Aesthetic Surgery of Charlotte Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 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 takes effect on October 1, 2016, and remains in effect until we replace it.

I. OUR PLEDGE REGARDING MEDICAL INFORMATION

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at Aesthetic Surgery of Charlotte. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

II. OUR LEGAL DUTY

Law Requires Us to:

  1. Keep your medical information private.
  2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
  3. Follow the terms of the current notice.

We Have the Right to:

  1. Change our privacy practices and the new terms of this notice at any time, provided that the changes are permitted by law.
  2. Make the changes in our privacy practice and the new terms of our notice effective for all medical information that we keep, including information previously created or received prior to the changes.

Notice of Change of Privacy Practices:

  1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies, please contact us using the information listed at the end of this Notice.

III. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION

The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice.

Treatment: Our practice may use your medical information to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your medical information in order to write a prescription for you, or we might disclose your medical information to a pharmacy when we order a prescription for you. Many of the people who work for our practice ¬including, but not limited to, our doctors and nurses ¬may use or disclose your medical information in order to treat you or to assist others in your treatment. Finally, we may also disclose your medical information to other health care providers for purposes related to your treatment.

Payment: Our practice may use and disclose your medical 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 medical information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your medical information to bill you directly for services and items. We may disclose your medical information to other health care providers and entities to assist in billing and collection efforts.

For Health Care Operations: Our practice may use and disclose your medical information to operate our business, which includes operation and maintenance of our electronic medical records system. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your medical information to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your medical information to other health care providers and entities to assist in their health care operations.

To Your Family, Friends, or Persons Involved In Care: Our practice must disclose medical information to you, as described in the Patient Rights section of this Notice. We may disclose your medical information to a family member, friend, or other person involved in your care to the extent necessary to help with your health care, but only if you agree we may do so. We will also use our professional judgment and our experience with common practice to make reasonable references of your best interest in allowing a person to pick up filled prescriptions, nutritional supplements, medical supplies, lab reports, or other similar forms of medical information.

Appointment Reminders: Our practice may use and disclose your medical information to contact you and remind you of an appointment.

Treatment Alternatives: Our practice may use and disclose your medical information to inform you of potential treatment options or alternatives.

Health-Related Benefits and Services: Our practice may use and disclose your medical information to inform you of health-related benefits or services that may be of interest to you.

Required By Law: Our practice may use or disclose your medical information when we are required to do so by federal, state or local law.

Public Health Risks: Our practice may disclose your medical information to public health authorities that are authorized by law to collect information for the purpose of:

  • Maintaining vital records, such as births and deaths,
  • Reporting child abuse or neglect,
  • Preventing or controlling disease, injury or disability,
  • Notifying a person regarding potential exposure to a communicable disease,
  • Notifying a person regarding a potential risk for spreading or contracting a disease or condition,
  • Reporting reactions to drugs or problems with products or devices,
  • Notifying individuals if a product or device they may be using has been recalled,
  • Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information,
  • Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

Health Oversight Activities: Our practice may disclose your medical information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

Lawsuits and Similar Proceedings: Our practice may use and disclose your medical information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your medical information in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information requested.

Law Enforcement: We may release your medical information if asked to do so by a law enforcement official:

  • Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement,
  • Concerning a death we believe has resulted from criminal conduct,
  • Regarding criminal conduct at our offices,
  • In response to a warrant, summons, court order, subpoena or similar legal process,
  • To identify/locate a suspect, material witness, fugitive or missing person,
  • In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

Serious Threats to Health or Safety: Our practice may use and disclose your medical information 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. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Military: Our practice may disclose your medical information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Inmates: Our practice may disclose your medical information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

Workers' Compensation: Our practice may release your medical information for workers' compensation and similar programs.

IV. PATIENT'S RIGHTS REGARDING MEDICAL INFORMATION

You have the following rights regarding medical information we maintain about you:

Right to Inspect & Copy: You have the right to look at or get copies of your medical information that may be used to make decisions about your care, with limited exceptions. Usually, this includes medical & billing records, but does not include psychotherapy notes. You must make a request in writing to obtain access to your medical information. Such requests can be sent to the address listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time.

Right to Amend: You may ask us to amend your medical 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, your request must be made in writing and submitted to the address at the end of this Notice. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the medical information kept by or for the practice; (c) not part of the medical information which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

Right to an Accounting of Disclosures: All of our patients have the right to request an "accounting of disclosures." An "accounting of disclosures" is a list of certain non-routine disclosures our practice has made of your medical information for purposes not related to treatment, payment or operations. Use of your medical information as part of the routine patient care in our practice is not required to be documented ¬ for example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to the address listed at the end of this Notice. All requests for an "accounting of disclosures" must state a time period, 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 Request Restrictions: You have the right to request a restriction in our use or disclosure of your medical information for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your medical 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. In order to request a restriction in our use or disclosure of your medical information, you must make your request in writing to the address listed at the end of this notice. Your request must 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,
  • 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. Such requests must be in writing and can be sent to the address listed at the end of this Notice. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

Right to a Paper Copy of the 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.

V. COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Aesthetic Surgery of Charlotte or with the Secretary of the Department of Health and Human Services. To file a complaint, contact Aesthetic Surgery of Charlotte. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

VI. CONTACT INFORMATION

Aesthetic Surgery of Charlotte
11835 Southmore Drive, Suite 202
Charlotte, NC 28277