Gryskiewicz Twin Cities Cosmetic Surgery
Health Insurance Portability and Accountability Act (HIPAA)
NOTICE OF MEDICAL INFORMATION PRIVACY RIGHTS
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.
During your treatment at Gryskiewicz Twin Cities Cosmetic Surgery, our doctor, nurse, and other caregivers may gather information about your current health. This notice will explain how such information may be used and shared with others. It will also explain your privacy rights regarding this kind of information.
Your medical information will be used and disclosed for the following purposes:
• Treatment: We will use your information to provide, coordinate, and manage your care and treatment. For example, our Gryskiewicz Twin Cities Cosmetic Surgery physician may share your medical information with another physician for a consultation or a referral.
• Payment: We will use your information to receive payment for the services we provide. For example, we will disclose information in order to submit bills or claims to insurance companies and/or Medicaid.
• Health Care Operations: We will use your information for certain activities related to the functioning of Gryskiewicz Twin Cities Cosmetic Surgery. For example, we may use or disclose information for quality assurance activities, legal services, underwriting, and other business management and administrative activities.
• Appointment Reminders and Other Health Information: We may use your medical information to send you reminders about future appointments. Your medical information may also be used to provide you with information about new or alternative treatments or other health services.
• Fund-Raising: Occasionally, Gryskiewicz Twin Cities Cosmetic Surgery may use your medical information to let you know about fund-raising activities for Gryskiewicz Twin Cities Cosmetic Surgery.
Gryskiewicz Twin Cities Cosmetic Surgery may also use or disclose your information for the following purposes:
• To people who will taking care of you or helping to pay your medical bills, such as family members or close friends. Gryskiewicz Twin Cities Cosmetic Surgery will only disclose medical information that these people need to know. We may also use your medical information to let family members or other responsible people know where you are and what your general medical condition is. If you are able to make your own health care decisions, Gryskiewicz Twin Cities Cosmetic Surgery will ask your permission before using your medical information for these purposes. If you are unable to make health care decisions, Gryskiewicz Twin Cities Cosmetic Surgery will disclose relevant medical information to family members or other responsible people if we feel it is in your best interest to do so. For example, we may provide limited medical information to allow a family member to pick up a prescription or x-ray for you.
• Under emergency conditions, to government or other groups that assist in emergencies or disasters
• Gryskiewicz Twin Cities Cosmetic Surgery also may disclose or use your information without your consent in the following cases: when required by law; for public health activities; relating to victims of abuse/neglect/domestic violence, if required/authorized by law and/or if you agree; for health oversight activities; for judicial and administrative proceedings to the extent permitted by law; for law enforcement purposes, as permitted or required by law; to coroners/medical examiners/funeral directors, as permitted by law; for organ donation purposes; for research purposes under certain circumstances; to avert a serious threat to health or safety; for certain specialized government functions, such as military discharge, and national security and intelligence; and for workers’ compensation purposes.
Gryskiewicz Twin Cities Cosmetic Surgery will not use or disclose your medical information in any other way unless you allow us to do so in writing. If you do give us permission to use or disclose your medical information for another purpose, you have the right to change you mind and revoke the permission at any time.
Your privacy rights:
• You may request that Gryskiewicz Twin Cities Cosmetic Surgery not use your medical information in certain ways or for certain purposes. You may also request that Gryskiewicz Twin Cities Cosmetic Surgery not provide your medical information to certain people. However, Gryskiewicz Twin Cities Cosmetic Surgery has the right to refuse your request, and Gryskiewicz Twin Cities Cosmetic Surgery may use or disclose your medical information in situations requiring emergency treatment, in which case we will ask the person(s) who receive the information not to further use or disclose the information.
• You may request that Gryskiewicz Twin Cities Cosmetic Surgery provide you with your medical information in a confidential manner. For example, you can request that we send your appointment reminders, bills, and other mailings to a different address or that we notify you of this kind of information in another way, such as by a phone call. You must make this request in writing and specify another address or means of communications. We may also ask you to give us information on how you will pay your bills.
• You may ask to see and copy you medical records, unless this information is protected by law. You must make these requests in writing. If you request to look at or copy your medical records is denied, you have the rights to have the denial reviewed by a health care professional. We will act upon your request within 30 days, and we may charge you a legally acceptable amount for copying costs.
• You may ask us to change information in your medical records. If you request is denied, you can write a statement of disagreement with the denial that we will keep your medical records.
• You may ask us to provide you with information about certain disclosures of you medical information in the past. You may request an accounting of disclosures make in the past six (6) years, but this accounting will only cover disclosures made after April 14, 2003.
• If you have received this notice of your medical information privacy rights electronically, you may ask us to provide you with a paper copy.
• If you feel you medical information privacy rights have been violated, you may file a complaint with the Secretary of Health and Human Services, and/or with the Gryskiewicz Twin Cities Cosmetic Surgery contact person listed below. Filing a complaint will not affect the quality of the services you receive from Gryskiewicz Twin Cities Cosmetic Surgery and you will not be retaliated against for filing a complaint.
• You can contact the designated privacy official at Gryskiewicz Twin Cities Cosmetic Surgery:
Name: Melanie Morrison
Title: Office Manager
Phone Number: (952) 435-0177
The effective date of this notice is April 14, 2003. Gryskiewicz Twin Cities Cosmetic Surgery is required by law to maintain the privacy of protected health information and to provide individuals with this notice of its legal duties and privacy practices with respect to health information. Gryskiewicz Twin Cities Cosmetic Surgery is required to abide by the terms of the notice currently in effect. Gryskiewicz Twin Cities Cosmetic Surgery reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information maintained by Gryskiewicz Twin Cities Cosmetic Surgery. If the terms of this notice are changed, Gryskiewicz Twin Cities Cosmetic Surgery will provide individuals with a revised notice upon request and by posting in designated locations at Gryskiewicz Twin Cities Cosmetic Surgery.
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