CosMedics

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HIPAA Agreement

1. Purpose

We understand that medical information about you and your health is personal and we are committed to protecting that information.  We create a record of the care and services you receive at the Medical Practice in order to provide you with quality care and to comply with certain legal requirements.

This Notice of Privacy Practices describes how we may use and disclose medical information about you, including demographic information, that may identify you and your related health care services to carry out your treatment, obtain payment for our services, to perform the daily health care operations of this practice and for other purposes that are permitted or required by law.  This notice also describes your rights to access and control your medical information.

We are required to abide by the terms of this Notice of Privacy Practices.

2.  Written Acknowledgement

You will be asked to sign a written statement acknowledging that you have received a copy of this notice.  The acknowledgement only serves to create a record that you have received a copy of the notice.

3.  Changes to this Notice

We may change the terms of our Notice, at any time.  The new Notice will be effective for all medical information that we maintain at that time.  Upon your request, we will provide you with any revised Notice of Privacy Practices.  To request a revised copy, you may call our office and request that a revised copy be sent to you in the mail or you may ask for one at the time of your next appointment.  The current Notice of Privacy Practices will be also posted on our Web site, www.xyzphysicians.com.
 
4.  How We May Use and Disclose Medical Information about You

The following categories describe the different ways that the Medical Practice may use and disclose your medical information and a few examples of what we mean.  These examples are not meant to describe every circumstance, but to give you an idea of the types of uses and disclosures that may be made by our office.  Other uses and disclosures of your medical information that are not listed or described below will be made only with your written authorization.  You may revoke this authorization, at any time, in writing, but it will not apply to any actions we have already taken.

For your treatment:  Your medical information may be used and disclosed by us for the purpose of providing medical treatment to you or for another health care provider providing medical treatment to you.  For example, a nurse obtains treatment information about you and documents it in your medical record and the physician has access to that information.  If you require an x-ray to be taken, the x-ray technician also has access to your medical information.  In addition, your medical information may be provided to a physician to whom you have been referred or are otherwise seeing to ensure that the physician has the necessary information to diagnose or treat you.

To obtain payment for our services:  Your medical information may be used and disclosed by us to obtain payment for your health care bills or to assist another health care provider in obtaining payment for their health care bills.  For example, we may submit requests for payment to your health insurance company for the medical services that you received.  We may also disclose your medical information as required by your health insurance plan before it approves or pays for the health care services we recommend for you.

For our health care operations:  Your medical information may be used and disclosed by us to support our daily operations.  These health care operation activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.  For example, we may disclose your medical information to medical school students that see patients at our office.  We may also use the medical information we have to determine where we can make improvements in the services and care we offer.

For the health care operations of other health care providers:  We may also use your medical information to assist another health care provider treating you with its quality improvement activities, evaluation of the health care professionals or for fraud and abuse detection or compliance.  For example, we may disclose your medical information to another physician to assist in its efforts to make sure it is complying with all rules related to operating a medical practice.

For appointment reminders:  We may use or disclose your medical information to contact you to remind you of your appointment, by mail or by telephone.  Our message will include the name of our practice or the name of our physician as well as the date and time for your appointment or a reminder that an appointment needs to be scheduled.

To provide you with treatment alternatives:  We may use or disclose your medical information to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.  For example, we may contact several home health agencies or physical therapy providers to discuss the services they provide when we have a patient who needs these services.

To our business associates:  We will share your medical information with third party Òbusiness associatesÓ that perform various activities (e.g., billing, transcription services) for the practice.  Whenever an arrangement between our office and a business associate involves the use or disclosure of your medical information, we will have a written agreement that contains terms that will protect the privacy of your medical information.  For example, the Medical Practice may hire a billing company to submit claims to your health care insurer.  Your medical information will be disclosed to this billing company, but a written agreement between our office and the billing company will prohibit the billing company from using your medical information in any way other than what we allow.

For fundraising activities:  We may use or disclose your demographic information and the dates that you received treatment from us in order to contact you for fundraising activities supported by our office.  If you do not want to receive these materials, please contact the Privacy Officer and request that these fundraising materials not be sent to you.

Others involved in your health care:  Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your medical information that directly relates to that person's involvement in your health care.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.  We may use or disclose your medical information to notify a family member or any other person that is responsible for your care of your location and general health condition.  Finally, we may use or disclose your medical information to an authorized public or private entity to assist in (1) disaster relief efforts and (2) to coordinate uses and disclosures to family or other individuals involved in your health care.

As required by law:  We may use or disclose your medical information to the extent that the 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.

For public health activities:  We may disclose your medical information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.  The disclosure will be made for the purpose of controlling disease, injury or disability.  We may also disclose your medical information, if directed by the public health authority, to any other government agency that is collaborating with the public health authority.

As required by the Food and Drug Administration:  We may disclose your medical information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, or to track products; to enable product recalls; to make repairs or replacements; or to conduct post marketing surveillance, as required.

For communicable disease exposure:  We may disclose your medical information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

To your employer:  We may disclose your medical information concerning a work related injury or illness to your employer if you are covered under your employer's policy in order to conduct an evaluation relating to medical surveillance of the work place or to evaluate whether you have a work-related injury, in accordance with the law.

For abuse or neglect:  We may disclose your medical information to a public health authority that is authorized by law to receive reports of child or adult abuse or neglect.  In addition, we may disclose your medical information if we believe that you have been a victim of abuse, neglect or domestic violence as may be required or permitted by Virginia and/or federal law.

For health oversight:  We may disclose your medical information to a health oversight agency for activities authorized by law.  Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs (such as Medicare or Medicaid), other government regulatory programs and civil rights laws.

In legal proceedings:  We may disclose your medical information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and in certain conditions in response to a subpoena or other lawful request.

For law enforcement:  We may also disclose your medical information, so long as all legal requirements are met, for law enforcement purposes.  Examples of these law enforcement purposes include (1) information requests for identification and location purposes, (2) pertaining to victims of a crime, (3) suspicion that death has occurred as a result of criminal conduct, (4) in the event that a crime occurs on the premises of the Practice, and (5) in an medical emergency where it is likely that a crime has occurred.

To coroners, to funeral directors, and for organ donation:  We may disclose your medical information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.  We may also disclose medical information to a funeral director in order to permit the funeral director to carry out its duties.  We may disclose such information in reasonable anticipation of death.  Your medical information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

For research:  We may disclose your medical information to researchers when their research has been established as required by federal and state law.

Due to criminal activity:  Consistent with applicable federal and state laws, we may disclose your medical information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose your medical information if it is necessary for law enforcement authorities to identify or apprehend an individual.

For military activity and national security:  When the appropriate conditions apply, we may use or disclose medical information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits; or (3) to foreign military authority if you are a member of that foreign military services.  We may also disclose your medical information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

For workers' compensation:  Your medical information may be disclosed by us as authorized to comply with workers' compensation laws and other similar legally established programs.

Regarding inmates:  We may use or disclose your medical information if you are an inmate of a correctional facility and your physician created or received your medical information in the course of providing care to you.

For required uses and disclosures:  Under the law, we must make disclosures to you and, when required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with the requirements of the Health Insurance Portability and Accountability Act and its regulations.

5.  Your Rights

Following is a statement of your rights with respect to your medical information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your medical information.  You may inspect and obtain a copy of your medical information that we maintain.  The information may contain medical and billing records and any other records that we use for making decisions about you.  However, under federal law, you may not inspect or copy the following records:  psychotherapy notes; information compiled related to a civil, criminal, or administrative action; and medical information that is subject to law that prohibits access to medical information in certain circumstances.  We may deny your request to inspect your medical information.  In some circumstances, you may have a right to have this decision reviewed.  Please contact our Privacy Officer if you have questions about access to your medical record.

You have the right to request a restriction of your medical information.  This means you may ask us not to use or disclose any part of your medical information for the purposes of treatment, payment or health care operations.  You may also request that any part of your medical information not be disclosed to family members or friends who may be involved in your care.  Your request must state the specific restriction requested and to whom you want the restriction to apply.

We are not required to agree to your request.  If we agree to the requested restriction, we may not use or disclose your medical information in violation of that restriction unless it is needed to provide emergency treatment or unless we otherwise notify you that we can no longer honor your request.  With this in mind, please discuss any restriction you wish to request with your physician.  Please request all restrictions in writing to our Privacy Officer.

You have the right to request that we accommodate you in communicating confidential medical information.  We will accommodate reasonable requests, but we may condition this accommodation by asking you for information as to how payment will be handled or other information necessary to honor your request.  Please make this request in writing to our Privacy Officer.

You may have the right to ask us to amend your medical information.  You may request an amendment of your medical information as long as we maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a disagreement with us and we may respond in writing to you.  Please contact our Privacy Officer if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your medical information.  This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made pursuant to your authorization (permission), made directly to you, to family members or friends involved in your care, or for appointment notification purposes.  You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003.  You may request a shorter timeframe.  The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notice from us.  If you would like a paper copy of this notice, please request one from our Privacy Officer or request one when you are in our offices.

6.  Complaints.

You may complain to us if you believe your privacy rights have been violated by us.  To file a complaint, please contact our Privacy Officer who will be happy to assist you.  You may file a complaint with us by notifying our Privacy Officer of your complaint.  We will not retaliate against you for filing a complaint.  If you do not wish to file a complaint with us, you may contact the Secretary of Health and Human Services.

7.  Privacy Contact.

If you have any questions about this Notice or require additional information, please contact our Privacy Officer, Sheila Secrecy, at (804) 555-1212 extension 103 or at 111 Doctor Drive, Richmond, Virginia 23226.  Our Privacy Officer is available during normal business hours to discuss your privacy questions, concerns or complaints.

8.  Effective Date.  This notice was published and becomes effective on April 14, 2003.

I have read and agree with the following terms.

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