GPS NOTICE OF PRIVACY PRACTICES(Must Sign Below)
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
Graham Plastic Surgery (GPS) is required by law to maintain the privacy of Protected Health Information (PHI) and to provide each patient with the GPS “Notice of Privacy Practices” detailing our legal duties and privacy practices with respect to PHI. PHI is information that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services. This Notice of Privacy Practices Guide outlines how we may use and disclose PHI to carry out treatment, payment, or health care operations and for other specified purposes that are permitted or required by law. The Notice booklet details your rights with respect to your PHI. We are required to prove the Notice booklet to you by the Health Insurance Portability and Accountability Act (HIPAA).
Graham Plastic Surgery is required to follow the terms contained in the “Notice of Privacy Practices”. We will not use or disclose your PHI without your written authorization, except as described or otherwise permitted in the Notice. We reserve the right to change our practices and the Notice and to make the new Notice effective for all PHI we maintain. Upon request, we will provide any revised Notice to you.
Examples of How We Use and Disclose Protected Health Information
The following categories describe different ways that we use and disclose your PHI. We have provided you with examples in certain categories; However, not every use or disclosure in a category is listed.
Treatment. We may use your PHI to provide and coordinate the treatment, medications, and services you receive. We may disclose PHI to doctors, nurses, technicians, administrators, staff, and others who are taking care of you. We may also disclose medical information with non-Graham Plastic Surgery providers, treatment team members, agencies, business associates or facilities in order to provide treatment, coordination or continuity of your care.
Payment. We may use your PHI for various payment related functions and we may disclose medical information so that the treatment and services you receive may be billed and payment collected. We will bill you or a third-party payer for the cost of treatment, equipment, and supplies provided to you.
Health Care Operations. We may use your health information for certain operational, administrative, and quality assurance activities. We may use information in your health record to monitor the quality and performance and to comply with laws and regulations. This information will be used in an effort to continually improve the quality and effectiveness of the health care and services we provide.
Appointment Reminders. We may contact you to remind you that you have an appointment at Graham Plastic Surgery.
To Communicate with Individuals Involved in Your Care or Payment for Your Care. We may disclose to a family member, other relative, close personal friend or any other person you identify that PHI which is directly relevant to that person’s involvement in your care or payment related to your care.
Notification. We may use or disclose your PHI to notify or assist in notifying a family member, personal representative, or another person responsible for your care, regarding your location and general condition.
We are permitted to use or disclose your PHI for the following purposes:
- Public Health. As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, and disability.
- Report Abuse. As required by law, we may disclose your PHI when the information relates to a victim of abuse, neglect, or domestic violence.
- Law Enforcement. We may disclose your PHI for law enforcement purposes as required by law or in response to a subpoena or court order.
- Lawsuits or Other Legal Actions. In connection with lawsuits or other legal proceedings we may disclose your PHI in response to a court or administrative order or other lawful process.
- As Required by Law. We will disclose your PHI when required to do so by federal, state, or local law.
- Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
- Marketing. We may contact you as part of certain marketing initiatives although you will be provided an opportunity to opt out of these communications.
- Other Uses and Disclosures of PHI. We will obtain your written authorization before using or disclosing your PHI for purposes other than those provided for above (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.
Your Health Information Rights
Obtain a paper copy of the Notice upon request. You may request a copy of our current “Notice of Privacy Practices” at any time.
Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of your PHI by sending a written request to GPS. We may not be required to agree to those restrictions. We cannot agree to restrictions on uses or disclosures that are legally required, or which are necessary to administer our business. We will agree to restrictions to withhold information from a health plan where you, the individual, pay out-of-pocket in full for services ahead of time.
Inspect and obtain a copy of PHI. In most cases you have a right to access and copy the PHI that we maintain about you. To inspect or copy your PHI, you must send a request in writing. We may charge you a fee for the costs of copying, mailing and any supplies that are necessary to fulfill your request. We may deny your request to inspect and copy in certain limited circumstances.
Request and amendment of PHI. If you feel the PHI we maintain about you is incomplete or incorrect, you may request that we amend it. To request an amendment, you must send a written request to GPS. You must include a reason that supports your request. In certain cases, we may deny your request for amendment.
Receive an accounting of disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of your PHI after November 1, 2016 for most purposes other than treatment, payment, or health care operations. The right to receive an accounting is subject to certain exceptions, restrictions, and limitations. To request an accounting, you must submit a request in writing to GPS. Your request must specify the time period. The time period may not be longer than six years and may not include dates before November 1, 2016.
Request communications of PHI by alternative means or at alternative locations. For instance, you may request that we contact you at a different residence or post office box. To request confidential communication of your PHI, you must submit a request in writing to GPS. Your request must tell us how or where you would like to be contacted. We will accommodate reasonable requests.
Notification of Breach. Affected individuals will be notified of breaches of their unsecured PHI pursuant to state and federal laws.
For More Information or To Report a Problem
If you have questions or would like additional information about GPS’s privacy practices you may contact our Practice Manager. If you believe your privacy rights have been violated, you can file a complaint with our Practice Manager by calling 585.300.4575.
GPS reserves the right to change our privacy practices and the “Notice of Privacy Practices” at any time. We will make available the current Notice at our practice.
Graham Plastic Surgery
6536 Anthony Drive, Suite C
Victor, NY 14564
Effective Date: October 2016