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
If you have any questions about this notice, please contact Betsi at 858-453-3133.
Who Will Follow This
Notice:
This notice describes information about privacy practices followed by
our employees, staff and office personnel. The practices describe in this
notice will also be followed by healthcare 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.
Your Health information:
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.
How We May Use and
Disclose Health Information About You:
We must have your written, signed consent to use and disclose health information
for the following purposes:
1. Treatment: We may use health information about you to provide you with
medical treatment or services. We may disclose health information about
you to doctors, nurses, technicians, office staff or other personnel who
are involved in taking care of you and your health.
Example: your doctor may be treating you for a cosmetic surgery, but will
need to know if you have other health problems that could complicate your
treatment. The doctor may use your medical history to decide what treatment
is best for you. The doctor may also tell another doctor about your condition
so that doctor can help determine the most appropriate care for you. Different
personnel in our office msy share information about you and disclose information
to people who do not work in our office in order to coordinate your care,
such as phoning in prescripitions to your pharmacy, scheduling lab work
and ordering tests, such as mammograms, EKG’s, etc. 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.
2. 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, and insurance company or a third party.
Example: We may need to give your health plan information about a service
you received 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 cover the treatment.
3. 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.
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.
3. Appointment Reminders: We may contact you as a reminder that you have an appointment for treatment or medical care at the office.
4. Treatment Alternatives: We may tell you about or recommend possible treatment options or alternatives that may be of interest of you.
5. Health-Related Products and Services: We may tell you about health related products or services that may be 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 ans 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 disclosure your information for these purposes. You may revoke your consent at any time by giving us a 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 disclosure information for purposes of treatment, payment or healthcare operation, and we may therefore choose to discontinue providing you with healthcare treatment and services.
SPECIAL SITUATIONS
We may use or disclosure 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.
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 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 personnel to the appropriate foreign military.
Workers’ Compensation: We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries of illness.
Public Health Risks: We may disclose health information to health oversight agency for audits, investigations, inspections, 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 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 a coroner or medical examiner. This may be necessary, 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 or your family members or friends only if we obtain your verbal agreement to do so. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgement that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room during treatment or while treatment is discussed. In situations when 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 judgement, determine that a disclosure to your family member or friends is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. We may also use our professional judgement and experience to make reasonable inferences that is in your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies, or etc.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION: We will not use or disclose your health information for any purposes 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 that 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 that complies with the law governing HIV or substance abuse records.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU: 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 (designated privacy official contact) in order to inspect and/or copy your health information. If you request a copy of information, we may change 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 Betsi Walker who is the designated privacy official contact. 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 Betsi Walker designated privacy official contact. 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. 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 limit 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 a friend. For example, you could ask that we not use or disclose information about a surgery you had.
WE ARE NOT REQUIRED TO AGREE TO YOUR REQUEST: If we do agree, we will comply with your request unless the information needed to provide you emergency treatment. To request restrictions, you may complete and submit for a Restriction on use/disclosure of medical information to Betsi Walker designated privacy official contact.
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 Betsi Walker designated privacy official contact. 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. Please take it home with you and read it, you are entitled nto this copy and upon receipt of this notice we will ask you to sign a receipt of which states we have given you this notice to take home with you.
CHANGES TO THIS NOTICE: 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.
COMPLAINTS: 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.
Thank You,
Scott R. Miller, M.D., F.A.C.S.
PRIVACY LETTER TO OUR PATIENTS
PLEASE REVIEW IT CAREFULLY
Scott R. Miller, M.D.,F.A.C.S.
Board Certified American Board Of Plastic Surgery
To Our Patients:
Welcome to our practice. We value your privacy. The misuse of Personal Health Information has been identified as a national problem causing patients inconvenience and aggravation. We want you to know that all of our employees continually undergo training so that we may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the “Privacy Rules.” We strive to achieve the very highest standards of ethics and integrity in performing services for our patients.
It is our policy to properly determine the appropriate use of Personal Health Information in accordance with government rules, laws and regulations. We want to be sure that our practice never contribute in any way to the growing problem of improper disclosure of Personal Health Information.
Our office has implemented a Compliance Program that we believe will help us prevent any inappropriate use of Personal Health Information. If you would like further information on our Compliance Program please mark the area below and our receptionist will supply you with a booklet explaining our Compliance Program.
Your signature below acknowledges that you have read the above statements and have been offered a booklet on the Compliance Program at the office of Dr. Scott Miller.
_____ Yes, I would like further information on the Compliance Program
_____ No, I would not like any further information of the Compliance Program
Print name: ____________________ Signature: ________________ Date: __________
Scripps Medical Office Building,
Suite 210
9834 Genesee Ave, La Jolla, Ca 92037
Tel: (858) 453-3133 Fax: (858) 453-0433
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