operations. It excludes disclosures to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures. The right to receive this information is subject to certain exceptions, restrictions, and limitations. Your request must be in writing, and we have 60 days to respond. Our accounting to you will be in writing, will include the dates of disclosure and to whom the information was sent, describe what information was sent, and will state the purpose of the disclosure.
Obtain a paper copy of this notice from us. Upon request, even if you agreed to accept this notice electronically.
Communications of protected health information will be handled carefully, and that care will be documented. Regarding the Medical Record, only the minimum necessary information will be shared, and only with the minimum number of personnel and/or entities.
Phone and Face to Face: Consultations with Dr. Laverson or other staff is private, and behind closed doors. However, in the reception area, the patient is in the presence of others who do not have a need to know the patient’s private details. Staff should not give information about a patient to another person without the patient’s permission. The same principle applies to the phone. When staff contacts the patient for reminders about appointments or staff is discussing a health or treatment issue with a patient by phone, they should take reasonable steps to avoid conveying private and protected health information to any individual other than the patient or patient guardian.
E-mail Policy: When e-mail is used for communication of individually identifiable health information, a notation referring to the confidential nature of the information should be made in the subject line. The information is to be distributed only to those with a legitimate need to know.
Retention of e-mail/text messaging: Non-vital information may be discarded immediately after communication. E-mail considered important, clinically or otherwise, may be printed and retained as a formal part of the written medical record.
Patient use of e-mail / text messaging: E-mail and text messaging communication are conveniences and NOT APPROPRIATE FOR EMERGENCIES OR TIME-SENSITIVE ISSUES. Text messaging may be used to communicate, but if not answered, should be followed up by telephone, paging, and/or Emergency Room visit.
Privacy of e-mail and/or text messages cannot be guaranteed.
Facsimile (FAX) Policy
Sending: Information sent by FAX will have a cover page specifying the addressee, the sender, and a notice mandating confidentiality of protected health information: Transmitted information is private, and a confidential part of the medical record. Reproduction, dissemination, distribution, and/or unauthorized use of this information is strictly prohibited, and punishable by law. If you are not the intended recipient of this information, please transmit or deliver directly to the intended recipient. If this is not possible, please notify the sender and destroy this information immediately.
Receiving: FAX machines will be regularly checked for transmissions, and protected health information filed appropriately. FAX machines will be placed in locations accessible to office staff, but not to passersby. Documents will be removed promptly, senders will be notified of problems, and cover page instructions will be implemented.
Acknowledgement of Receipt of Notice of Privacy Practices:
Please sign and print your name and the date below, and return this form to office staff.