PRIVACY POLICY

1. How This Medical Practice May Use or Disclose Your Health Information  

2. When This Medical Practice May Not Use or Disclose Your Health Information    

3. Your Health Information Rights     

4. Changes to this Notice of Privacy Practices  

5. Complaints   

6. Consent  

 

1. How This Medical Practice May Use or Disclose Your Health Information  

This medical practice collects health information about you and stores it in an electronic health

record.  This is your medical record.  The medical record is the property of this medical practice,

but the information in the medical record belongs to you.  The law permits us to use or disclose

your health information for the following purposes:  

 

Treatment :  We use medical information about you to provide your medical care.  We disclose

medical information to our employees and others who are involved in providing the care you

need.  For example, we may share your medical information with other physicians or other

health care providers who will provide services that we do not provide.  Or we may share this

information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that

performs a test.  We may also disclose medical information to members of your family or others

who can help you when you are sick or injured, or after you die. 

 

Payment :  We use and disclose medical information about you to obtain payment for the services

we provide.  For example, we may disclose medical information to your credit card company to

obtain payment for the services we provide. We may also disclose medical information to your

credit card company to challenge a payment chargeback.    

 

Health Care Operations : We may use and disclose medical information about you to operate this

medical practice. We may also use and disclose this information as necessary for medical

reviews, legal services, and audits, including fraud and abuse detection and compliance

programs and business planning and management.  We may also share your medical information

with our "business associates," that perform administrative services for us. Examples of business

associates include, MD Ware (PM and EMR). 

 

Appointment Reminders.  We may use and disclose medical information to contact and remind

you about appointments.  If you are not home, we may leave this information on your answering

machine or in a message left with the person answering the phone. We may also choose to email

you an appointment confirmation or to send you an appointment reminder by text. We may also

choose to call or email you regarding treatment reminders. For example, a staff member may

call, email or text you letting you know that our records indicate that you may be due for Botox

or Dysport treatment.   

 

Sign In.  We may use and disclose medical information about you by having you sign in when

you arrive at our office.  We may also call out your name when we are ready to see you or while

you are checking out.   

 

Notification and Communication with Family.  We may disclose your health information to

notify or assist in notifying a family member, your personal representative, or another person

responsible for your care about your location, your general condition or, unless you had

instructed us otherwise, in the event of your death. We may also disclose information to someone

who is involved with your care or helps pay for your care.

  

Marketing.  We may contact you to give you information about products or services we offer. We

may add you to our electronic mailing list (currently maintained through MailChimp.com) and

we may email you news and special offers from our practice.  

We may contact you by text message or email with a request to leave a review of your

experience at our clinic on Yelp, Google, or a similar platform.

 

Sale of Health Information. We will not sell your health information without your prior written

authorization.  

 

Required by Law.  As required by law, we will use and disclose your health information, but we

will limit our use or disclosure to the relevant requirements of the law.  When the law requires us

to report abuse, neglect, or domestic violence, or respond to judicial or administrative

proceedings, or to law enforcement officials, we will further comply with the requirement set

forth below concerning those activities.  

 

Public Health.  We may, and are sometimes required by law, to disclose your health information

to public health authorities for purposes related to preventing or controlling disease, injury, or

disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic

violence; reporting to the Food and Drug Administration problems with products and reactions to

medications; and reporting disease or infection exposure. 

 

Health Oversight Activities.  We may, and are sometimes required by law, to disclose your health

information to health oversight agencies during audits, investigations, inspections, licensure, and

other proceedings, subject to the limitations imposed by law.  

Judicial and Administrative Proceedings. We may, and are sometimes required by law, to disclose

your health information during any administrative or judicial proceeding to the extent expressly

authorized by a court or administrative order.  We may also disclose information about you in

response to a subpoena, discovery request or other lawful process if reasonable efforts have been

made to notify you of the request and you have not objected, or if your objections have been

resolved by a court or administrative order.  

 

Law Enforcement.  We may, and are sometimes required by law, to disclose your health

information to a law enforcement official for purposes such as identifying or locating a suspect,

fugitive, material witness or missing person, complying with a court order, warrant, grand jury

subpoena and other law enforcement purposes.  

 

Coroners.  We may, and are often required by law, to disclose your health information to

coroners in connection with their investigations of deaths.  

 

Public Safety.  We may, and are sometimes required by law, to disclose your health information

to appropriate persons to prevent or lessen a serious and imminent threat to the health or safety

of a particular person or the public.  

 

 

Specialized Government Functions.  We may disclose your health information for military or

national security purposes or to correctional institutions or law enforcement officers that have

you in their lawful custody.  

 

Workers' Compensation.  We may disclose your health information as necessary to comply with

workers' compensation laws.  For example, to the extent your care is covered by workers'

compensation, we will make periodic reports to your employer about your condition.  We are

also required by law to report cases of occupational injury or occupational illness to the

employer or workers' compensation insurer.  

 

Change of Ownership.  If this medical practice is sold or merged with another organization, your

health information/record will become the property of the new owner, although you will

maintain the right to request that copies of your health information be transferred to another

physician or medical group.  

 

Breach Notification. In the case of a breach of unsecured protected health information, we will

notify you as required by law. If you have provided us with an e-mail address, we may use email

to communicate information related to the breach. In some circumstances our business associate

may provide the notification. We may also provide notification by other methods as appropriate.   

 

 2. When This Medical Practice May Not Use or Disclose Your Health Information  

Except as described in this Notice of Privacy Practices, this medical practice will, consistent with

its legal obligations, not use or disclose health information which identifies you without your

written authorization.  If you do authorize this medical practice to use or disclose your health

information for another purpose, you may revoke your authorization in writing at any time.  

 

3. Your Health Information Rights  

Right to Request Special Privacy Protections.  You have the right to request restrictions on

certain uses and disclosures of your health information by a written request specifying what

information you want to limit, and what limitations on our use or disclosure of that information

you wish to have imposed.  If you tell us not to disclose information to your commercial health

plan concerning health care items or services for which you paid for in full out-of-pocket, we

will abide by your request, unless we must disclose the information for treatment or legal

reasons. We reserve the right to accept or reject any other request and will notify you of our

decision.  

 

Right to Request Confidential Communications.  You have the right to request that you receive

your health information in a specific way or at a specific location.  For example, you may ask

that we send information to a particular e-mail account or to your work address.  We will comply

with all reasonable requests submitted in writing which specify how or where you wish to

receive these communications.  

 

Right to Inspect and Copy.  You have the right to inspect and copy your health information, with

limited exceptions.  To access your medical information, you must submit a written request

detailing what information you want access to and whether you want to get a copy of it, and if

you want a copy, how you want it sent to you.  We will provide copies in your requested form

and format if it is readily producible, or we will provide you with an alternative format you find

acceptable, or if we can't agree and we maintain the record in an electronic format, your choice

of a readable electronic or hardcopy format. We will also send a copy to any other person you

designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies,

postage, and if requested and agreed to in advance, the cost of preparing an explanation or

summary. We may deny your request under limited circumstances.   

 

Right to Amend or Supplement.  You have a right to request that we amend your health

information that you believe is incorrect or incomplete.  You must make a request to amend in

writing and include the reasons you believe the information is inaccurate or incomplete.  We are

not required to change your health information and will provide you with information about this

medical practice's denial and how you can disagree with the denial.  We may deny your request

if we do not have the information, if we did not create the information (unless the person or

entity that created the information is no longer available to make the amendment), if you would

not be permitted to inspect or copy the information at issue, or if the information is accurate and

complete as is.  If we deny your request, you may submit a written statement of your

disagreement with that decision, and we may, in turn, prepare a written rebuttal. All information

related to any request to amend will be maintained and disclosed in conjunction with any

subsequent disclosure of the disputed information.  

 

Right to an Accounting of Disclosures.  You have a right to receive an accounting of disclosures

of your health information made by this medical practice, except that this medical practice does

not have to account for the disclosures provided to you or pursuant to your written authorization,

or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6

(notification and communication with family) and 16 (specialized government functions) of

Section A of this Notice of Privacy Practices or disclosures for purposes of research or public

health which exclude direct patient identifiers, or which are incident to a use or disclosure

otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law

enforcement official to the extent this medical practice has received notice from that agency or

official that providing this accounting would be reasonably likely to impede their activities.  

 

Right to a Paper or Electronic Copy of this Notice.  You have a right to notice of our legal duties

and privacy practices with respect to your health information, including a right to a paper copy

of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail.  

If you would like to have a more detailed explanation of these rights or if you would like to

exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of

Privacy Practices.  

 

4.  Changes to this Notice of Privacy Practices  

We reserve the right to amend this Notice of Privacy Practices at any time in the future.  Until

such amendment is made, we are required by law to comply with the terms of this Notice

currently in effect.  After an amendment is made, the revised Notice of Privacy Protections will

apply to all protected health information that we maintain, regardless of when it was created or

received.  We will keep a copy of the current notice at the front desk, and a copy will be

available at each appointment.

   

1. Complaints  

Complaints about this Notice of Privacy Practices or how this medical practice handles your

health information should be directed to our Privacy Officer listed at the top of this Notice of

Privacy Practices.  

2. Consent  

I acknowledge and agree that I have read and agree to the above Notice of Privacy Practices that

describes how my protected health information must be protected and my rights to access and

control such information. I acknowledge and agree that I have reviewed the Notice of Privacy

Practices in its entirety and been given the opportunity to ask any questions regarding the use or

disclosure of my protected health information and my associated rights. I acknowledge and agree

that I have had all my questions answered to my satisfaction. I confirm this by signing in the

electronic medical record.