NOTICE OF PRIVACY PRACTICES EFF. 4/14/03
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.
If you have questions about this notice, please contact Jeffrey
C. Popp, M.D. of our office at 402/391-4558 or mail to Popp Cosmetic Surgery, P.C., 11919 Grant Street Suite
100, Omaha, NE 68164.
This notice describes information about privacy
practices followed by our employees, health care providers and contracted
staff. The practices described in this notice will also be followed by
providers you consult with by telephone (when your regular healthcare provider
from our office is not available) who provide “call coverage” for your
healthcare provider.
This notice applies to the information and records
we have about your health, health status, and the healthcare and services you
receive at this office. We are required by law to give you this notice.
It will tell you about the ways in which we may use and disclose health
information about you and describes your rights and our obligations regarding
the use and disclosure of that information.
We must have your written, signed Consent to use and
disclose health information for the following purposes:
For treatment: We may use
health information about you to provide you with medical treatment or services.
We may disclose health information about you to physicians, nurses,
technicians, office staff or other personnel who are involved in taking care of
you and your health. For example, your physician may be treating you for a
condition that requires surgery and needs to know if you have other health
problems that could complicate your treatment. The physician may use your
medical history to decide what treatment is best for you. The physician may
also tell another provider about your condition so that physician can help
determine the most appropriate care for you.
Different personnel in our office may share
information about you and disclose information to people who do not work in our
office in order to coordinate your care, such as telephoning in prescriptions
to your pharmacy, scheduling laboratory tests and X-rays. Family members and
other healthcare providers may be part of your medical care outside this office
and may require information about you that we have.
For payment: We may use
and disclose health information about you so that the treatment and services
you receive at this office may be billed to and payment may be collected from
you, an insurance company or a third party. For example, we may need to give
your health plan information about a service you received here so your health
plan will pay us or reimburse you for the service. We may also tell your health
plan about a treatment you are going to receive to obtain prior approval, or to
determine whether your plan will pay for a particular treatment.
For healthcare operations: We may use and disclose health information about you in order to
run the office and make sure that you and our other patients receive quality
care. For example, we may use your health information to evaluate the performance
of our staff in caring for you. We may also use health information about all or
many of our patients to help us decide what additional services we should
offer, how we can become more efficient, or whether certain new treatments are
effective.
Appointment reminders: We may contact you as reminder that you have an appointment for
treatment or medical care at the office. This may be done by telephone
(including leaving a message on a private answering machine or voice mail), by
postcard or by letter, or by e-mail. It may even be accomplished by an
automated system.
Treatment alternatives: We may tell you about or recommend possible treatment options or
alternatives that may be of interest to you.
Health-related products and services: We may tell you about health-related products or services that
may of interest to you.
Please notify us if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services. If you advise us in writing (at the address listed at the top of this Notice) that you do not wish to receive such communications, we will not use or disclose your information for these purposes.
You may revoke your Consent at any time by giving us
written notice. Your revocation will be effective when we receive it, but it
will not apply to any uses and disclosures that occurred before that time.
If you do revoke your Consent, we will not be
permitted to use or disclose information for purposes of treatment, payment or
healthcare operations, and we may therefore choose to discontinue providing you
with healthcare treatment and services.
We may use or disclose health information about you
without your permission for the following purposes, subject to all applicable
legal requirements and limitations:
To avert a serious threat to health or safety: We may use and disclose health information about you when
necessary to prevent a serious threat to your health and safety or the health
and safety of the public or another person.
Required by law: We
will disclose health information about you when required to do so by federal,
state or local law.
Research: We may use
and disclose health information about you for research projects that are
subject to a special approval process. We will ask you for your permission if
the researcher will have access to your name, address or other information that
reveals who you are, or will be involved in your care at the office. However,
if information is disclosed only in an anonymous or not individually
identifiable form, your consent will not be needed.
Organ and tissue donation: If you are an organ donor, we may release health information to
organizations that handle organ procurement or organ, eye or tissue transplantation
or to an organ donation bank, as necessary to facilitate such donation and
transplantation.
Military, veterans, national security and
intelligence: If you are or were a member of the armed
forces, or part of the national security or intelligence communities, we may be
required by military command or other government authorities to release health
information about you. We may also release information about foreign military
personnel to the appropriate foreign military authority.
Worker’s Compensation: We may release health information about you for worker’s
compensation or similar programs. These programs provide benefits for
work-related injuries or illness.
Public health risks: We may disclose health information about you for public health
reasons in order to prevent or control disease, injury or disability; or report
births, deaths, suspected abuse or neglect, non-accidental physical injuries,
reactions to medications or problems with products.
Health oversight activities: We may disclose health information to a health oversight agency
for audits, investigations, inspections, accreditation or licensing purposes.
These disclosures may be necessary for certain state and federal agencies to
monitor the healthcare system, government programs, and compliance with civil
rights laws.
Lawsuits and disputes: If you are involved in a lawsuit or a dispute, we may disclose
health information about you in response to a court or administrative order.
Subject to all applicable legal requirements, we may also disclose health
information about you in response to a subpoena.
Law enforcement: We
may release health information if asked to do so by a law enforcement official
in response to a court order, subpoena, warrant, summons or similar process,
subject to all applicable legal requirements.
Coroners, Medical Examiners and Funeral Directors: We may release health information to these persons, for example,
to identify a deceased person or determine the cause of death.
Information not personally identifiable: We may use or disclose health information about you in a way that
does not personally identify you or reveal who you are.
Family and friends: We
may disclose health information about you to your family members or friends if
we obtain your verbal agreement to do so or if we give you an opportunity to
object to such a disclosure and you do not raise an objection. We may also
disclose health information to your family or friends if we can infer from the
circumstances, based on our professional judgment, that you would not object.
For example, we may assume you agree to our disclosure of your personal health
information to your spouse or adult child when you bring those persons into the
exam room during treatment or while treatment is discussed.
In situations where you are not capable of giving
consent (because you are not present or due to your incapacity or medical
emergency), we may, using our professional judgment, determine that a
disclosure to your family member or friend is in your best interest. In that
situation, we will disclose only health information relevant to the person’s
involvement in your care. For example, we may inform the person who accompanied
you to the emergency room or who is present during a surgery that you suffered
a heart attack and provide updates on your progress and prognosis. We may also
use our professional judgment and experience to make reasonable inferences that
it is in your best interest to allow another person to act on your behalf to
pick up, for example, filled prescriptions, medical supplies or X-rays.
We will not use or disclose your health information
for any purpose other than those identified in the previous sections without
your specific, written authorization. We must obtain your authorization
separate from any consent we may have obtained from you. If you give us authorization
to use or disclose health information about you, you may revoke your authorization,
in writing, at any time. If you revoke your authorization, we will no
longer use or disclose information about you for the reasons covered by your
written authorization, but we cannot take back any uses or disclosures
already made with your permission.
If we have HIV or substance abuse information about
you, we cannot release that information without a special signed, written authorization
(different than the authorization and consent mentioned above)
from you. In order to disclose these types of records for purposes of
treatment, payment or healthcare operations, we will have to have both your
signed consent and a special written authorization that complies
with the law governing HIV or substance abuse records.
You have the following rights regarding health
information we maintain about you:
Right to inspect and copy. You have the right to inspect and copy your health information,
such as medical and billing records, that we use to make decisions about your
care. You must submit a written request to Jeffrey C. Popp, M.D., Privacy
Officer, in order to inspect and/or copy your health information. If you
request a copy of the information, we may charge a fee for the costs of
copying, mailing or other associated supplies. We may deny your request to
inspect and/or copy in certain limited circumstances. If you are denied access
to your health information, you may ask that the denial be reviewed. If such a
review is required by law, we will select a licensed healthcare professional to
review your request and our denial. The person conducting the review will not
be the person who denied your request, and we will comply with the outcome of
the review.
Right to amend. If
you believe health information we have about you is incorrect or incomplete,
you may ask us to amend the information. You have the right to request an
amendment as long as the information is kept by this office.
To request an amendment, complete and submit a
Medical Record Amendment/Correction Form to Jeffrey C. Popp, M.D. We may deny your request for an amendment if
it is not in writing or does not include a reason to support the request. In
addition, we may deny your request if you ask us to amend information that:
a)
We
did not create, unless the person or entity that created the information is no
longer available to make the amendment.
b)
Is
not part of the health information that we keep.
c)
You
would not be permitted to inspect and copy.
d)
Is
accurate and complete.
Right to an accounting of disclosures. You have the right to request an “accounting of disclosures”.
This is a list of the disclosures we made of medical information about you for
purposes other than treatment, payment and healthcare operations. To obtain
this list, you must submit your request in writing to Jeffrey C. Popp, M.D. It
must state a time period, which may not be longer than six years and may not
include dates before April 14, 2003. Your request should indicate in what form
you want the list (for example, on paper or electronically). We may charge you
for the costs of providing the list. We will notify you of the cost involved
and you may choose to withdraw or modify your request at that time before any
costs are incurred.
Right to request restrictions. You have the right to request a restriction or limitation on the
health information we use or disclose about you for treatment, payment or
healthcare operations. You also have the right to request a limit on the health
information we disclose about you to someone who is involved in your care or
the payment for it, like a family member or friend. For example, you could ask
that we not use or disclose information about a surgery you had. To request
restrictions, you may complete and submit the Request for Restriction on
Use/Disclosure of Medical Information to Jeffrey C. Popp, M.D.
We are not required to agree to your request. If we do agree, we will comply with your request unless the
information is needed to provide you emergency treatment.
Right to request confidential communications. You have the right to request that we communicate with you about
medical matters in a certain way or at a certain location. For example, you can
ask that we only contact you at work or by mail. To request confidential
communications, you may complete and submit the Request for Restriction on
Use/Disclosure of Medical Information and/or Confidential Communication to Jeffrey
C. Popp, M.D. We will not ask you the reason for your request. We will
accommodate all reasonable requests. Your request must specify how or where you
wish to be contacted.
Right to a paper copy of this Notice. You have the right to a paper copy of this notice. You may ask us
to give you a copy of this notice at any time. Even if you have agreed to
receive it electronically, you are still entitled to a paper copy. To obtain
such a copy, contact Jeffrey C. Popp, M.D.
We reserve the right to change this notice, and to
make the revised or changed notice effective for medical information we already
have about you as well as any information we receive in the future. We will
post a summary of the current notice in the office with its effective date in
the top right hand corner. You are entitled to a copy of the notice currently
in effect.
If you believe your privacy rights have been violated,
you may file a complaint with our office or with the Secretary of the
Department of Health and Human Services. To file a complaint with our office,
contact Jeffrey C. Popp, M.D., Privacy Office at 402/391-4558 for more
information. You will not be penalized for filing a complaint.
P:\HIPAA DOCUMENTS\NOTICE OF PRIVACY PRACTICES.doc 04/14/2003