HIPPA Notice of Privacy Practice
Eugene D. Elliot, MD., Inc., F.A.C.S
Cosmetic and Reconstructive Plastic Surgery
Diplomatic American Board of Plastic and Reconstructive surgery
1441 Avocado Ave., Suite 710, Newport Beach, CA92660 714-241-0646
9900 Talbert Ave., Suite 101 Fountain Valley, CA 92708 714-241-0646
THI NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS O THIS INFORMATION. PLEASE REVIEW THIS CAREFULLY.
This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition related health care services.
1.Uses and disclosures of protected health information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, top support the operation of the physicians practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, pr manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example we would disclose your protected health information, as necessary, to a home health agency that provide care to you. For example, you protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital to stay may require that your relevant protected health information e disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of you physicians practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example we may disclose your protected health information to medical students that see patients at our office. In addition, we may use a sign in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you for your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by Law, Public Health issues as required by law, Communicable Diseases: Health Oversight Abuse or Neglect: Food and Drug Administrations requirements: legal proceeding: Law Enforcement: Coroners, Funerals Directors, and Organ Donation: Research: criminal activity: military activity and national security: workers compensation: inmates: required uses and disclosures: under the law, we must make disclosures to you and when required by the secretary of the department of health and human services to investigate or determine to compliance with the requirements of section 164.500
Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physicians practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may inspect or the following records; psychotherapy notes information compiled in reasonable or anticipation of or use of civil administrative action or proceeding criminal proceeding. And protected health information. That is subject to law that prohibits access to protected health information.
You have the right to request a restriction or your protected health information.
This means you may ask us not to use or disclose any party of protected health information for the purposes of treatment payment or health care operations. You may also request that any party of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this notice of privacy practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If physician believes it is in you best interest to permit use and disclosure of your protected heath information will not be restricted. You then have the right to use another health care professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us. Upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You have the right to receive an accounting of certain disclosures we have made if any of your protected health information
If
we deny your request for amendment you have the right to file statement of
disagreement with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information
We
reserve the right to change terms of this notice and will inform you by mail
of any changes. You then have the right to object or withdraw as provided
in this notice.
Complaints
You
may complain to us or to our secretary of health and human services if you
believe your privacy rights have been violated by us. You may file complaint
with us by notifying our privacy contact of your complaint. We
will not retaliate against you for making your complaint.
This
notice was published and becomes effective on/ or before April 14, 2003
We
are required by law to maintain the privacy of and provide individuals with
this notice of our legal duties and privacy practices with respect to protected
health information. If you have any objections to this form please ask to
speak with our HIPPA compliance officer in person or by phone at our main
phone number.
Signature
below is only acknowledgment that you have received this notice of our privacy
practices.
Print name: Signature Date: