New government regulation under HIPAA
require the notification of Privacy Rights.
Please read or print off the following and
then answer accept to continue." Please call our office at (703) 742-8004 with
questions.
Effective Date of this Notice: 4-14-2003
New Image Plastic Surgery
Roberta L. Gartside,MD
Notice Of Privacy
Practices
As Required by the Privacy Regulations Created as
a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
| THIS NOTICE DESCRIBES HOW HEALTH INFORMATION
ABOUT YOU (AS A PATIENT OF THIS PRACTICE ) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET
ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. |
PLEASE REVIEW THIS NOTICE CAREFULLY.
A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy
of your individually identifiable health information (IIHI). In conducting our business,
we will create records regarding you and the treatment and services we provide to you. We
are required by law to maintain the confidentiality of health information that identifies
you. We also are required by law to provide you with this notice of our legal duties and
the privacy practices that we maintain in our practice concerning your IIHI. By federal
and state law, we must follow the terms of the notice of privacy practices that we have in
effect at the time.
We realize that these laws are complicated, but we
must provide you with the following important information:
- How we may use and disclose your IIHI
- Your privacy rights in your IIHI
- Our obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your
IIHI that are created or retained by our practice. We reserve the right to revise or amend
this Notice of Privacy Practices. Any revision or amendment to this notice will be
effective for all of your records that our practice has created or maintained in the past,
and for any of your records that we may create or maintain in the future. Our practice
will post a copy of our current Notice in our offices in a visible location at all times,
and you may request a copy of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Pauline Totaro, Office Manager, 703-742-8004
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE
HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS
The following categories describe the different ways in
which we may use and disclose your IIHI.
1. Treatment. Our practice may use your IIHI to treat you.
For example, we may ask you to have laboratory tests (such as blood or urine tests), and
we may use the results to help us reach a diagnosis. We might use your IIHI in order to
write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a
prescription for you. Many of the people who work for our practice – including, but
not limited to, our doctors and nurses – may use or disclose your IIHI in order to
treat you or to assist others in your treatment. Additionally, we may disclose your IIHI
to others who may assist in your care, such as your spouse, children or parents.
Finally, we may also disclose your IIHI to other health care
providers for purposes related to your treatment.
2. Payment. Our practice may use and disclose your IIHI in
order to bill and collect payment for the services and items you may receive from us. For
example, we may contact your health insurer to certify that you are eligible for benefits
(and for what range of benefits), and we may provide your insurer with details regarding
your treatment to determine if your insurer will cover, or pay for, your treatment. We
also may use and disclose your IIHI to obtain payment from third parties that may be
responsible for such costs, such as family members. Also, we may use your IIHI to bill you
directly for services and items. We may disclose your IIHI to other health care providers
and entities to assist in their billing and collection efforts.
3. Health Care Operations. Our practice may use and
disclose your IIHI to operate our business. As examples of the ways in which we may use
and disclose your information for our operations, our practice may use your IIHI to
evaluate the quality of care you received from us, or to conduct cost-management and
business planning activities for our practice. We may disclose your IIHI to other health
care providers and entities to assist in their health care operations.
4. Appointment Reminders. Our practice may use and
disclose your IIHI to contact you and remind you of an appointment.
5. Treatment Options. Our practice may use and
disclose your IIHI to inform you o potential treatment options or alternatives.
6. Health-Related Benefits and Services. Our practice may
use and disclose your IIHI to inform you of health-related benefits or services that may
be of interest to you.
7. Release of Information to Family/Friends. Our practice
may release your IIHI to a friend or family member that is involved in your care, or who
assists in taking care of you. For example, a parent or guardian may ask that a babysitter
take their child to the pediatrician’s office for treatment of a cold. In this
example, the babysitter may have access to this child’s medical information.
8. Disclosures Required By Law. Our practice will use and
disclose your IIHI when we are required to do so by federal, state or local law.
D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL
CIRCUMSTANCES
The following categories describe unique scenarios in which
we may use or disclose your identifiable health information:
1. Public Health Risks. Our practice may disclose your
IIHI to public health authorities that are authorized by law to collect information for
the purpose of:
maintaining vital records, such as births and deaths
reporting child abuse or neglect
preventing or controlling disease, injury or disability
notifying a person regarding potential exposure to a communicable
disease
notifying a person regarding a potential risk for spreading or
contracting a disease or condition
reporting reactions to drugs or problems with products or devices
notifying individuals if a product or device they may be using has
been recalled
notifying appropriate government agency(ies) and authority(ies)
regarding the potential abuse or neglect of an adult patient (including domestic
violence); however, we will only disclose this information if the patient agrees or we are
required or authorized by law to disclose this information
notifying your employer under limited circumstances related
primarily to workplace injury or illness or medical surveillance.
2. Health Oversight Activities. Our practice may disclose
your IIHI to a health oversight agency for activities authorized by law. Oversight
activities can include, for example, investigations, inspections, audits, surveys,
licensure and disciplinary actions; civil, administrative, and criminal procedures or
actions; or other activities necessary for the government to monitor government programs,
compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use
and disclose your IIHI in response to a court or administrative order, if you are involved
in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a
discovery request, subpoena, or other lawful process by another party involved in the
dispute, but only if we have made an effort to inform you of the request or to obtain an
order protecting the information the party has requested.
4. Law Enforcement. We may release IIHI if asked to do so
by a law enforcement official:
Regarding a crime victim in certain situations, if we are unable
to obtain the person’s agreement
Concerning a death we believe has resulted from criminal conduct
Regarding criminal conduct at our offices
In response to a warrant, summons, court order, subpoena or
similar legal process
To identify/locate a suspect, material witness, fugitive or
missing person
In an emergency, to report a crime (including the location or
victim(s) of the crime, or the description, identity or location of the perpetrator)
5. Deceased Patients. Our practice may release IIHI to a
medical examiner or coroner to identify a deceased individual or to identify the cause of
death. If necessary, we also may release information in order for funeral directors to
perform their jobs.
6. Organ and Tissue Donation. Our practice may release
your IIHI to organizations that handle organ, eye or tissue procurement or
transplantation, including organ donation banks, as necessary to facilitate organ or
tissue donation and transplantation if you are an organ donor.
7. Research. Our practice may use and disclose your IIHI
for research purposes in certain limited circumstances. We will obtain your written
authorization to use your IIHI for research purposes except when an Institutional
Review Board or Privacy Board has determined that the waiver of your authorization
satisfies the following: (i) the use or disclosure involves no more than a minimal risk to
your privacy based on the following: (A) an adequate plan to protect the identifiers from
improper use and disclosure; (B) an adequate plan to destroy the identifiers at the
earliest opportunity consistent with the research (unless there is a health or research
justification for retaining the identifiers or such retention is otherwise required by
law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to
any other person or entity (except as required by law) for authorized oversight of the
research study, or for other research for which the use or disclosure would otherwise be
permitted; (ii) the research could not practicably be conducted without the waiver; and
(iii) the research could not practicably be conducted without access to and use of the
PHI.
8. Serious Threats to Health or Safety. Our practice may
use and disclose your IIHI when necessary to reduce or prevent a serious threat to your
health and safety or the health and safety of another individual or the public. Under
these circumstances, we will only make disclosures to a person or organization able to
help prevent the threat.
9. Military. Our practice may disclose your IIHI if
you are a member of U.S. or foreign military forces (including veterans) and if required
by the appropriate authorities.
10. National Security. Our practice may disclose your IIHI
to federal officials for intelligence and national security activities authorized by law.
We also may disclose your IIHI to federal officials in order to protect the President,
other officials or foreign heads of state, or to conduct investigations.
11. Inmates. Our practice may disclose your IIHI to
correctional institutions or law enforcement officials if you are an inmate or under the
custody of a law enforcement official. Disclosure for these purposes would be necessary:
(a) for the institution to provide health care services to you, (b) for the safety and
security of the institution, and/or (c) to protect your health and safety or the health
and safety of other individuals.
12. Workers’ Compensation. Our practice may release
your IIHI for workers’ compensation and similar programs.
E. YOUR RIGHTS REGARDING YOUR IIHI
You have the following rights regarding the IIHI that we maintain
about you:
1. Confidential Communications. You have the right to
request that our practice communicate with you about your health and related issues in a
particular manner or at a certain location. For instance, you may ask that we contact you
at home, rather than work. In order to request a type of confidential communication, you
must make a written request Dr. Roberta L. Gartside specifying the requested method of
contact, or the location where you wish to be contacted. Our practice will accommodate reasonable
requests. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request
a restriction in our use or disclosure of your IIHI for treatment, payment or health care
operations. Additionally, you have the right to request that we restrict our disclosure of
your IIHI to only certain individuals involved in your care or the payment for your care,
such as family members and friends. We are not required to agree to your request;
however, if we do agree, we are bound by our agreement except when otherwise required by
law, in emergencies, or when the information is necessary to treat you. In order to
request a restriction in our use or disclosure of your IIHI, you must make your request in
writing to Dr. Roberta L. Gartside. Your request must describe in a clear and
concise fashion:
- the information you wish restricted;
- whether you are requesting to limit our practice’s use,
disclosure or both; and
- to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect
and obtain a copy of the IIHI that may be used to make decisions about you, including
patient medical records and billing records, but not including psychotherapy notes. You
must submit your request in writing to Dr. Roberta L. Gartside in order to inspect
and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying,
mailing, labor and supplies associated with your request. Our practice may deny your
request to inspect and/or copy in certain limited circumstances; however, you may request
a review of our denial. Another licensed health care professional chosen by us will
conduct reviews.
4. Amendment. You may ask us to amend your health
information if you believe it is incorrect or incomplete, and you may request an amendment
for as long as the information is kept by or for our practice. To request an amendment,
your request must be made in writing and submitted Dr. Roberta L. Gartside You must
provide us with a reason that supports your request for amendment. Our practice will deny
your request if you fail to submit your request (and the reason supporting your request)
in writing. Also, we may deny your request if you ask us to amend information that is in
our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the
practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or
(d) not created by our practice, unless the individual or entity that created the
information is not available to amend the information.
5. Accounting of Disclosures. All of our patients have the
right to request an "accounting of disclosures." An "accounting of
disclosures" is a list of certain non-routine disclosures our practice has made of
your IIHI for non-treatment, non-payment or non-operations purposes. Use of your IIHI as
part of the routine patient care in our practice is not required to be documented. For
example, the doctor sharing information with the nurse; or the billing department using
your information to file your insurance claim. In order to obtain an accounting of
disclosures, you must submit your request in writing to Dr. Roberta L. Gartside. All
requests for an "accounting of disclosures" must state a time period, which may
not be longer than six (6) years from the date of disclosure and may not include dates
before April 14, 2003. The first list you request within a 12-month period is free of
charge, but our practice may charge you for additional lists within the same 12-month
period. Our practice will notify you of the costs involved with additional requests, and
you may withdraw your request before you incur any costs.
6. Right to a Paper Copy of This Notice. You are entitled
to receive a paper copy of our notice of privacy practices. You may ask us to give you a
copy of this notice at any time. To obtain a paper copy of this notice, contact Dr.
Roberta L. Gartside
7. Right to File a Complaint. If you believe your privacy
rights have been violated, you may file a complaint with our practice or with the
Secretary of the Department of Health and Human Services. To file a complaint with our
practice, contact Dr. Roberta L. Gartside. All complaints must be submitted in writing. You
will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and
Disclosures. Our practice will obtain your written authorization for uses and
disclosures that are not identified by this notice or permitted by applicable law. Any
authorization you provide to us regarding the use and disclosure of your IIHI may be
revoked at any time in writing. After you revoke your authorization, we will no
longer use or disclose your IIHI for the reasons described in the authorization. Please
note, we are required to retain records of your care.
Again, if you have any questions regarding this notice or our
health information privacy policies, please contact Dr. Roberta L. Gartside or Pauline
Totaro (703-742-8004).
Acknowledgement of Notice of Privacy Rights
I hereby acknowledge that I've read and understand the Notice
of Privacy Practices.
If you want to download the acknowledgement form to sign and
send to Dr. Gartside's office, please click here. (Adobe
Acrobat Reader required)
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