NOTICE OF PRIVACY PRACTICES
DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Who We Are
This Notice describes the privacy practices of SMPHair.clinic and its personnel (“we” or “us”). We are committed to protecting the privacy and confidentiality of your health information.
II. Our Privacy Obligations Regarding Your Protected Health Information
We are required by law to maintain the privacy of your Protected Health Information and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. “Protected Health Information” is your demographic information, medical history, laboratory results, insurance information and other health information that is collected, generated, used, and/or communicated by SMPHair.clinic to provide you with products and/or services. Examples of Protected Health Information include your name, date of birth, medical record number, Social Security number, insurance beneficiary number, and test results. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure). We also are required to notify you following a breach of your health information, if that information is unsecured.
III. How We Use and Disclose Your Protected Health Information
Your Protected Health Information may be used and disclosed for treatment, payment, healthcare operations and other purposes permitted or required by law. We may use and disclose your Protected Health Information without your written authorization for the following purposes:
Treatment. We use and disclose your Protected Health Information to provide treatment and other services to you–for example, to provide reminders, services or to consult with your physician about your health. In addition, we may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose Protected Health Information to other providers involved in your treatment.
Health Care Operations. We may use and disclose your Protected Health Information for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may disclose your Protected Health Information for case management or care coordination purposes. We may use Protected Health Information to evaluate the quality and competence of our employees or health care professionals.
We also may disclose Protected Health Information to our Quality Assurance team in order to resolve any complaints you may have and ensure that you are satisfied with our services.
Persons Involved in Your Care or Payment for Your Care: Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose your Protected Health Information to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if: (1) we obtain your agreement or provide you with the opportunity to object to the disclosure and you do not object; or (2) we reasonably infer that you do not object to the disclosure.
If you are not present for or unavailable prior to a disclosure (e.g., when we receive a telephone call from a family member or other caregiver), we may exercise our reasonable judgment to determine whether a disclosure is in your best interests. If we disclose information under such circumstances, we would disclose only information that is directly relevant to the person’s involvement with your care.
Personal Representatives. We may disclose Protected Health Information about you to your authorized personal representative, such as a lawyer, administrator, executor or other authorized person responsible you or your estate.
Minors’ Protected Health Information. We may disclose Protected Health Information about minors to their parents or legal guardians.
Communications about Products and Services. We may use and disclose your Protected Health Information to contact you about other SMPHair.clinic services which we believe may be of interest to you. Any use, disclosure, or sale of Protected Health Information to third parties for marketing purposes requires your written authorization.
Disclosures to Business Associates. We may disclose your Protected Health Information to other companies or individuals, known as “Business Associates,” who provide services to us. For example, we may use a company to perform billing services on our behalf. Our Business Associates are required to protect the privacy and security of your Protected Health Information and notify us of any as required by Law. We may use and disclose your Protected Health Information when required to do so by any applicable federal, state or local law.
Public Health Activities. We may disclose your Protected Health Information: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to a government authority authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
Victims of Abuse, Neglect or Domestic Violence. We may disclose your Protected Health Information if we reasonably believe you are a victim of abuse, neglect or domestic violence to a government authority authorized by law to receive reports of such abuse, neglect, or domestic violence.
Health Oversight Activities. We may disclose your Protected Health Information to an agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
Judicial and Administrative Proceedings. We may disclose your Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
Law Enforcement Officials. We may disclose your Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.
Decedents. We may disclose your Protected Health Information to a coroner or medical examiner as authorized by law.
Organ and Tissue Procurement. We may disclose your Protected Health Information to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
Threats to Health or Safety. We may use or disclose your Protected Health Information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
Specialized Government Functions. We may use and disclose your Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
Workers’ Compensation. We may disclose your Protected Health Information as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.
IV. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III, we may use or disclose your Protected Health Information only when you grant us your written authorization on an appropriate authorization form. For instance, generally, we must obtain your written authorization prior to using your Protected Health Information for marketing purposes. We can, however, communicate with you about products or services related to your treatment, for case management or care coordination purposes, or about alternative treatments, therapies, providers or care settings without your written authorization. In addition, we may market to you in a face-to-face encounter and give you promotional gifts of nominal value without obtaining your written authorization.
B. Uses and Disclosures of Your Highly Confidential Information. Federal and state law requires special privacy protections for certain health information about you (“Highly Confidential Information”), including Psychotherapy Notes created by a mental health professional, Alcohol and Drug Abuse Treatment Program records and other health information that is given special privacy protection under state or federal laws other than HIPAA. However, in order for us to disclose any Highly Confidential Information for a purpose other than those permitted by law, we must obtain your authorization.
C. Revocation of Your Authorization. You may revoke your authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below.
V. Your Individual Rights
A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your Protected Health Information, you may contact our Privacy Office. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or with the Director.
B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your Protected Health Information (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction unless the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service for which you have paid us out of pocket in full. If you wish to request additional restrictions, obtain a request form from our Privacy Office and submit the completed form to the Privacy Office. We will send you a written response.
C. Right to Receive Communications by Alternative Means or at Alternative Locations. You may request, and we will accommodate, any reasonable written request for you to receive your Protected Health Information by alternative means of communication or at alternative locations.
D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we may charge you a reasonable copy fee.
E. Right to Amend Your Records. You have the right to request that we amend your Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Privacy Office and submit the completed form to the Privacy Office. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
F. Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years. If you request an accounting more than once during a twelve (12) month period, we may charge you a reasonable fee for the accounting statement.
G. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on January 01, 2018.
B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all your Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in our offices and on our website at www.smphair.clinic
VII. Privacy Office (By appointment only – no walk ins)
You may contact:
OC – with Dr Ahmed
Dallas – with Dr Johnson
Telephone number: (949) 342-5598
E-mail: firstname.lastname@example.org; email@example.com