Notice of Privacy Practices
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.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This notice applies to all records of your care generated and maintained by this medical spa.
We are required by law to: 1) make sure that medical information that identifies you is kept private; 2) make available to you this notice of our legal and privacy practices with respect to medical information about you; and 3) follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
• We may disclose medical information about you to doctors, nurses, or other personnel involved in taking care of you. We may also disclose medical information to people outside the medical group, such as family members, specialists or others who are involved in providing services that are part of your care.
• We may use or disclose medical information about you for operations. These may include use of information to evaluate the performance of our staff, effectiveness of programs, and ways to improve care and services we offer. These uses and disclosures are necessary to ensure that all of our patients receive quality care.
• We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or care.
• We may use or disclose medical information to tell you about or recommend possible treatment options or alternatives, and about health-related benefits, services, events and activities that may be of interest to you.
• We may disclose medical information about you to other healthcare providers in the event you need emergency care.
• We may disclose medical information about you as required by federal, state or local law.
• We may use or disclose medical information to a public health organization or federal organization
when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
• We may disclose medical information about you in special situations such as for workers’
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compensation programs, as required by military command authorities or the Department of Veterans Affairs, in response to a court or administrative order, or for public health activities.
• 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 authorization. You may later revoke this permission in writing at any time.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
• You have the right to review and receive a copy of medical information that may be used to make decisions about your care. Usually this includes medical and billing records. You must submit a written request to review and copy your medical information. We may charge a fee for the costs of supplying a copy of the records.
• You have the right to ask us to amend medical information that you feel is incorrect or incomplete. Your request for an amendment must be submitted in writing and must provide a reason that supports your request. We may deny your request for 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 the information: 1) was not created by us; 2) is not part of the medical information kept by or for us; 3) is not part of the information which you are permitted to inspect and copy; or 4) is accurate and complete.
• You have the right to request an “accounting of disclosures.” This is a list of disclosures we have made of medical information about you, with some exceptions. The exceptions are governed by federal health privacy law, and include: 1) routine disclosures for treatment, payment and operations conducted pursuant to your signed consent form; and 2) disclosures to you. You must submit a written request. The request must state a time period that may not be longer than six years and may not include dates before April 14, 2003, when current federal health privacy laws became effective.
• You have the right to request restrictions or limitations on the use or disclosure of medical information about you. You must submit a written request for restriction that specifies: 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. We reserve the right to refuse your restriction if it conflicts with providing you quality healthcare or in an emergency situation.
• You have the right to request that we communicate with you about medical matters in a certain way or at a certain location, such as only at work or by mail. You must submit a written request for confidential communications restrictions, specifying how or where you wish to be contacted. We will accommodate reasonable requests.
• You have the right to possess a copy of this Privacy Notice upon request. You may receive a paper copy of this notice, or you can also obtain a copy of this notice at our offices.
• You have the right to file a complaint if you believe your rights to privacy have been violated. All
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complaints must be submitted in writing. All complaints will be investigated. No personal issue will be raised for filing a complaint.
CHANGES TO THIS NOTICE
We reserve the right to change this notice at any time. We will post a copy of the current notice at our clinical site.
ACKNOWLEDGMENT OF RECEIPT
Notice of Privacy Practices provides information about how we may use and disclose your protected health information.
In addition to the copy we are providing you, copies of the current notice are available at our office. I, _____________________________________________________ acknowledge that I have received the Notice of Privacy Practices.
  __________________________________________ Signature of Patient or Patient’s Representative
__________________________________________ Print Name
______________________ Date
______________________ Relationship to Patient
_____________________________________________________________________________________
WRITTEN ACKNOWLEDGMENT NOT OBTAINED Please document your efforts to obtain acknowledgment and reason it was not obtained.
_____ Notice of Practices Given — Patient Unable to Sign
_____ Notice of Practices Given — Patient Declined to Sign
_____ Notice of Privacy Practices and Acknowledgment Mailed to Patient
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_____ Other Reason Patient Did Not Sign _____________________________________
__________________________________________ ______________________ Signature of Representative Date
Rev. 4/17/2019 Bloom Copy
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