Mommy Makeover Hawaii & Pheonix Group, LLC
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 Sheri Yoro, General Manager & HIPAA Officer (808) 597-8835.
WHO WILL FOLLOW THIS NOTICE
This notice describes our facility’s privacy practices and that of:
• Any physician or health care professional authorized to enter information into your medical chart.
• All departments and units of our facility.
• All employees, staff and other office personnel.
• All these individuals, sites and locations follow the terms of this notice. In addition, these individuals, sites and locations may share medical information with each other or with third party specialists for treatment, payment or office operations purposes described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at our facility. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our facility.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
• maintain the privacy of your Personal Health Information;
• provide you this notice of our legal duties and privacy practices with respect to your Personal Health Information; and
follow the terms of this notice.
The main reasons for which we may use and may disclose your Personal Health Information are to evaluate and process any requests for coverage and claims for benefits you may make or in connection with other health-related benefits or services that may be of interest to you. The following describes these and other uses and disclosures, together with some examples.
• 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 the facility’s office personnel who are involved in taking care of you at the facility or elsewhere. We also may disclose medical information about you to people outside our facility who may be involved in your care after you leave the facility, such as family members or others we use to provide services that are part of your care provided you have consented to such disclosure. These entities include third party physicians, hospitals, nursing homes, pharmacies or clinical labs with whom the office consults or makes referrals.
• For Payment. We may use and disclose medical information about you so that the treatment and services you receive at out office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about procedures you received at the facility so your health plan will pay us or reimburse you for the services. We may also tell your health plan about a treatment you are going to received to obtain prior approval or to determine whether your plan will cover the treatment.
• For Health Care Operations. We may use and disclose medical information about you for our internal operations. These uses and disclosures are necessary to run our facility and make sure that all of our patients receive quality care. For example, we may use medical information about you to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services the facility should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to our physicians, staff and other office personnel for review and learning purposes.
• Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care provided you have consented to such disclosure. We may also give information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
• Where Required by Law or for Public Health Activities. We disclose Personal Health Information when required by federal, state or local law. Examples of such mandatory disclosures include notifying state or local health authorities regarding particular communicable diseases, or providing Personal Health Information to a governmental agency or regulator with health care oversight responsibilities. We may also release Personal Health Information to a coroner or medical examiner to assist in identifying a deceased individual or to determine the cause of death.
• To Avert a Serious Threat to Health or Safety. We may disclose Personal Health Information to avert a serious threat to someone’s health or safety. We may also disclose Personal Health Information to federal, state or local agencies engaged in disaster relief as well as to private disaster relief or disaster assistance agencies to allow such entities to carry out their responsibilities in specific disaster situations.
• For Health-Related Benefits or Services. We may use Personal Health Information to provide you with information about benefits available to you under your current coverage or policy and, in limited situations, about health-related products or services that may be of interest to you.
• For Law Enforcement or Specific Government Functions. We may disclose Personal Health Information in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose Personal Health Information about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
• When Requested as Part of a Regulatory or Legal Proceeding. If you or your estate are involved in a lawsuit or a dispute, we may disclose Personal Health Information about you in response to a court or administrative order. We may also disclose Personal Health Information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the Personal Health Information requested. We may disclose Personal Health Information to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination.
• Other Uses of Personal Health Information. Other uses and disclosures of Personal Health Information not covered by this notice and permitted by the laws that apply to us will be made only with your written authorization or that of your legal representative. If we are authorized to use or disclose Personal Health Information about you, you or your legally authorized representative may revoke that authorization, in writing, at any time, except to the extent that we have taken action relying on the authorization or if the authorization was obtained as a condition of obtaining your Health Insurance coverage. You should understand that we will not be able to take back any disclosures we have already made with authorization.
Your Rights Regarding Personal Health Information We Maintain About You
The following are your various rights as a consumer under HIPAA concerning your Personal Health Information.
• Right to Inspect and Copy Your Personal Health Information. In most cases, you have the right to inspect and obtain a copy of the Personal Health Information that we maintain about you. To inspect and copy Personal Health Information, you must submit your request in writing to the applicable administrator listed above. To receive a copy of your Personal Health Information, you may be charged a fee for the costs of copying, mailing or other supplies associated with your request. However, certain types of Personal Health Information will not be made available for inspection and copying. This includes psychotherapy notes; and also includes Personal Health Information collected by us in connection with, or in reasonable anticipation of any claim or legal proceeding. In very limited circumstances we may deny your request to inspect and obtain a copy of your Personal Health Information. If we do, you may request that the denial be reviewed. The review will be conducted by an individual chosen by us who was not involved in the original decision to deny your request. We will comply with the outcome of that review.
• Right to Amend Your Personal Health Information. If you believe that your Personal Health Information is incorrect or that an important part of it is missing, you have the right to ask us to amend your Personal Health Information while it is kept by or for us. You must provide your request and your reason for the request in writing, and submit it to the applicable administrator listed above. We may deny your request if it is not in writing or does not include a reason that supports the request. In addition, we may deny your request if you ask us to amend Personal Health Information that:
• is accurate and complete;
• was not created by us, unless the person or entity that created the Personal Health Information is no longer available to make the amendment;
• is not part of the Personal Health Information kept by or for us; or
• is not part of the Personal Health Information which you would be permitted to inspect and copy.
• Right to an Accounting of Disclosures You have the right to request a list of the disclosures we have made of Personal Health Information about you. This list will not include disclosures made for treatment, payment, health care operations, for purposes of national security, made to law enforcement or to corrections personnel or made pursuant to your authorization or made directly to you. To request this list, you must submit your request in writing to the applicable administrator listed above. Your request must state the time period from which you want to receive a list of disclosures. The time period 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 or electronically). The first list you request within a 12-month period will be free. We may charge you for responding to any additional requests. 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 restriction or limitation on Personal Health Information we use or disclose about you for treatment, payment or health care operations, or that we disclose to someone who may be involved in your care or payment for your care, like a family member or friend. While we will consider your request, we are not required to agree to it. If we do agree to it, we will comply with your request. To request a restriction, you must make your request in writing to the applicable administrator listed above. 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 or parent). We will not agree to restrictions on Personal Health Information uses or disclosures that are legally required, or which are necessary to administer our business.
• Right to Request Confidential Communications You have the right to request that we communicate with you about Personal Health Information in a certain way or at a certain location if you tell us that communication in another manner may endanger you. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the applicable administrator listed above and specify how or where you wish to be contacted. We will accommodate all reasonable requests.
• Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact us at Hale Pawaa 1401 S Beretania St., Suite 590, Honolulu, HI 96813. All complaints must be submitted in writing. You will not be penalized for filing a complaint. If you have questions as to how to file a complaint please contact us at: (808) 695-2400.
Changes to This Notice. We reserve the right to change the terms of this notice at any time. We reserve the right to make the revised or changed notice effective for Personal Health Information we already have about you as well as any Personal Health Information we receive in the future. The effective date of this notice and any revised or changed notice may be found on the last page, on the bottom right hand corner of the notice. You will receive a copy of any revised notice from us by mail or by e-mail, but only if e-mail delivery is offered by us and you agree to such delivery.
Other Uses of Medical Information. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.