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
Understanding Your Health Records Information:
Each time you visit a hospital, physician, or another healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment. This information, often referred to as your health or medical records, serves as a basis for planning your care and treatment and serves as a means of communication among the many healthcare professionals who contribute to your care. Understanding what is in your records and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
Your Health Information Rights:
Unless otherwise required by law your health records are the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to request a restriction on certain uses and disclosures of your information, and request amendments to your health record. This includes the right to obtain a paper copy of the information practices upon request, inspect, and obtain a copy of your health records. Obtain an accounting of disclosures of your health information, request communications of your health information by alternative means or at alternative locations, revoke your authorization to use or disclose health information except to the extent that action has already been taken.
Mid-Atlantic Plastic Surgeons is required to maintain the privacy of your health information. In addition, we are required to provide you with a notice as to our legal duties and privacy practices with respect to the information we collect and maintain about you. Mid-Atlantic Plastic Surgeons must abide by the terms of this notice, notify you if we are unable to agree to a requested restriction, accommodate reasonable requests you may have to communicate health information by alternative means or alternative locations. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us. Should our information practices change, we will post our new notice on our Web site. We will not use or disclose your health information without your authorization, except as described in this notice.
For More Information or to Report a Problem: If you have questions and would like additional information, you may contact Angie Guzman at 540-345-3556. If you believe your privacy rights have been violated, you can file a complaint with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS
We will use your health information for treatment: For example, information obtained by a healthcare practitioner will be recorded in your records and used to determine the course of treatment that should work best for you. By way of example, the Physician will document in your record his/her expectations of the members of your healthcare team. Members of your healthcare team will then record actions they took and their observations (example varies by practitioner type). We will also provide your other practitioners with copies of various reports that should assist them in treating you.
We will use your health information for payment: For example, A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
We will use your health information for regular health operations: For example Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health records to access the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare service we provide.
Business Associates: There may be some services provided in our organization through contracts with Business Associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health records. When these services are contracted, we may disclose some or all of your health information to our Business Associate so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the Business Associate to appropriately safeguard your information
Notification. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Communication with Family: The Practice and Physician, using his/her best judgment, may disclose to a family member, other relatives, close personal friends or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Food and Drug Administration (FDA): As required by law, we may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.
Workers’ Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs established by law.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with tracking births and deaths, as well as with preventing or controlling disease, injury, or disability
Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
Notice of Privacy Practices Availability: This notice will be prominently posted in the office where registration occurs. Patients will be provided a hard copy and the notice will be maintained on the Practice’s website for downloading.
A copy of the Privacy Practice for Mid-Atlantic Plastic Surgeons has been provided to me. I understand that it will be updated every three years and will be made available to me upon request.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.