By Diana Dunn,2014-05-12 06:10
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     Effective Date of this Notice:____________




    NOTICE OF PRIVACY PRACTICES As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability

    and Accountability Act of 1996 (HIPAA)







    A. OUR COMMITMENT TO YOUR PRIVACY B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Our practice is dedicated to maintaining the privacy of your individually identifiable health information Business Manager, Skin Care Specialists of (IIHI). In conducting our business, we will create Colorado, 776 W. Eisenhower Blvd., Loveland, records regarding you and the treatment and services CO 970-667-3116 we provide to you. We are required by law to maintain the confidentiality of health information that C. WE MAY USE AND DISCLOSE YOUR identifies you. We also are required by law to INDIVIDUALLY IDENTIFIABLE HEALTH provide you with this notice of our legal duties and INFORMATION (IIHI) IN THE the privacy practices that we maintain in our practice FOLLOWING WAYS concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy The following categories describe the different ways practices that we have in effect at the time. in which we may use and disclose your IIHI. We realize that these laws are complicated, but we 1. Treatment. Our practice may use your IIHI to must provide you with the following important treat you. For example, we may ask you to have information: laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We ? How we may use and disclose your IIHI might use your IIHI in order to write a prescription ? Your privacy rights in your IIHI for you, or we might disclose your IIHI to a ? Our obligations concerning the use and pharmacy when we order a prescription for you.

    disclosure of your IIHI Many of the people who work for our practice

     including, but not limited to, our doctors and nurses

    may use or disclose your IIHI in order to treat you or The terms of this notice apply to all records

    to assist others in your treatment. Additionally, we containing your IIHI that are created or retained

    may disclose your IIHI to others who may assist in by our practice. We reserve the right to revise or

    your care, such as your spouse, children or parents. amend this Notice of Privacy Practices. Any

    Finally, we may also disclose your IIHI to other revision or amendment to this notice will be

    health care providers for purposes related to your effective for all of your records that our practice

    treatment. has created or maintained in the past, and for any

     of your records that we may create or maintain in

    2. Payment. Our practice may use and disclose your the future. Our practice will post a copy of our

    IIHI in order to bill and collect payment for the current Notice in our offices in a visible location at

    services and items you may receive from us. For all times, and you may request a copy of our most

    example, we may contact your health insurer to current Notice at any time.

    certify that you are eligible for benefits (and for what

    range of benefits), and we may provide your insurer

    ? 2001 Gates, Moore & Company American Academy of Dermatology Association

     Effective Date of this Notice:____________

    with details regarding your treatment to determine if ? maintaining vital records, such as births your insurer will cover, or pay for, your treatment. and deaths We also may use and disclose your IIHI to obtain ? reporting child abuse or neglect

    payment from third parties that may be responsible ? preventing or controlling disease, injury for such costs, such as family members. Also, we or disability may use your IIHI to bill you directly for services ? notifying a person regarding potential and items. We may disclose your IIHI to other health exposure to a communicable disease

    care providers and entities to assist in their billing ? notifying a person regarding a potential and collection efforts. risk for spreading or contracting a

     disease or condition 3. Health Care Operations. Our practice may use ? reporting reactions to drugs or problems and disclose your IIHI to operate our business. As with products or devices examples of the ways in which we may use and ? notifying individuals if a product or disclose your information for our operations, our device they may be using has been practice may use your IIHI to evaluate the quality of recalled care you received from us, or to conduct cost-? notifying appropriate government management and business planning activities for our agency(ies) and authority(ies) regarding practice. We may disclose your IIHI to other health the potential abuse or neglect of an care providers and entities to assist in their health adult patient (including domestic care operations. violence); however, we will only

     disclose this information if the patient 4. Appointment Reminders. Our practice may use agrees or we are required or authorized and disclose your IIHI to contact you and remind you by law to disclose this information of an appointment. ? notifying your employer under limited circumstances related primarily to 5. Treatment Options. Our practice may use and workplace injury or illness or medical disclose your IIHI to inform you of potential surveillance. treatment options or alternatives. 2. Health Oversight Activities. Our practice may 6. Health-Related Benefits and Services. Our disclose your IIHI to a health oversight agency for practice may use and disclose your IIHI to inform activities authorized by law. Oversight activities can you of health-related benefits or services that may be include, for example, investigations, inspections, of interest to you. audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or 7. Release of Information to Family/Friends. Our actions; or other activities necessary for the practice may release your IIHI to a friend or family government to monitor government programs, member that is involved in your care, or who assists compliance with civil rights laws and the health care in taking care of you. For example, a parent or system in general. guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In 3. Lawsuits and Similar Proceedings. Our practice this example, the babysitter may have access to this may use and disclose your IIHI in response to a court child’s medical information. or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose 8. Disclosures Required By Law. Our practice will your IIHI in response to a discovery request, use and disclose your IIHI when we are required to subpoena, or other lawful process by another party do so by federal, state or local law. involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an D. USE AND DISCLOSURE OF YOUR IIHI IN order protecting the information the party has CERTAIN SPECIAL CIRCUMSTANCES requested. The following categories describe unique scenarios in 4. Law Enforcement. We may release IIHI if asked which we may use or disclose your identifiable health to do so by a law enforcement official: information: ? Regarding a crime victim in certain 1. Public Health Risks. Our practice may disclose situations, if we are unable to obtain the your IIHI to public health authorities that are person’s agreement authorized by law to collect information for the ? Concerning a death we believe has purpose of: resulted from criminal conduct

    ? 2001 Gates, Moore & Company American Academy of Dermatology Association

     Effective Date of this Notice:____________

    ? Regarding criminal conduct at our written request to Skin Care Specialists of Colorado,

    offices 776 W. Eisenhower Blvd., Loveland, CO 80537.

    ? In response to a warrant, summons, 970-667-3116 specifying the requested method of

    court order, subpoena or similar legal contact, or the location where you wish to be

    process contacted. Our practice will accommodate

    ? To identify/locate a suspect, material reasonable requests. You do not need to give a

    witness, fugitive or missing person reason for your request.

    ? In an emergency, to report a crime

    (including the location or victim(s) of 2. Requesting Restrictions. You have the right to

    the crime, or the description, identity or request a restriction in our use or disclosure of your

    location of the perpetrator) IIHI for treatment, payment or health care operations.

    Additionally, you have the right to request that we

     restrict our disclosure of your IIHI to only certain 5. Serious Threats to Health or Safety. Our individuals involved in your care or the payment for practice may use and disclose your IIHI when your care, such as family members and friends. We

    necessary to reduce or prevent a serious threat to your are not required to agree to your request; however,

    health and safety or the health and safety of another if we do agree, we are bound by our agreement individual or the public. Under these circumstances, except when otherwise required by law, in

    we will only make disclosures to a person or emergencies, or when the information is necessary to organization able to help prevent the threat. treat you. In order to request a restriction in our use

     or disclosure of your IIHI, you must make your 6. Military. Our practice may disclose your IIHI if request in writing to Business Manager, Skin Care

    you are a member of U.S. or foreign military Specialists of Colorado, 776 W. Eisenhower Blvd.

    forces (including veterans) and if required by the Loveland, Co 80537. Your request must describe in

    appropriate authorities. a clear and concise fashion:

    7. National Security. Our practice may disclose (a) the information you wish restricted; your IIHI to federal officials for intelligence and (b) whether you are requesting to limit our national security activities authorized by law. We practice’s use, disclosure or both; and

    also may disclose your IIHI to federal officials in (c) to whom you want the limits to apply. order to protect the President, other officials or

    foreign heads of state, or to conduct investigations. 3. Inspection and Copies. You have the right to

    inspect and obtain a copy of the IIHI that may be

    8. Inmates. Our practice may disclose your IIHI to used to make decisions about you, including patient correctional institutions or law enforcement officials medical records and billing records, but not including if you are an inmate or under the custody of a law psychotherapy notes. You must submit your request enforcement official. Disclosure for these purposes in writing to Skin Care Specialists of Colorado, would be necessary: (a) for the institution to provide 776 W. Eisenhower Blvd., Loveland, CO 80537. health care services to you, (b) for the safety and 970-667-3116 in order to inspect and/or obtain a security of the institution, and/or (c) to protect your copy of your IIHI. Our practice may charge a fee for health and safety or the health and safety of other the costs of copying, mailing, labor and supplies individuals. associated with your request. Our practice may deny

     your request to inspect and/or copy in certain limited 9. Workers’ Compensation. Our practice may circumstances; however, you may request a review of release your IIHI for workers’ compensation and our denial. Another licensed health care professional similar programs. chosen by us will conduct reviews.

    4. Amendment. You may ask us to amend your E. YOUR RIGHTS REGARDING YOUR IIHI

     health information if you believe it is incorrect or You have the following rights regarding the IIHI that incomplete, and you may request an amendment for we maintain about you: as long as the information is kept by or for our

     practice. To request an amendment, your request 1. Confidential Communications. You have the must be made in writing and submitted to Skin Care

    right to request that our practice communicate with Specialists of Colorado, 776 W. Eisenhower Blvd., you about your health and related issues in a Loveland Co 80537. 970-667-3116 You

    particular manner or at a certain location. For must provide us with a reason that supports your instance, you may ask that we contact you at home, request for amendment. Our practice will deny your rather than work. In order to request a type of request if you fail to submit your request (and the confidential communication, you must make a reason supporting your request) in writing. Also, we

    ? 2001 Gates, Moore & Company American Academy of Dermatology Association

     Effective Date of this Notice:____________

    may deny your request if you ask us to amend Colorado, 776 W. Eisenhower Blvd., Loveland, information that is in our opinion: (a) accurate and CO 80537. 970-667-3116 complete; (b) not part of the IIHI kept by or for the

    practice; (c) not part of the IIHI which you would be 7. Right to File a Complaint. If you believe your permitted to inspect and copy; or (d) not created by privacy rights have been violated, you may file a our practice, unless the individual or entity that complaint with our practice or with the Secretary of created the information is not available to amend the the Department of Health and Human Services. To information. file a complaint with our practice, contact Business

     Manager, Lake Loveland Dermatology, 776 W. 5. Accounting of Disclosures. All of our patients Eisenhower Blvd., Loveland, CO 80357. All have the right to request an “accounting of complaints must be submitted in writing. You will

    disclosures.” An “accounting of disclosures” is a list not be penalized for filing a complaint.

    of certain non-routine disclosures our practice has

    made of your IIHI for non-treatment, non-payment or 8. Right to Provide an Authorization for Other non-operations purposes. Use of your IIHI as part of Uses and Disclosures. Our practice will obtain your the routine patient care in our practice is not required written authorization for uses and disclosures that are to be documented. For example, the doctor sharing not identified by this notice or permitted by information with the nurse; or the billing department applicable law. Any authorization you provide to us using your information to file your insurance claim. regarding the use and disclosure of your IIHI may be In order to obtain an accounting of disclosures, you revoked at any time in writing. After you revoke your must submit your request in writing to Skin Care authorization, we will no longer use or disclose your

    IIHI for the reasons described in the authorization. Specialists of Colorado, 776 W. Eisenhower Blvd.,

    Loveland, CO 80537. 970-667-3116 All requests Please note, we are required to retain records of your for an “accounting of disclosures” must state a time care.

    period, which may not be longer than six (6) years

    from the date of disclosure and may not include dates Again, if you have any questions regarding this before April 14, 2003. The first list you request notice or our health information privacy policies, within a 12-month period is free of charge, but our please contact Tim St. Louis, Business Manager, practice may charge you for additional lists within Skin Care Specialists of Colorado 776 W. the same 12-month period. Our practice will notify Eisenhower Blvd., Loveland Co 80537. 970-667-you of the costs involved with additional requests, 3116 and you may withdraw your request before you incur

    any costs.

6. Right to a Paper Copy of This Notice. You are

    entitled to receive a paper copy of our notice of

    privacy practices. You may ask us to give you a

    copy of this notice at any time. To obtain a paper

    copy of this notice, contact Skin Care Specialists of

    ? 2001 Gates, Moore & Company American Academy of Dermatology Association

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