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.
This notice takes effect on April 14, 2003, and remains in effect until
we replace it.
OUR PLEDGE REGARDING MEDICAL INFORMATION
The privacy of your medical information is important to us. We understand
that your medical information is personal and we are committed to protecting
it. We create a record of the care and services you receive at our organization.
We need this record to provide you with quality care and to comply with
certain legal requirements. This notice will tell you about the ways
we may use and share medical information about you. We also describe
your rights and certain duties we have regarding the use and disclosure
of medical information.
OUR LEGAL DUTY
Law Requires Us to:
 1. Keep
your medical information private.
2. Give
you this notice describing our legal duties, privacy practices, and
your rights regarding your medical information.
3. Follow
the terms of the notice that is now in effect.
We Have the Right to:
1. Change
our privacy practices and the terms of this notice at any time, provided
that the changes are permitted by law.
2. Make
the changes in our privacy practices and the new terms of our notice
effective for all medical information that we keep, including information
previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before
we make an important change in our privacy practices, we will change
this notice and make the new notice available upon request.
USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways that we use and disclose
medical information. Not every use or disclosure will be listed. However,
we have listed all of the different ways we are permitted to use and
disclose medical information. We will not use or disclose your medical
information for any purpose not listed below, without your specific
written authorization. Any specific written authorization you provide
may be revoked at any time by writing to us.
FOR TREATMENT: We may use medical information about you to provide
you with medical treatment or services. We may disclose medical information
about you to doctors, nurses, technicians, medical students, or other
people who are taking care of you. We may also share medical information
about you to your other health care providers to assist them in treating
you.
FOR PAYMENT: We may use and disclose your medical information
for payment purposes.
FOR HEALTH CARE OPERATIONS: We may use and disclose your medical
information for our health care operations. This might include measuring
and improving quality, evaluating the performance of employees, conducting
training programs, and getting accreditation, certificates, licenses,
and credentials we need to serve you.
ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing
your medical information for treatment, payment, and health care operations,
we may use and disclose medical information for the following purposes.
Facility Directory: Unless you notify us that you object,
the following medical information about you will be placed in our facilities’
directories: your name; your location in our facility; your condition
described in general terms; your religious affiliation, if any. We may
disclose this information to members of the clergy or, except for your
religious affiliation, to others who contact us and ask for information
about you by name.
Notification: Medical information to notify or help notify:
a family member, your personal representative or another person responsible
for your care. We will share information about your location, general
condition, or death. If you are present, we will get your permission
if possible before we share, or give you the opportunity to refuse permission.
In case of emergency, and if you are not able to give or refuse permission,
we will share only the health information that is directly necessary
for your health care, according to our professional judgment. We will
also use our professional judgment to make decisions in your best interest
about allowing someone to pick up medicine, medical supplies, x-ray
or medical information for you.
Disaster Relief: Medical information with a public or
private organization or person who can legally assist in disaster relief
efforts.
Fundraising: We may provide medical information to one
of our affiliated fundraising foundations to contact you for fundraising
purposes. We will limit our use and sharing to information that describes
you in general, not personal, terms and the dates of your health care.
In any fundraising materials, we will provide you a description of how
you may choose not to receive future fundraising communications.
Research in Limited Circumstances: Medical information
for research purposes in limited circumstances where the research has
been approved by a review board that has reviewed the research proposal
and established protocols to ensure the privacy of medical information.
Funeral Director, Coroner, Medical Examiner: To help
them carry out their duties, we may share the medical information of
a person who has died with a coroner, medical examiner, funeral director,
or an organ procurement organization.
Specialized Government Functions: Subject to certain
requirements, we may disclose or use health information for military
personnel and veterans, for national security and intelligence activities,
for protective services for the President and others, for medical suitability
determinations for the Department of State, for correctional institutions
and other law enforcement custodial situations, and for government programs
providing public benefits.
Court Orders and Judicial and Administrative Proceedings:
We may disclose medical information in response to a court or administrative
order, subpoena, discovery request, or other lawful process, under certain
circumstances. Under limited circumstances, such as a court order, warrant,
or grand jury subpoena, we may share your medical information with law
enforcement officials. We may share limited information with a law enforcement
official concerning the medical information of a suspect, fugitive,
material witness, crime victim or missing person. We may share the medical
information of an inmate or other person in lawful custody with a law
enforcement official or correctional institution under certain circumstances.
Public Health Activities: As required by law, we may
disclose your medical information to public health or legal authorities
charged with preventing or controlling disease, injury or disability,
including child abuse or neglect. We may also disclose your medical
information to persons subject to jurisdiction of the Food and Drug
Administration for purposes of reporting adverse events associated with
product defects or problems, to enable product recalls, repairs or replacements,
to track products, or to conduct activities required by the Food and
Drug Administration. We may also, when we are authorized by law to do
so, notify a person who may have been exposed to a communicable disease
or otherwise be at risk of contracting or spreading a disease or condition.
Victims of Abuse, Neglect, or Domestic Violence: We may
disclose medical information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect, or domestic
violence or the possible victim of other crimes. We may share your medical
information if it is necessary to prevent a serious threat to your health
or safety or the health or safety of others. We may share medical information
when necessary to help law enforcement officials capture a person who
has admitted to being part of a crime or has escaped from legal custody.
Workers Compensation: We may disclose health information
when authorized and necessary to comply with laws relating to workers
compensation or other similar programs.
Health Oversight Activities: We may disclose medical
information to an agency providing health oversight for oversight activities
authorized by law, including audits, civil, administrative, or criminal
investigations or proceedings, inspections, licensure or disciplinary
actions, or other authorized activities.
Law Enforcement: Under certain circumstances, we may
disclose health information to law enforcement officials. These circumstances
include reporting required by certain laws (such as the reporting of
certain types of wounds), pursuant to certain subpoenas or court orders,
reporting limited information concerning identification and location
at the request of a law enforcement official, reports regarding suspected
victims of crimes at the request of a law enforcement official, reporting
death, crimes on our premises, and crimes in emergencies.
YOUR INDIVIDUAL RIGHTS
You Have a Right to:
1. Look
at or get copies of your medical information. You may request that we
provide copies in a format other than photocopies. We will use the format
you request unless it is not practical for us to do so. You must make
your request in writing. You may get the form to request access by using
the contact information listed at the end of this notice. You may also
request access by sending a letter to the contact person listed at the
end of this notice. If you request copies, we will charge you $ .50__
for each page, and postage if you want the copies mailed to you. Contact
us using the information listed at the end of this notice for a full
explanation of our fee structure.
2. Receive
a list of all the times we or our business associates shared your medical
information for purposes other than treatment, payment, and health care
operations and other specified exceptions.
3. Request
that we place additional restrictions on our use or disclosure of your
medical information. We are not required to agree to these additional
restrictions, but if we do, we will abide by our agreement (except in
the case of an emergency).
4. Request
that we communicate with you about your medical information by different
means or to different locations. Your request that we communicate your
medical information to you by different means or at different locations
must be made in writing to the contact person listed at the end of this
notice.
5. Request
that we change your medical information. We may deny your request if
we did not create the information you want changed or for certain other
reasons. If we deny your request, we will provide you a written explanation.
You may respond with a statement of disagreement that will be added
to the information you wanted changed. If we accept your request to
change the information, we will make reasonable efforts to tell others,
including people you name, of the change and to include the changes
in any future sharing of that information.
6. If
you have received this notice electronically, and wish to receive a
paper copy, you have the right to obtain a paper copy by making a request
in writing to the Privacy Officer at your office.
QUESTIONS AND COMPLAINTS
If you have any questions about this notice or if you think that we
may have violated your privacy rights, please contact us. You may also
submit a written complaint to the U.S. Department of Health and Human
Services. We will provide you with the address to file your complaint
with the U.S. Department of Health and Human Services. We will not retaliate
in any way if you choose to file a complaint.
Aesthetic Plastic Surgery Center
Dr. John W. Harlan, M.D., F.A.C.S.
900 North Orange Street
Missoula, MT 59802
(406)-542-7300
Contact: Donna Peterson
NOTICE OF PRIVACY PRACTICES is ©2002 Medical Arts Press®
All other content on this site © 2000 to 2005 Aesthetic Plastic
Surgery Center
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