Notice of Privacy Practices
Revised: July 13, 2018
Aesthetic Wellness Institute of Palm Beach is committed to maintaining the privacy of your health information. We are required by law to give you this Notice that describes our legal duties and privacy practices concerning your health information. If you have any questions about this notice, please contact our privacy contact at the address or telephone number listed at the end of this Notice.
Who will Follow this Notice
This Notice describes the health information privacy practices of Aesthetic Wellness Institute of Palm Beach and its contracted physicians related to the services provided. The words “we” or “our” used in this Notice refer to the Facility and its employees and physicians providing services at the Facility.
Written Authorization: Unless you object in writing and there is not an emergency situation, we are permitted to release health information to people identified by you, such as family members, relatives, or close personal friends or others who are helping to care for you or helping you pay your medical bills. You may identify those individuals who you authorize to receive your health information or restrict these disclosures by informing the Facility Manager, Privacy Contact or the registration staff when you are registering at the Facility. You may also request the restriction in writing addressed to the Facility Manager or Privacy Contact at the address at the bottom of this Notice.
NOTE: Except for the situations described in this notice, we must obtain your specific written authorization for any other release of your health information. If you sign an authorization form, you may withdraw that authorization at any time, as long as your withdrawal is in writing. If you wish to withdraw an authorization signed by you, please contact the Facility directly.
Uses and Disclosures: In general, when we release your health information, we must release only the information needed to achieve the purpose of the use or disclosure. However, all of your health information will be available for release to you, to a health care provider regarding your treatment, or as required by law.
More specifically, we are permitted to use and disclose your health information for the following purposes:
1. Treatment. We are permitted to use and disclose your health information to provide you with medical treatment or services. For example, we are permitted to disclose medical information about you to doctors, technicians, healthcare students, or other facility personnel who are involved in your care at the facility.
2. Payment. We are permitted to use and disclose medical information about you in order to bill and receive payment for the services you receive at the facility. For example, in order to receive payment from your insurance company, we might need to provide specific health information to your health insurance plan about your diagnosis or health services you received at the facility. We are permitted to tell your health insurance plan about a treatment or service you are going to receive and your diagnosis in order to obtain pre-authorization or to determine whether your plan covers the treatment or service.
3. Health Care Operations. We are permitted to use and disclose your health information for facility operations. These uses and disclosures are necessary to run the facility and help to assure that we provide quality services to all of our patients. For example, we are permitted to use medical information to evaluate the performance of the staff in caring for you and to assist us in making improvements in the care and services we offer.
4. Appointment Reminders/New Treatments. Unless you request that we do not, we are permitted to use your health information to provide you with appointment reminders or other information about treatment alternatives or health-related benefits or services that we offer that might be of interest to you. For example, we are permitted to contact our patients to announce new services we are offering or events we are hosting at our facility.
5. As required or permitted by law. Under certain circumstances, we are required to report specific health
information to legal authorities, such as law enforcement officials, court officials, or government agencies. For
example, we are permitted to disclose your health information in relation to cases of abuse, neglect, domestic
violence or certain physical injuries, or to respond to a subpoena or court order.
6. For public health activities. We are, at times, required to report your health information to authorities to help prevent or control disease, injury, or disability. This might include disclosing information in your medical record to report certain diseases, injuries, birth or death information to the Health Department, information of concern to the Food and Drug Administration, or information related to child or vulnerable adult abuse or neglect.
7. For health oversight activities. We are permitted to disclose your health information to a health oversight agency for monitoring and oversight activities authorized by law. This might include release of information to the State agency that licenses the Facility for the purpose of monitoring or inspecting the Facility related to that license. This will also include the release of information to organizations responsible for government benefit programs such as Medicare or Medicaid.
8. For research. If you are participating in a research protocol, please notify the Facility. Your medical information will not be released for a research project unless you consent in writing or, in the case of pre-study evaluation; an authorized Institutional Review Board has issued a waiver of authorization for review of records at the Facility.
9. To avoid a serious threat to health or safety. As required by law and standards of ethical conduct, we are
permitted to release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to your, the public’s, or another individual’s health or safety.
10. For military, national security, or incarceration/law enforcement custody. If you are involved with the military national security or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, we are permitted to release your health information to the proper authorities so they may carry out their duties under the law. We are permitted to release medical information about you to authorized federal officials so that they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
11. For workers’ compensation. We are permitted to disclose your health information to the appropriate persons in order to comply with the laws related to workers’ compensation or other similar programs.
Your Health Information Rights
You have several rights with regard to your health information. Specifically, you have the right to:
1. Inspect and copy your health information. With a few exceptions, you have the right to inspect and obtain a copy of your medical record. However, this right does not apply to psychotherapy notes or information gathered for judicial proceedings. In addition, we are permitted to charge you a reasonable fee to copy of your health information. If you wish to inspect and/or copy the health information in your medical record, please notify the medical records department, facility manager or privacy contact at the facility.
2. Request to amend your health information. If you believe the health information within your medical record is incorrect, you may ask us to amend the information. You will be asked to make such requests in writing to the facility at the address at the bottom of this notice and to include the requested amendment along with a reason as to why your health information should be amended. We are not required, however, to honor your request if we did not create the information you are requesting be amended or if it is our professional opinion that the information in your record is accurate and complete. We will respond to your request in writing within 60 days of the date of receipt of your written request for amendment of your information.
3. Request restrictions on certain uses and disclosures. You have the right to ask for restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities. However, we are not required to agree to your requested restriction.
4. As applicable, receive confidential communication of health information. You have the right to ask that we communicate your health information to you by different means or places. For example, you may ask to receive information about your health status in a special, private room or through correspondence sent to a private address. Proper documentation must be in place prior to the release of information.
5. Receive a record of disclosures of your health information. You have the right to ask for a list of the disclosures of your health information we have made during the previous six years, but the request cannot include dates before April 14, 2003. This listing will include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and the reason for the disclosure. This listing will not include the following disclosures:
- Disclosures made for the purpose of treatment, payment or healthcare operations or disclosures made to family or responsible caregivers as described above
- Disclosures made directly to you
- Disclosures made based on a valid authorization from you or from your legally authorized representative
- Disclosures made for purposes of national security or to correctional institutions or law enforcement officers as described above
- Disclosures made prior to April 14, 2003
You must request this listing of disclosures in writing to the Facility at the address at the top of this Notice. We will generally provide you with the list within 60 days of receipt of your request, unless you are notified that we require an extension. There is no charge to you for the list, unless you request such a list more than once per year.
6. Obtain a paper copy of this Notice. Upon your request, you may at any time receive a paper copy of this Notice. Copies of our Notice are available at the Registration desk at the Facility.
7. Complaint. If you believe your privacy rights related to services received at the Facility have been violated by the Facility, you may file a complaint with our Corporate Privacy Compliance Officer at the address listed below or by email at email@example.com.
This Notice of Privacy Practices is effective based on a revision of privacy practices originally implemented. We must follow the privacy practices described in this Notice. However, the Facility reserves the right to change its privacy practices described in this Notice at any time, and to apply these changes retroactively. Changes to our privacy practices would apply to all health information we maintain. If you have any questions or concerns regarding your privacy rights or the information in this Notice, please contact the Facility‘s Manager or Privacy Contact, or the Corporate Privacy Officer at the address below.