CHARLOTTE PLASTIC SURGERY

NOTICE OF PRIVACY PRACTICES
OF
CHARLOTTE PLASTIC SURGERY

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.

Effective: April 14, 2003

A. We have a legal duty to protect health information about you.

B. We may use and disclose Protected Health Information (PHI) about you without your authorization in the following circumstances.

1. We may use and disclose PHI about you to provide health care treatment to you.
2. We may use and disclose PHI about you to obtain payment for services.
3. We may use and disclose PHI about you for health care operations.
4. We may use and disclose PHI UNDER other circumstances without your authorization or an opportunity to agree or object.
5. You can object to certain uses and disclosures.
6. We may contact you to provide appointment reminders.
7. We may contact you with information about treatment, services, products or health care providers.

C. You have several rights regarding PHI about you.

1. You have the right to request restrictions on uses and disclosures of PHI about you.
2. You have the right to request different ways to communicate with you.
3. You have the right to see and copy PHI about you.
4. You have the right to request amendment of PHI about you.
5. You have the right to a listing of disclosures we have made.
6. You have a right to a copy of this Notice.
7. You have the right to be notified of breaches of your PHI.

D. You may file a complaint about our privacy practices.

E. Effective date of this notice: April 14, 2003.

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A. We Have A Legal Duty to Protect Health Information About You

We are required by law to protect the privacy of health information about you and that can be identified with you, which we call “protected health information”, or “PHI” for short. We must give you notice of our legal duties and privacy practices concerning PHI:

• We must protect PHI that we have created or received about: your past, present, or future health condition; health care we provide to you; or payment for your health care.
• We must notify you about how we protect PHI about you.
• We must explain how, when, and why we use and/or disclose PHI about you.
• We may only use and/or disclose PHI as we have described in this Notice.

This Notice describes the types of uses and disclosures that we may make and gives you some examples. In addition, we may make other uses and disclosures that occur as a byproduct of the permitted uses and disclosures described in this Notice. If we participate in an “organized health care arrangement” (defined in subsection B.3 below), the providers participating in the “organized health care arrangement” will share PHI with each other, as necessary to carry out treatment, payment or health care operations (defined below) relating to the “organized health care arrangement”.

We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all PHI that we maintain by first:

• Posting the revised notice in our offices;
• Making copies of the revised notice available upon request (either at our offices or through the contact person listed in this Notice); and
• Posting the revised notice on our website.

B. We May Use and Disclosure PHI About You Without Your Authorization in The Following Circumstances

1. We may use and disclose PHI about you to provide health care treatment to you.

We may use and disclose PHI about you to provide, coordinate or manage your health care and related services. This may include communications with other health care providers regarding your treatment and coordinating and managing your health care with others. For example, we may use and disclose PHI about you when you need a prescription, lab work, an x-ray, or other health care services. In addition, we may use and disclose PHI about you when referring you to another health care provider.

EXAMPLE: Your doctor may share medical information about you with another health care provider. For example, if you are referred to another doctor, that doctor will need to know if you are allergic to any medications. Similarly, your doctor may share PHI about you with a pharmacy when calling in a prescription.

2. We may use and disclose PHI about you to obtain payment for services.

Generally, we may use and give your medical information to others to bill and collect payment for the treatment and services provided to you by us or by another provider. Before you receive scheduled services, we may share information about these services with your health plan(s). Sharing information allows us to ask for coverage under your plan or policy and for approval of payment before we provide the services. We may also share portions of medical information about you with the following:

• Billing departments;
• Collection departments or agencies, or attorneys assisting us with collections;
• Insurance companies, health plans and their agents which provide you coverage;
• Hospital departments that review the care you received to check that it and the costs associated with it were appropriate for your illness or injury; and
• Consumer reporting agencies (e.g., credit bureaus).

EXAMPLE: Let’s say you come in for treatment. We may need to give your health plan(s) information about your condition, supplies used, and services you received. The information is given to our billing department and your health plan so we can be paid or you can be reimbursed.

3. We may use and disclose PHI about your for health care operations.

We may use and disclose PHI in performing business activities, which we call “health care operations”. These “health care operations” allow us to improve the quality of care we provide and reduce health care costs. We may also disclose PHI for the “health care operations” of any “organized health care arrangement” in which we participate. An example of “organized health care arrangement” is the care provided by a hospital and the physicians who see patients at the hospital. In addition, we may disclose PHI about you for the “health care operations” of other providers involved in your care to improve the quality, efficiency, and costs of their care or to evaluate and improve the performance of their providers. Examples of the way we use or disclose PHI about you for “health care operations” include the following:

• Reviewing and improving quality, efficiency, and cost of care that we provide to you and our other patients. For example, we may use PHI about you to develop ways to assist our health care providers and staff in deciding what medical treatment should be provided to others.
• Assisting various people who review our activities. For example, PHI may be seen by doctors reviewing the services provided to you, and by accountants, lawyers, and others who assist us in complying with applicable laws.
• Planning for our organization’s future operations.
• Conducting business management and general administrative activities related to our organization and the services it provides.
• Resolving grievances within our organization.
• Complying with this Notice and with applicable laws.

4. We may use and disclose PHI under other circumstances without your authorization or an opportunity to agree or object.

We may use and/or disclose PHI about you for a number of circumstances in which you do not have to consent, give authorization, or otherwise have an opportunity to agree or object. Those circumstances include:

• When the use and/or disclosure is required by law. For example, when a disclosure is required by federal, state or local law, or other judicial or administrative proceeding.
• When the use and/or disclosure is necessary for public health activities. For example, we may disclose PHI about you if you have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
• When the disclosure relates to victims of abuse, neglect or domestic violence.
• When the use and/or disclosure is for health oversight activities. For example, we may disclose about you to a state or federal health oversight agency which is authorized by law to oversee our operations.
• When the disclosure is for judicial and administrative proceedings. For example, we may disclose PHI about you in response to an order of a court or administrative tribunal.
• When the disclosure is for law enforcement purposes. For example, we may disclose PHI about you in order to comply with the laws that require the reporting of certain types of wounds or other physical injuries.
• When the use and/or disclosure relates to decedents. For example, we may disclose PHI about you to a coroner or medical examiner for the purposes of identifying you should you die.
• When the use and/or disclosure relates to organ, eye or tissue donation purposes.
• When the use and/or disclosure relates to medical research. Under certain circumstances, we may disclose PHI about you for medical research.
• When the use and/or disclosure is to avert a serious threat to health or safety. For example, we may disclose PHI about you to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
• When the use and/or disclosure relates to specialized government functions. For example, we may disclose PHI about you if it relates to military and veterans’ activities, national security and intelligence activities, protective services for the President, and medically suitability or determinations of the Department of State.
• When the use and/or disclosure relates to correctional institutions and in other law enforcement custodial situations. For example, in certain circumstances, we may disclose PHI about you to a correctional institution having lawful custody of you.

5. You can object to certain uses and disclosures.

Unless you object, we may use or disclose PHI about you in the following circumstances:

• We may share with a family member, relative, friend or other person identified by you PHI directly related to that person’s involvement in your care or payment for your care. We may share with a family member, personal representative or other person responsible for your care PHI necessary to notify such individuals of your location, general condition or death.
• We may share with a public or private agency (for example, American Red Cross) PHI about you for disaster relief purposes. Even if you object, we may still share the PHI about you. if necessary, for the emergency circumstances.

If you would like to object to our use and disclosure of PHI about you in the above circumstances, please call or write to our contact person listed on the cover page of this Notice.

6. We may contact you to provide appointment reminders.

We may use and/or disclose PHI to contact you to provide a reminder to you about an appointment you have for treatment or medical care.

7. We may contact you with information about treatment, services, products or health care providers.

We may use and/or disclose PHI about you to manage or coordinate your healthcare. This may include telling you about treatments, services, products and/or other healthcare providers. We may also use and/or disclose PHI to give you gifts of a small value.

EXAMPLE: If you are diagnosed with a certain condition, we may tell you about nutritional and other counseling services that may be of interest to you.

However, any general marketing communications require your authorization.

Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you. If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing by contacting the practice’s Privacy Officer. If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures which were being processed before we received your cancellation.

C. You Have Several Rights Regarding PHI About You

1. You have the right to request restrictions on uses and disclosures of PHI about you.

You have the right to request that we restrict the use and disclosure of PHI about you. We are not required to agree to your requested restrictions. However, even if we agree to your request, in certain situations your restrictions may not be followed. These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services and uses and disclosures described in subsection B.4 of the previous section of this Notice. You may request a restriction by completing the form, “Request for Limitation on Disclosure” which is available at the front desk. The practice’s Privacy Officer will evaluate your request.

You have the right to restrict certain disclosures of PHI to your health plan(s) where you have paid in full out of pocket for your healthcare items or services.

2. You have the right to request different ways to communicate with you.

You have the right to request how and where we contact you about PHI. For example, you may request that we contact you at your work address or phone number or by e-mail. Your request must be in writing. We must accommodate reasonable requests, but, when appropriate, may condition that accommodation on your providing us with information regarding how payment, if any, will be handled and your specification of an alternative address or other method of contact. You may request alternative communications by completing the form “Request to Receive Communications by Alternative Means,” which is available at the front desk. The practice’s Privacy Officer will evaluate your request.

3. You have the right to see and copy PHI about you.

You have the right to request to see and receive a copy of PHI contained in clinical, billing and other records used to make decisions about you. Your request must be in writing. We may charge you related fees. Instead of providing you with a full copy of the PHI, we may give you a summary or explanation of the PHI about you, if you agree in advance to the form and cost of the summary or explanation. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing stating why we will not grant your request and describing any rights you may have to request a review of our denial. You may request to see and receive a copy of PHI by completing the form “Request for Access to Patient’s Health Information,” which is available at the front desk.

4. You have the right to request amendment of PHI about you.

You have the right to request that we make amendments to clinical, billing and other records used to make decisions about you. Your request must be in writing and must explain your reason(s) for the amendment. We may deny your request if: 1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record); 2) the information is not part of the records used to make decisions about you; 3) we believe the information is correct and complete; 4) you would not have the right to see and copy the record as described in paragraph 3 above. We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received PHI about you and who need the amendment. You may request an amendment of PHI about you by contacting the practice’s Privacy Officer in writing.

5. You have the right to a listing of disclosures we have made.

If you ask our contact person in writing, you have the right to receive a written list of certain of our disclosures of PHI about you. You may ask for disclosures made up to six (6) years before your request (not including disclosures made prior to April 14, 2003). We are required to provide a list of all disclosures except the following:

• For your treatment
• For billing and collection of payment for your treatment
• For health care operations
• Made to or requested by you, or that you authorized
• Occurring as a byproduct of permitted uses and disclosures
• Made to individuals involved in your care, for directory or notification purposes, or for other purposes described in the subsection B.5 above
• Allowed by law when the use and/or disclosure relates to certain specialized government functions or relates to correctional institutions and in other law enforcement custodial situations (please see subsection B.4 above) and
• As part of a limited set of information which does not contain certain information which would identify you.

The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. If, under permitted circumstances, PHI about you has been disclosed for certain types of research projects, the list may include different types of information.

If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee. You may request a listing of disclosures by completing the form “Request for Accounting of Disclosures” which is available at the front desk.

6. You have the right to a copy of this Notice.

You have the right to request a paper copy of this Notice at any time by contacting a staff member. We will provide a copy of this Notice no later than the date you first receive services from us (except for emergency services, and then we will provide the Notice to you as soon as possible).

7. You have the right to be notified of a breach of your unsecured PHI.

In the rare instance where your unsecured PHI may be inadvertently released to an unauthorized party, you have the right to know what information was released, and to the party who received the information. This notification will be in writing to you.

D. You May File A Complaint About Our Privacy Practices

If you think we have violated your privacy rights, or you want to complain to us about our privacy practices, you can contact the practice’s Privacy Officer listed above.

You may also send a written complaint to the United States Secretary of the Department of Health and Human Services.

If you file a complaint, we will not take any action against you or change our treatment of you in any way.

E. SMS Consent

Information obtained as part of SMS consent will not be shared with third parties or affiliates.

If you have consented to receive text messages from Charlotte Plastic Surgery you may receive texts about your appointment or your treatment regimen.

Message rates may apply, and messaging frequency may vary. You may opt out at any time by texting STOP. For additional assistance, text HELP. For more information, please review our terms and conditions here https://www.charlotteplasticsurgery.com/terms-of-service/.

F. Effective Date Of This Notice

This Notice of Privacy Practices is effective April 14, 2003.