NOTICE OF PRIVACY PRACTICES

This Privacy Notice is required by the Privacy Regulations stemming from the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

This Privacy Notice explains to you, a patient of this practice, how your medical information may be used and disclosed, and how you can get access to your medical information.

This Notice of Privacy Practices describes how the Center for Plastic & Aesthetic Surgery may use and disclose your individually identifiable health information (IIHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control of your IIHI. “IIHI” is information about you, including demographic information that may identify you and that relates to your past, present, or future physical or mental condition and related health care services.

We are required to abide by the terms of the Notice of Privacy Practices. The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices at any time. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our office in a visible location at all times, and you may request a copy of our most current Notice at any time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website www.newyouplasticsurgery.com, calling our office and requesting a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

Our medical practice is defined legally as Stephen A. Goldstein, MD, PC, dba Center for Plastic & Aesthetic Surgery. The physicians in our medical practice are Stephen A. Goldstein, MD, FACS and Gregory A. Buford, MD. The Notice of Privacy Practices also includes our skin care division known as New You Skin Care.

Uses and Disclosure of Individually Identifiable Health Information (IIHI) Based on Your Written Consent

You will be asked by your physician or their medical staff to sign a Consent for Purposes of Treatment, Payment and Healthcare Operations. Once you have consented to use and disclosure of your IIHI for treatment, payment and healthcare operations by signing the consent form, your physician will use or disclose your IIHI as described. Your IIHI may be used and disclosed by your physician, our medical office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your IIHI may also be used and disclosed to pay your health care bills and to support the operation of the physician’s medical practice.

Following are examples of the types of uses and disclosures of protected health care information the physician’s office is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent.

TREATMENT -- We will use and disclose your IIHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to have access to your IIHI.

Examples of how we would disclose your IIHI are as follows, but not limited to:

To other physicians who may be treating you or that we may ask to assist in your care
To the physician that referred you to our medical practice
To a laboratory or diagnostic facility that may become involved in your care
To Surgical Assistant or Anesthesia group for coordination of medical care
To a hospital or surgery center where medical care may be conducted
Consent for treatment, pictures and after care information to hospital or surgery center
To a pharmacy when we order a prescription for you
To a third party that has already obtained permission to have access to your IIHI
To a home health agency that may provide care to you
To a designated individual that will provide necessary care for you following surgery

PAYMENT -- Your IIHI will be used, as needed to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as, but not limited to the following:

Obtain demographic & employment information on you, your spouse and your dependents, if necessary
Obtain insurance eligibility and benefits for services from your insurance carrier(s)
Obtain deductible, co-payment and co-insurance information
Review of services and diagnosis provided to you for medical necessity and appeal processes
Provide pictures to insurance carrier for obtaining medical necessity, appeal and payment
Obtain approval for ambulatory surgery center or hospital admission for upcoming surgery
Coordinate approval for cosmetic surgery financing with an outside financial agency
Coordinate payment arrangements for an independent party for cosmetic surgery
Undertake utilization review of medical services
File a claim for medical services to your insurance carrier or third party payer

HEALTHCARE OPERATIONS -- We may use to disclose, as needed, your IIHI in order to support the business activities of your physician’s practice. These activities include but are not limited to quality assessment activities, employee review activities, training of medical students, licensing, credentialing, licensing, marketing, fundraising activities, and conducting or arranging for other business activities.

Other healthcare operations where we may disclose your IIHI are such examples as follows, but not limited to:

Sign in sheet at the registration desk indicating your name, physician or insurance information
Call you by name in the waiting room when the physician is ready to see you or in patient care rooms
To remind you of your appointment
With medical students that are observing medical care given by our physicians
Call you by name when telephone contact for medical information is requested or given
Register implant product information with vendors for future medical tracking
Order garments, implants or specific products requiring patient specific IIHI
Compliance with mandated health care programs
Business management and general administrative activities of the practice
Discussion of treatment alternatives with products or services

We will share your IIHI with third party “business associates” that perform various activities for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your IIHI, we will have a written contract that contains terms that will protect the privacy of your IIHI. Business Associate examples would be as follows but not limited to:

Medical transcription service
Software vendor for medical billing and electronic claims filing
Accountant or Practice Management Firm providing a financial or consulting service
Law Firm for practice management, consulting and other medical management agreements
Collection Agency
Electronic medical records software vendor
Answering service
Hardware maintenance service
Off-site record storage firm
Other independent contractors who provide business/administrative services on site

We may use or disclose your IIHI, as necessary, to provide you with information about treatment alternatives, other health related benefits, services or products that may be new to the market or of interest to you. Marketing activities may be another form we may use and disclose your IIHI. Your name and address may be used to send you a newsletter or brochure about cosmetic procedures, skin care products or services or upcoming events for education and informational purposes.

Privacy Officer -- Our Privacy Officer is also our Practice Administrator, Debbie Kubik, RN. We may use or disclose your demographic information and the dates you received treatment from your physician, as necessary, in order to contact you for marketing activities supported by our office. If you wish to not receive these marketing materials you need to contact our Privacy Officer.

Uses and Disclosures of Individually Identifiable Health Information (IIHI) Based Upon Your Written Authorization

Other uses and disclosures of your IIHI will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization at any time in writing except to the extent that your physician or the physician’s practice has previously taken an action in reliance on the use or disclosure indicated in the authorization.

Other Permitted and Required Uses and Disclosure That May be Made with Your Consent, Authorization or Opportunity to Object

We may use and disclose your IIHI in the following instances. You have the opportunity to agree or object to the use of disclosure of all or part of your IIHI. If you are not present or able to agree or object to the use or disclosure of the IIHI, then your physician may, using professional judgment determine whether the disclosure is in your best interest. In this case, only the IIHI that is relevant to your health care will be disclosed.

Others Involved in Your Healthcare -- Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your IIHI that directly relates to that person’s involvement in your healthcare. 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 IIHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your IIHI to an authorized public or private entity to assist in disaster relief efforts and coordinate uses and disclosure to family or other individuals involved in your health care.

Emergencies -- We may use or disclose your IIHI in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonable after the delivery of treatment. If your physician or another physician in the practice is required to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your IIHI to treat you.

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

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

Public Health Risks -- Colorado Rev. Statues required physicians and others to report incidents of cancer, communicable diseases, venereal diseases and other specified conditions to the health authorities. These cases where we may disclose your IIHI without your consent is as follows, but not limited to:

Maintaining vital records, such as births and deaths
Reporting child abuse or neglect
Notifying a person or agency regarding a potential exposure to a communicable disease
Notifying a person regarding a potential risk for spreading or contracting a disease or condition
Reporting reactions to drugs or problems with products, implants or devices
Notifying individuals if a product or device they may be using has been recalled
Notifying appropriate government agencies and authorities regarding potential abuse or neglect of an adult
patient (including domestic violence); however we will only disclose this information if the law
requires us to disclose this information
Notifying your employer under limited circumstances related primarily to workplace injury or illness or
medical surveillance

Health Oversight Activities -- Our practice may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

Lawsuits and Similar Proceedings -- Our practice may use and disclose your IIHI in response to a court or administrative order, if you’re involved in a lawsuit or similar proceeding. We may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information.

Law Enforcement -- We may release IIHI if asked to do so by a law enforcement official:

Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreements
Concerning a death we believe has resulted from criminal conduct
Regarding criminal conduct at our offices
In response to a warrant, summons, court order, subpoena or similar legal process
To identify or locate a suspect, material witness, fugitive or missing person
In an emergency to report a crime, (including the location or victim(s) of the crime, or the description,
identity or location of the perpetrator)

Serious Threats to Health or Safety -- Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Military and National Security -- Our practice may disclose your IIHI if you are a member of U.S. for foreign military forces, including veterans, and if required by the appropriate authorities. This includes our practice to disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President of the United States, other officials or foreign heads of state, or to conduct investigations.

Inmates -- Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

Workers’ Compensation -- Our practice may release your IIHI for workers’ compensation and similar programs.

Your Rights Regarding Your Protect Health Information

Confidential Communications -- You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. In order to request a type of confidential communication, you must make a written request to the Center for Plastic & Aesthetic Surgery, Privacy Officer -- Debbie Kubik, RN at 125 Inverness Drive East, Suite 200, Englewood, Colorado, 80112 specifying the requested method of contact, or the locations where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

Requesting Restrictions -- You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment of health care operations. Additionally, you have the right to request that we restrict our disclosure of the protected heath information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your IIHI, you must make your request in writing to Center for Plastic & Aesthetic Surgery, Privacy Officer – Debbie Kubik, RN at 125 Inverness Drive East, Suite 200, Englewood, Colorado, 80112. Your request must describe in a clear and concise fashion:

The information you wish restricted
Whether you are requesting to limit our practice’s use, disclosure or both
To whom you want the limits to apply

Inspection of Copies -- You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Center for Plastic & Aesthetic Surgery, Privacy Officer – Debbie Kubik, RN at 125 Inverness Drive East, Suite 200, Englewood, Colorado, 80112 in order to inspect and/or obtain a copy of the IIHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional or team of professionals chosen by us will conduct reviews.

Amendment -- You may ask us to amend you health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for your practice. To request an amendment, your request must be made in writing and submitted to the Center for Plastic & Aesthetic Surgery, Privacy Officer – Debbie Kubik, RN at 125 Inverness Drive East, Englewood, Colorado, 80112. You must provide us with a reason that supports your request for amendment. Our Practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

Accounting of Disclosures -- All of our patients have the right to request and “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment, non-payment or non-operations purposes. Use of your IIHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor shares information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, your must submit your request in writing to the Center for Plastic & Aesthetic Surgery, Privacy Officer – Debbie Kubik, RN at 125 Inverness Drive East, Englewood, Colorado, 80112. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period if free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Right to File a Complaint -- If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact the Privacy Officer – Debbie Kubik, RN. All complaints musts be submitted in writing to our office. You will not be penalized for filing a complaint.

Right to Provide an Authorization for Other Uses and Disclosures -- Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to use regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records for your care.

If you have any questions regarding this notice of our health information privacy policies, please contact our Privacy Officer -- Debbie Kubik, RN at 303 708-8234.

Center For Plastic & Aesthetic Surgery
At Dry Creek Medical Campus
125 Inverness Drive East - Suite 200 - Englewood, Colorado 80112
Toll Free 1-877-831-0539 - Phone: 303.708.8234 - Fax: 303.649.9694
Email: info@newyouplasticsurgery.com

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