Notice of Privacy Policy

Virginia Center for Plastic Surgery

NOTICE OF PRIVACY POLICY

The following is the privacy policy of Virginia Center for Plastic Surgery ("Covered Entity") as described in the Health Insurance Portability and Accountability Act of 1996 ("HIPAA").

Your Personal Health Information

We collect personal health information from you through treatment, payment and related healthcare operations. "Personal health information" means information that identifies you and relates to your past, present or future physical or mental health condition and related healthcare services.

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Use or Disclosures of Your Personal Health Information

Generally, we may not use or disclose your personal health information without your permission. Further, if we are to use your personal health information for marketing purposes or sell your personal health information you must give express written authorization allowing us to do so. However, the following describes the circumstances under which and purposes for which your personal health information may be used or disclosed.

Without Your Consent

Without your consent, we may use or disclose your personal health information in order to provide you with treatment, obtain payment for services rendered to you and conduct health care operations. Below are examples of various types of uses and disclosures of personal health information that we are permitted to make without your written consent. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment: Examples of treatment activities include: (a) the provision, coordination, or management of health care and related services by one or more healthcare providers and a third party, (b) consultations between healthcare providers regarding a patient, or (c) the referral of a patient from one healthcare provider to another.

Payment: Examples of payment activities include: (a) billing and collection activities and related data processing; (b) actions by a health plan to obtain premiums, to fulfill their coverage responsibilities and provide benefits under the plan, and to obtain or provide reimbursement for healthcare delivered to a patient; (c) determinations of eligibility or coverage and adjudication or subrogation of health benefit claims; (d) risk adjusting amounts due based on enrollee health status and demographic characteristics; (e) billing, claims management, collection activities, obtaining payment under a contract for reinsurance, and related healthcare data processing; (f) review of healthcare services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges; (g) utilization review activities.

Health Care Operations: Examples of health care operations include:

(a) development of clinical guidelines; (b) contacting patients with information about treatment alternatives or other related functions that do not include treatment; (c) quality assessment and improvement activities, including outcomes evaluation and development of clinical guidelines, provided that obtaining generalizable knowledge is not the primary purpose of any studies resulting from such activities, population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, contacting of healthcare providers and patients with information about treatment alternatives and related functions; (d) reviewing the qualifications and performance of healthcare providers, health plan performance, conducting training programs, accreditation, certification, licensing or credentialing activities; (e) underwriting, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care; (f) conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse compliance programs; (g) business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating the entity; (h) business management and general administrative activities of the entity.

Business Associates: There may be some services provided in our organization through contracts with business associates. Examples include physician services in the emergency department or radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.

We may use or disclose your personal health information to the extent that such use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

All Other Situations, With Your Specific Authorization

Except as otherwise permitted or required, as described above, we may not use or disclose your personal health information without your express written authorization. If you provide us authorization to use or disclose your personal health information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your personal health information for the purposes covered by the authorization, but we are unable to take back any uses or disclosures already made with your permission.

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Your Rights with Respect to Your Personal Health Information

Under HIPAA, you have certain rights with respect to your personal health information. The following is a summary of your rights, together with a brief explanation of each right.

Right to Inspect and Copy Your Personal Health Information

You have the right to inspect and copy certain personal health information that may be used to make decisions about your care. To inspect and copy your personal health information, you must submit your request in writing to our Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your personal health information, you may request that the denial be reviewed.

Right to Amend Your Personal Health Information

If you feel that personal health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, you must provide us with a reason that supports your request. We may deny your request if you ask us to amend information that: (a) was not created by us; (b) is not part of the personal health information kept by or for the Covered Entity; (c) is not part of the information which you would be permitted to inspect and copy; or (d) is accurate and complete.

Right to Receive an Accounting of Disclosures of Your Personal Health Information

You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of your personal health information. To request this list or accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period that 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, electronically). The first list you request within a 12-month period will be free. For additional lists within the 12-month period, 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 on Uses and Disclosures of Your Personal Health Information

You have the right to request a restriction or limitation on the personal health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the personal 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. To request restrictions, you must make your request in writing to our Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. 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 of Your Personal Health Information

You have the right to request that we communicate with you about your personal health information by alternative means or at alternative locations. For example, you may request that we contact you only at work or by mail. To request confidential communications, you must make your request in writing to our Privacy Officer. 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 Receive a Paper Copy of this Notice

You have the right to receive 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 this notice electronically, you are still entitled to receive a paper copy of this notice. To obtain such a copy, contact our Privacy Officer.

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Restrictions on Certain Uses and Disclosures

Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. Such highly confidential information may include:

• Alcohol and/or substance abuse records covered by federal and/or state law;
• HIV/AIDS testing, diagnosis or treatment information covered by federal and/or state law;
• Mental health records or psychotherapy notes (process notes) covered by federal and/or state law; and
• Genetic testing information covered by federal and/or state law.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.

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How to Make a Privacy Complaint

If you believe your privacy rights have been violated, you may file a complaint with the Covered Entity or with the Secretary of the Department of Health and Human Services. To file a complaint with the Covered Entity, please contact our Privacy Officer. All complaints must be submitted in writing. You will not be retaliated against for filing a complaint.

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How We May Change Our Privacy Policies and This Notice

We reserve the right to revise or amend this Notice of Privacy Practices. These changes will be effective for personal health information we already have about you, as well as any information we receive in the future. The Covered Entity will post a copy of the current notice in the facility. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at the Covered Entity for treatment as an inpatient or outpatient, we will offer to provide a copy of the current notice in effect.

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How to Contact Us

If you have any questions about this notice, please contact:

Privacy Officer
Virginia Center for Plastic Surgery
Phone: (804) 273-5000
Address: 11800 W. Broad Street, Suite 140, Richmond, VA 23233

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HIPAA - ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I have been provided with a copy of the Notice of Privacy Practices of Virginia Center for Plastic Surgery and that I have been provided with an opportunity to review said Notice of Privacy Practices prior to signing this acknowledgment.

I understand that the terms of the Notice of Privacy Practices may change and that I may contact Virginia Center for Plastic Surgery at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that Virginia Center for Plastic Surgery restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations and that Virginia Center for Plastic Surgery is not required to agree to the restrictions requested. I understand that any agreed-upon restriction may be terminated by written notice to Virginia Center for Plastic Surgery. I further understand that I will be notified by mail within a reasonable time if any of my requested restrictions are terminated.

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