AESTHETIC AND COSMETIC PLASTIC SURGERY CENTER, LLC
LORELLE L. KRAMER, M.D.
10624 N. Port Washington Road
Mequon, Wisconsin 53092
Fax: (262) 241-7989
Notice of Privacy Practices
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. (Effective Date: April 14, 2003; Rev. 5/5/03)
We care about our patients' privacy and strive to protect the confidentiality of your medical information (also known as "protected health information" or "PHI") at our practice. New federal legislation requires that we issue this official notice of our privacy practices, which is required under the Health Insurance Portability and
Accountability Act of 1996 ("HIPPA"). You have the right to the confidentiality of your medical information, and this practice is required by law to maintain the privacy of your health information.
Aesthetic and Cosmetic Plastic Surgery Center, LLC is required to follow the terms of this Notice or any revision to it that is in effect. If you have any questions about this notice please contact our privacy officer.
Who Will Follow This Notice
Any health care professional authorized to enter information into your medical record, all employees and other personnel at this practice whomay need access to your information must abide by this Notice. All subsidiaries, business associates (e.g. a billing service), sites and
locations of this practice may share medical information with each other for treatment, payment purposes or health care operations described in this Notice. Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared.
How We May Use and Disclose Medical Information About You
The following categories describe different ways that we may use and disclose medical information without your specific consent or authorization. Examples are provided for each category of use or disclosures. Not every possible use or disclosure in a category is listed.
We may use or disclose medical information to provide treatment to you or for others to provide treatment to you. We may disclose your PHI to hospitals or other facilities outside of Aesthetic and Cosmetic Plastic Surgery Center, LLC to schedule procedures. We may also disclose your PHI for implant registration or ordering specific products related to your cosmetic surgery, treatment, or services. We may also use your PHI to contact you to remind you that you have an appointment for treatment at our facility, or to tell you about or recommend possible treatment options or alternatives, or about health-related benefits or services that may interest you.
We may use and disclose additional information about you so that the treatment and services you receive from us may be billed and payment may be obtained from you or another party. Example: We may send a statement to your home of the services that were rendered and the balance that is
due. We may disclose your PHI to another health care provider or collection agency for their payment-related activities to enable them to receive payment for the treatment or services provided to you.
For Health Care Operation
We may use and disclose PHI about you for health care operations to assure that you receive quality care. Example: We may use medical information to review our treatment and services and evaluate the performance of those involved with your care. We may also provide your PHI to our attorneys, accountants, and other consultants to make sure we are complying with the laws that affect us.
Uses And Disclosures That You May Object
Unless you object, we may provide relevant portions of your PHI to a family member, friend or other person involved in your health care or in helping you get payment for your health care. In an emergency or when you are not capable of agreeing or objecting to these disclosures, we will disclose your PHI as we determine is in your best interest. We will tell you about such disclosure and give you the opportunity to object to future disclosures to family and friends when it becomes practicable to do so. Unless you object, we may also disclose your PHI to persons performing disaster relief activities.
Other Uses And Disclosures That Can Be Made Without Consent or Authorization
. As required or permitted by law, such as law enforcement officials, court officials, correctional institutions or government agencies, when required to do so by law.
. For public health activities to help prevent or control disease, injury, or disability. As required by the US Food and Drug Administration (FDA).
. For health oversight activities we may disclose your PHI to authorities and agencies authorized by law, including audits, investigations, inspections, licensure, disciplinary actions or legal proceedings.
. For activities related to death we may disclose your PHI to coroners and medical examiners so they can carry out their duties, such as identifying the body or determining cause of death, and to funeral directors to carry out funeral preparation activities. We may also disclose your PHI to organ procurement agencies who are involved in organ donation if you have indicated that you desire to be a donor.
. For medical research we may disclose your PHI to researchers affiliated with Aesthetic and Cosmetic Plastic Surgery Center, LLC who request it for medical research projects that are approved by Aesthetic and Cosmetic Plastic Surgery Center, LLC.
. For Workers' Compensation we may disclose your PHI to comply with laws related to workers' compensation or other similar benefits for work-related injuries or illness. Except as described above, we may only use and disclose your PHI with your written authorization. If you give us a written authorization, you may revoke it at any time by notifying our office in writing. If you revoke your authorization, we will no longer use or disclose your PHI for the purposes specified in the authorization, except to the extent we have already taken action in reliance upon your authorization.
Please be aware that state and federal law may have more requirements than HIPPA on how we use and disclose your medical information if there are more restrictive requirements, including any of the purposes listed above, we may not disclose your PHI without your signed authorization as required by these laws. For example, we will not disclose your HIV test results without obtaining your written authorization, except as permitted by the state law. There may be other restrictions on how we use and disclose your PHI other than those listed above. As of the date of this Notice, we are aware of the following state and federal laws discussing such restrictions; Wisconsin Statutes Sections 146.82, 51.30, 252.15, 895.50 and 905.04; Wisconsin Administrative Code HFS 92 and
124.14; and 42 C.F.R. Part 2. These laws may change from time to time. Please contact our Privacy Officer, if you have further questions.
Your Rights Related To Your Protected Health Information
You have the following rights as a patient or customer of Aesthetic and Cosmetic Plastic Surgery Center, LLC.
. The Right to File a Complaint. If you believe your rights have been violated, you may file a written complaint with the privacy officer at our practice or with the Secretary of the Dept. of Health and Human Services. All complaints must be in writing. You will not be penalized or discriminated against for filing a complaint. You may also contact our Privacy Officer if you have questions or comments about our privacy practices.
. The Right to See and Copy your PHI. Except for limited circumstances, you may review and request a copy of your PHI by providing our office with a written request. We will respond to your request within 30 days unless we send written notification that extra time is needed. We may deny your requests, but if we do, we will tell you in writing of the reason(s) for the denial and explain your rights with regard to having the denial reviewed. We have the right to charge for the copying of your PHI and you will be notified of this cost before the PHI is copied.
. The Right to Correct or Update your PHI. If you believe that the PHI listed in your records is incomplete or incorrect you may ask Aesthetic and Cosmetic Plastic Surgery Center, LLC to amend it. This request must be in writing stating why you think this amendment is appropriate; otherwise, it will not be processed. We will act on your request within 60 days unless notified that extra time is needed. We will inform you in writing if the amendment would be granted or denied. If the amendment is granted, you can notify us if others are to be informed, but if your amendment is denied you also have the right to submit a written statement of disagreement and/or to request inclusion of your original amendment request in your PHI. Please contact our privacy officer for specific filing details.
. The Right to Get a List of the Disclosures We Have Made. You have the right to receive a list of instances we have disclosed your PHI to on or after April 14, 2003. A written request for this list is required and we will respond to your request within 60 days unless notified that extra time is needed. The list will include all disclosures for up to six years but may be shorter if specified. The first list you request within a 12-month period will be free. For additional lists, we reserve the right to charge you for the cost of providing the list. This list will not include disclosures made to the patient, or for purposes of treatment, payment, health care operations, byproduct of another use/disclosure permitted under our privacy policies or by law, national security, law enforcement/corrections, and certain health oversight activities. . The Right to Request Limits on Uses and Disclosures of Your PHI.
You have the right to limit uses and disclosures of your PHI, but these requests must be received in writing to our office. We are not required by law to agree to your request. If we agree, we will abide by your request unless it is during emergency treatment.
. The Right to Choose How We Communicate With You. You have the right to request that we contact you at an alternate address, phone number(s), or location.
. The Right to Get a Paper Copy of This Notice. You have the right to a paper copy of this Notice at any time. To obtain a paper copy of the current Notice, please request one in writing to our privacy officer.
Changes To This Notice
We reserve the right to change this Notice as allowed by law. Changes to our privacy practices would apply to all PHI we maintain at our office. You may obtain a copy of any revised Notice by contacting our Privacy Officer. We will also post a copy of the current Notice in our office waiting room and on our website: www.greatyou.com.