Privacy Policy

NOTICE OF PRIVACY PRACTICES

We understand that medical information about you and your health is personal and we are committed to maintaining the confidentiality of your medical information. We create and maintain a record of the care and services that you receive at our practice. We need this record to treat you and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our practice, whether made by your personal doctor or by other personnel within our practice.

This notice advises you about the ways in which we may use and disclose medical information about you. It also describes your rights to access and control your medical information. “Medical information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical health or condition and related health care services. This notice also describes your rights and explains certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Make sure that medical information that identifies you is kept private.
• Provide you with this notice of our legal duties and privacy practices with respect to medical information about you.
• Follow the terms described in this notice.

We reserve the right to change the terms of this notice at any time. This notice will be in effect for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised NOTICE OF PRIVACY PRACTICES by calling our office and requesting that a revised copy be sent to you in the mail, by asking for one at the time of your next office visit, or by accessing our website at: www.kaplancosmeticsurgery.com

How We May Use and Disclose Medical Information About You

The following categories describe different ways that we may use and disclose medical information. Not every use or disclosure in a category will necessarily be listed below. However, all of the ways which we are permitted to use and disclose information will fall within one of the categories .

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, or other practice personnel who are involved in your medical care and treatment.

Payment - We may use and disclose medical information about you so that the treatment and services which we provide to you at our practice or other facilities may be billed to and payment may be collected from you or other responsible third parties.

Health Care Operations - We may use and disclose medical information about you for our practice operations. These uses and disclosures are necessary to operate our practice and make sure that all of our patients receive quality care. For example, we may use medical information 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 practice patients to decide what additional services the practice should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, and other practice personnel for review and learning purposes. We may also combine the medical information we have with medical information from other practices to compare how we are doing and see where we can make improvements in the care and services that we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders - We may use and disclose medical information in connection with our efforts to remind you that you have on appointment.

Health-Related Benefits and Services - We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Electronic Communications - We may use your email address to contact you for upcoming appointments, monthly newsletters, seminars, workshops, or other contact and promotional purposes. If you do not wish to be contacted electronically, or receive these materials, please contact the Office Manager by phone within the Winter Park location or send an email request to info@kaplancosmeticsurgery.com and type “REMOVE” in the subject line. Your request will be honored within 3-5 business days and permanently deleted from our mailing list.

Individuals Involved in Your Care - We may release medical information about you to a friend, relative, or family member who is directly involved in your medical care. We may also give information to someone who helps pay for your care.

Special Situations - Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object:

Emergencies - We may use or disclose your medical information in an emergency treatment situation. If this happens, your doctor shall try to obtain your consent as soon as reasonably possible after the delivery of treatment. If your doctor or another doctor participates or is requested or required by law to treat you, and the doctor has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your medical information in order to treat you.

Communication Barriers - We may use and disclose your medical information if your doctor or another doctor in the attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the doctor determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.

As Required By Law - We will disclose your medical information when required to do so by federal, state or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.

Legal Proceedings -If you are involved in a lawsuit or a dispute, we may disclose medial information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if required by law or if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Public Health - We may disclose medical information about you for public health activities. These activities generally include the following:

• To report reactions to medications or problems with products.
• To notify people of recalls of products they may be using.
• To prevent or control disease, injury or disability.
• To notify a person who may hove been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. In this case, the disclosure will be made consistent with the requirements of applicable federal, state and local laws.

Law Enforcement - We will disclose medical information when required to do so for law enforcement purposes. These law enforcement purposes include: (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the practice's premises) and it is likely that a crime has occurred.

Criminal Activity - Consistent with applicable federal and state lows, 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 medical information if it is necessary for law enforcement authorities to identify or apprehend an individual.

National Security and Intelligence Activities - We may release medical information about you to authorized federal officials for intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.

Health Oversight Activities - We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. 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 Section 164500 et. seq.

Your Rights Regarding Medical Information About You. You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy - You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records and any other records that your doctor and the practice use for making decisions about you. We may deny your request to inspect and copy in certain limited circumstances. Under federal law, you may not inspect or copy (1) psychotherapy notes; (2) information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; (3) medical information that is subject to law that prohibits access to medical information. If you are denied access to medical information, you may request that the denial be reviewed. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to our office Privacy Contact. If you request a copy of the information, we may charge a fee as permitted by state law for the costs of copying, mailing or other supplies associated with your request. Right to Amend -If you feel that medical information we have about you is incorrect or incomplete you have the right to request on amendment for as long as the information is maintained by the practice. Your request must be made in writing to our Privacy Contact and you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
• Is not part of the medical information maintained by the practice.
• Is not part of the information which you would be permitted to inspect and copy.
• Is accurate and complete.

Right to Request Confidential Communications - You have the right to request that we communicate with you about medical matters in an alternative way or at an alternative location. For example, you can ask that we only contact you at work or by mail. We will accommodate reasonable requests and we will not request an explanation for your request. Please make this request in writing to our practice Privacy Contact.

Right to Request Restrictions - You have the right to request a restriction or limitation on the medical 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 medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery that you had. Your request must be made in writing to our office Privacy Contact and 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.

The practice is not required to agree to your request. If your doctor believes it is in your best interest to permit the use and disclosure of your medical information, then your medical information will not be restricted. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. With this in mind, please discuss any restriction you wish to request with your doctor.

Right to an Accounting of Disclosures - You have the right to request an "accounting of disclosures”: This is a list of the disclosures we made of medical information about you. This right applies to disclosures other than purposes of treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. Your request must be made in writing to our office Privacy Contact and must indicate a time-period that may not be longer than six years and may not include dates prior to 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 provided at no cost to you. For additional lists, 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 a Paper Copy of This Notice - You have the right to a paper copy of this notice, even if you have agreed to receive this notice electronically. You may ask us to provide you with a copy of this notice at any time.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services. All complaints must be made in writing. You wiII not be penalized for filing a complaint. To file a complaint with the practice, contact our office Privacy Contact listed on page 1 of this notice.

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.

Patient Instructions

Please complete by signing and dating the Patient's Acknowledgement section below. We recommend you retain a copy of this NOTICE OF PRIVACY PRACTICES for your records.

Patient's Acknowledgement

I hereby acknowledge that I have been provided with the practice's NOTICE OF PRIVACY PRACTICES and that I have read and fully understand the notice. I have been provided the opportunity to ask questions about the notice and my questions have been answered to my satisfaction.

Patient Name: _________________________

Patient Signature: ______________________ Date: ___________

Witness Name: _________________________

Signature of Witness: ____________________ Date:___________

Notice Effective Date: 04/01/04

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 was published and becomes effective on April 1, 2004