JUDITH GURLEY PLASTIC SURGERY, LLC
PATIENT PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW YOUR INFORMATION MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.
If you have questions about this notice or want more information, please contact our Privacy Officer at 636-812-4300. The effective date of this notice is July 1, 2019.
We provide services entirely on a self-pay basis. We do not engage in any electronic transactions with health plans and, therefore, we are not a “covered entity” as defined by the Health Insurance Portability and Accountability Act of 1996, as amended, and its implementing regulations found at 45 C.F.R. Parts 160 to 164 (“HIPAA”). As such, we are not subject to HIPAA requirements.
We take the privacy and security of our patients’ information seriously and provide this Notice to inform you of how we will use and disclose your information, consistent with ethical medical practice and requirements under Missouri law. To help you understand how we will use and disclose your information we have put the different uses and disclosures into categories and give examples of each. All of the ways we use or disclose your information will fit into one of the categories listed below, but we cannot list all of the uses and discloses in each category.
We may use and disclose your health information for certain functions related to your healthcare:
- Treatment. We may use and disclose your information to provide you with medical treatment and services. Your information may be disclosed to individuals and facilities providing care to you. These individuals and facilities need your information to provide care, and to coordinate and provide services (such as prescriptions, lab tests, meals, and x-rays). Please note that the medical facilities where your care is provided may have separate policies and procedures regarding how they use and disclose your information. Please contact your healthcare facility with any questions regarding their policies.
- Payment. We may use and disclose your information to receive payment for the services and treatment provided to you. For example, if you pay for services by credit card, our office information and the amount paid will be disclosed to your credit card company for purposes of processing the payment.
- Health Care Operations. We may use and disclose your information for health care operation purposes. Health care operations includes review of the care you receive for quality assessment, educational, business planning, and compliance plan purposes. For example, we may discuss outcomes of your procedure with the healthcare facility where services are performed in order to evaluate and improve the quality of the services we offer.
- Appointment Reminders. We may provide appointment reminders to you. You may request in writing that we send reminders to a confidential or alternative address.
- Treatment Alternatives. We may provide you with information about treatment alternatives and other health related benefits and services.
- We may provide your information to parties with whom we have a contract to perform some of the functions described above. Where we use a vendor to perform services, we will require that they maintain the privacy and security of your information.
We may also disclose your health information to outside entities without your consent or authorization in the following circumstances as authorized by law:
- Required by Law. We disclose information as required by law.
- Public Health Purposes. We disclose information to health agencies as required by law for preventing or controlling disease. Examples are reporting of sexually transmitted, communicable, and infectious diseases.
- To Prevent a Serious Threat to Health or Safety. We may disclose information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.
- Research. Your information may be used by or disclosed to researchers for research approved by a privacy board or an institutional review board.
- Health Oversight Activities. Your health information may be disclosed to governmental agencies and boards for investigations, audits, licensing, and compliance purposes.
- Judicial and Administrative Proceedings. We may be required to disclose your health information to a court or for an administrative proceeding, consistent with the obligations of a court order, subpoena, or similar legal process.
- Law Enforcement Activities. We may be required to disclose your information as required by law for certain law enforcement activities.
- Deceased Individual. We may disclose information for the identification of the body or to determine the cause of death.
- Military and Veterans. If you are a member of the armed forces we may release information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.
- Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official. This release must be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety or security of the correctional institution.
- Organ and Tissue Donation. If you are an organ donor, we may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ bank, as necessary to facilitate organ or tissue donation.
- Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs.
- Specialized Governmental Functions. We may release information about you to authorized Federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
We will give you the opportunity to object to the following uses and disclosure of your information:
- Individuals Involved in Care. We may tell your friends, relatives and other caretakers limited information which is relevant to their involvement in your care.
- Disaster Relief. We may disclose information about you to public or private agencies for disaster relief purposes.
Except as provided above, we will obtain your written authorization prior to disclosure of your information for any other purpose. Specifically, written authorization is required prior to the disclosure of your information:
Where a disclosure is made under your written authorization, you have the right to revoke the authorization at any time. Revocation of an authorization must be in writing. The revocation is effective as of the date you provide it to us and does not affect any prior disclosures made under the authorization.
If a state or federal law provides additional restrictions or protections to your information, we will comply with the most stringent requirement.
- You have the right to obtain a copy of your medical record. To inspect and copy your medical record a request must be made in writing to our office. We may charge a fee for the copy of your information.
- You have the right to request a paper copy of this Notice.
- You have the right to be notified in the event of a breach to your personal information, consistent with obligations under Missouri law.
We may change the terms of this Notice and the revised Notice will apply to all health information in our possession. If we revise this Notice, a copy of the revised Notice will be posted on our website and a copy may be requested from our Privacy Officer at the number listed at the beginning of this form.
If you believe your privacy rights have been violated you may contact our Privacy Officer at the number at the beginning of this Notice.