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. The Health Insurance Portability and Accountability Act (HIPAA; "Act") of 1996, revised in 2013, requires us as your health care provider to maintain the privacy of your protected health information, to provide you with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We are required to maintain these records of your health care and to main-tain confidentiality of these records. The Act also allows us to use your information for treatment, payment, and certain health operations unless otherwise prohibited by law and without your authorization.
• Treatment: We may disclose your protected health information to you and to our staff or to other health care providers in order to get you the care you need. This includes information that may go to the pharmacy to get your prescription filled, to a diagnostic center to assist with your diagnosis, or to the hospital should you need to be admitted. If necessary to ensure that you get this care, we may also discuss the minimum necessary with friends or family members involved in your care unless you request otherwise.
• Payment: We may send information to you or to your health plan in order to receive payment for the service or item we delivered. We may discuss the minimum necessary with friends or family members involved in your payment unless you request otherwise.
• Health operations: We are allowed to use or disclose your protected health information to train new health care workers, to evaluate the health care delivered, to improve our business development, or for other internal needs.
• We are required to disclose information as required by law, such as public health regulations, health care oversight activities, certain law suits and law enforcement. Certain ways that your protected health information could be used or disclosed require an authorization from you: disclosure of psychotherapy notes, use or disclosure of your information for marketing, disclosures or uses that constitute a sale of protected health information, and any uses or disclosures not described in this NPP. We cannot disclose your protected health information to your employer or to your school without your authorization unless required by law. You will receive a copy of your authorization and may revoke the authorization in writing. We will honor that revocation beginning the date we receive the written signed revocation. You have several rights concerning your protected health information. When you wish to use one of these rights, please inform our office so that we may give you the correct form for documenting your request.
• You have the right to access your records and/or to receive a copy of your records, with the exception of psychotherapy notes. Your request must be in writing, and we must verify your identity before allowing the requested access. We are required to allow the access or provide the copy within 30 days of your request. We may provide the copy to you or to your designee in an electronic format acceptable to you or as a hard copy. We may charge you our cost for making and providing the copy. If your request is denied, you may request a review of this denial by a licensed health care provider.
• You have the right to request restrictions on how your protected health information is used for treatment, payment, and health operations. For example, you may request that a certain friend or family member not have access to this information. We are not required to agree to this request, but if we agree to your request, we are obligated to fulfill the request, except in an emergency where this restriction might interfere with your care. We may terminate these restrictions if necessary to fulfill treatment a payment.
• We are required to grant your request for restriction if the requested restriction applies only to information that
would be submitted to a health plan for payment for a health care service or item for which you have paid in full
out-of-pocket, and if the restriction is not otherwise forbidden by law. For
example, we are required to submit information to federal health plans and managed care organizations even if you
request a restriction. We must have your restriction documented prior to initiating the
service. Some exceptions may apply, so ask for a form to request the restriction and to get additional
information. We are not required to inform other covered entities of this request, but we are not allowed to use or
disclose information that has been restricted to business associates that may disclose the
information to the health plan.
• You have the right to request confidential communications. For example, you may prefer that we call your cell
phone number rather than your home phone. These requests must be in writing, may be
revoked in writing, and must give us an effective means of communication for us to comply. If the
alternate means of communication incurs additional cost, that cost will be passed on to you.
• Your medical records are legal documents that provide crucial information regarding your care. You have the
right to request an amendment to your medical records, but you must make this request in writing and understand that
we are not required to grant this request.
• You have the right to an accounting of disclosures. This will tell you how we have used or
disclosed your protected health information. We are required to inform you of a breach that may have aected your
protected health information.
• You have the right to receive a copy of this notice, either electronic or paper or both.
• You have the right to opt out of fund raising communications.
If you have any questions about our privacy practices, please contact our Privacy Officer at the number below.
You have the right to file a complaint with us or with the Office for Civil Rights. We will not discriminate or retaliate in any
way for this action. To file a complaint, please contact the applicable party:
Privacy Officer: _______________________________ Phone number: _______________
Fax number: _______________
Office for Civil Rights
We are required to abide by the policies stated in this Notice of Privacy Practices, which became
effective on (date) ___________
All patients have the right to review our Notice of Privacy Practices below. If you would like to restrict access or to request modifications be made to your personal health information, please request the required form from a member of our staff. Any member of our staff may use telephone or fax to contact your insurance company, physician, or pharmacy to release your personal health information, photos, etc., as needed for treatment, payment and health operations. Limitation of Practice: I understand that Sieveking Plastic Surgery is limited to Plastic and Reconstructive Surgery, as well as Cosmetic Laser and Skin Care. NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:
• Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessment and physician certifications.
I received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.
PATIENT NAME (PRINT)_______________________________________________________________ PATIENT/LEGAL GUARDIAN SIGNATURE______________________________________________________ DATE__________________________
FOR PRACTICE USE ONLY:
I attempted to obtain the patient’s signature in acknowledgement of the Notice of Privacy Practices Acknowledgement but was unable to do so documented below:
Date: _________________ Initials: ___________ Reason: _____________________________________________________ ____________________________________________________________________________________________________
- Choosing a selection results in a full page refresh.
- Press the space key then arrow keys to make a selection.