RENEW DERMATOLOGY NOTICE OF PRACTICES Effective Date: September 21, 2013 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. If yu have any questins abut this Ntice f Privacy Practices ( Ntice ), please cntact: Privacy Officer: Heather Laskin Phne Number: 804.440.3376 ext. 203 Sectin A: Wh Will Fllw This Ntice? This Ntice describes Renew Dermatlgy (hereafter referred t as Prvider ) Privacy Practices and that f: Any wrkfrce member authrized t create medical infrmatin referred t as Prtected Health Infrmatin (PHI) which may be used fr purpses such as Treatment, Payment and Healthcare Operatins. These wrkfrce members may include: All emplyees, staff and ther Prvider persnnel. Any member f a vlunteer grup. Any entity prviding services under the Prvider's directin and cntrl will fllw the terms f this ntice. In additin, these entities, sites and lcatins may share medical infrmatin with each ther fr Treatment, Payment r Healthcare Operatinal purpses described in this Ntice. Sectin B: Our Pledge Regarding Medical Infrmatin We understand that medical infrmatin abut yu and yur health is persnal. We are cmmitted t prtecting medical infrmatin abut yu. We create a recrd f the care and services yu receive at the Prvider. We need this recrd t prvide yu with quality care and t cmply with certain legal requirements. This Ntice applies t all f the recrds f yur care generated r maintained by the Prvider, whether made by Prvider persnnel r yur persnal dctr. This Ntice will tell yu abut the ways in which we may use and disclse medical infrmatin abut yu. We als describe yur rights and certain bligatins we have regarding the use and disclsure f medical infrmatin. We are required by law t: Make sure that medical infrmatin that identifies yu is kept private; Give yu this Ntice f ur legal duties and privacy practices with respect t medical infrmatin abut yu; and Page 1 f 7 Cpyright 2013 Stericycle, Inc. All rights reserved. HIPAA Cmpliance Prgram
Fllw the terms f the Ntice that is currently in effect. Sectin C: Hw We May Use and Disclse Medical Infrmatin Abut Yu The fllwing categries describe different ways that we use and disclse medical infrmatin. Nt every use r disclsure in a categry will be listed. Hwever, all f the ways we are permitted t use and disclse infrmatin will fall within ne f the categries. Treatment. We may use medical infrmatin abut yu t prvide yu with medical treatment r services. We may disclse medical infrmatin abut yu t dctrs, nurses, technicians, health care students, r ther Prvider persnnel wh are invlved in taking care f yu at the Prvider. Different departments f the Prvider als may share medical infrmatin abut yu in rder t crdinate different items, such as prescriptins, lab wrk and x-rays. We als may disclse medical infrmatin abut yu t peple utside the Prvider wh may be invlved in yur medical care after yu leave the Prvider. Payment. We may use and disclse medical infrmatin abut yu s that the treatment and services yu receive at the Prvider may be billed and payment may be cllected frm yu, an insurance cmpany r a third party. We may als tell yur health plan abut a prescribed treatment t btain prir apprval r t determine whether yur plan will cver the treatment. Healthcare Operatins. We may use and disclse medical infrmatin abut yu fr Prvider peratins. These uses and disclsures are necessary t run the Prvider and make sure that all f ur patients receive quality care. We may als disclse infrmatin t dctrs, nurses, technicians, health care students, and ther Prvider persnnel fr review and learning purpses. We may als cmbine the medical infrmatin we have with medical infrmatin frm ther Prviders t cmpare hw we are ding and see where we can make imprvements in the care and services we ffer. We may remve infrmatin that identifies yu frm this set f medical infrmatin s thers may use it t study health care and health care delivery withut learning a patient's identity. Appintment Reminders. We may use and disclse medical infrmatin t cntact yu as a reminder that yu have an appintment fr treatment r medical care at the Prvider. Treatment Alternatives. We may use and disclse medical infrmatin t tell yu abut r recmmend pssible treatment ptins r alternatives that may be f interest t yu. Health-Related Benefits and Services. We may use and disclse medical infrmatin t tell yu abut health-related benefits r services that may be f interest t yu. Authrizatins Required We will nt use yur prtected health infrmatin fr any purpses nt specifically allwed by Federal r State laws r regulatins withut yur written r electrnic authrizatin, this includes uses f yur PHI fr marketing r sales activities. Emergencies. We may use r disclse yur medical infrmatin if yu need emergency treatment r if we are required by law t treat yu but are unable t btain yur cnsent. If this happens, we will try t btain yur cnsent as sn as we reasnably can after we treat yu. Psychtherapy Ntes Psychtherapy ntes are accrded strict prtectins under several laws and regulatins. Therefre, we will disclsure psychtherapy ntes nly upn yur written authrizatin with limited exceptins. Page 2 f 7 Cpyright 2013 Stericycle, Inc. All rights reserved. HIPAA Cmpliance Prgram
Cmmunicatin Barriers. We may use and disclse yur health infrmatin if we are unable t btain yur cnsent because f substantial cmmunicatin barriers, and we believe yu wuld want us t treat yu if we culd cmmunicate with yu. Individuals Invlved in Yur Care r Payment fr Yur Care. We may release medical infrmatin abut yu t a friend r family member wh is invlved in yur medical care and we may als give infrmatin t smene wh helps pay fr yur care, unless yu bject in writing and ask us nt t prvide this infrmatin t specific individuals. In additin, we may disclse medical infrmatin abut yu t an entity assisting in a disaster relief effrt s that yur family can be ntified abut yur cnditin, status and lcatin. Research. Under certain circumstances, we may use and disclse medical infrmatin abut yu fr research purpses. All research prjects, hwever, are subject t a special apprval prcess. This prcess evaluates a prpsed research prject and its use f medical infrmatin, trying t balance the research needs with patients' need fr privacy f their medical infrmatin. Befre we use r disclse medical infrmatin fr research, the prject will have been apprved thrugh this research apprval prcess, but we may, hwever, disclse medical infrmatin abut yu t peple preparing t cnduct a research prject s lng as the medical infrmatin they review des nt leave the Prvider. We will almst always generally ask fr yur specific permissin if the researcher will have access t yur name, address r ther infrmatin that reveals wh yu are, r will be invlved in yur care at the Prvider. As Required By Law. We will disclse medical infrmatin abut yu when required t d s by federal, state r lcal law. T Avert a Serius Threat t Health r Safety. We may use and disclse medical infrmatin abut yu when necessary t prevent a serius threat t yur health and safety r the health and safety f the public r anther persn. Any disclsure, hwever, wuld nly be t smene able t help prevent the threat. E-mail Use. E-mail will nly be used fllwing this Organizatin s current plicies and practices and with yur permissin. The use f secured, encrypted e-mail is encuraged. Sectin D: Special Situatins Organ and Tissue Dnatin. If yu are an rgan dnr, we may release medical infrmatin t rganizatins that handle rgan prcurement r rgan, eye r tissue transplantatin r t an rgan dnatin bank, as necessary t facilitate rgan r tissue dnatin and transplantatin. Military and Veterans. If yu are a member f the armed frces, we may release medical infrmatin abut yu as required by military cmmand authrities. We may als release medical infrmatin abut freign military persnnel t the apprpriate freign military authrity. Wrkers' Cmpensatin. We may release medical infrmatin abut yu fr wrkers' cmpensatin r similar prgrams. Public Health Risks. We may disclse medical infrmatin abut yu fr public health activities. These activities generally include the fllwing: t prevent r cntrl disease, injury r disability; Page 3 f 7 Cpyright 2013 Stericycle, Inc. All rights reserved. HIPAA Cmpliance Prgram
t reprt births and deaths; t reprt child abuse r neglect; t reprt reactins t medicatins r prblems with prducts; t ntify peple f recalls f prducts they may be using; t ntify a persn wh may have been expsed t a disease r may be at risk fr cntracting r spreading a disease r cnditin; and t ntify the apprpriate gvernment authrity if we believe a patient has been the victim f abuse, neglect r dmestic vilence. We will nly make this disclsure if yu agree r when required r authrized by law. Health Oversight Activities. We may disclse medical infrmatin t a health versight agency fr activities authrized by law. These versight activities include, fr example but nt limited t, audits, investigatins, inspectins, and licensure. These activities are necessary fr the gvernment t mnitr the health care system, gvernment prgrams, and cmpliance with civil rights laws. Lawsuits and Disputes. If yu are invlved in a lawsuit r a dispute, we may disclse medical infrmatin abut yu in respnse t a curt r administrative rder. We may als disclse medical infrmatin abut yu in respnse t a subpena, discvery request, r ther lawful prcess by smene else invlved in the dispute, but nly if effrts have been made t tell yu abut the request r t btain an rder prtecting the infrmatin requested. Law Enfrcement. We may release medical infrmatin if asked t d s by a law enfrcement fficial: in respnse t a curt rder, subpena, warrant, summns r similar prcess; t identify r lcate a suspect, fugitive, material witness, r missing persn; abut the victim f a crime if, under certain limited circumstances, we are unable t btain the persn's agreement; abut a death we believe may be the result f criminal cnduct; abut criminal cnduct at the Prvider; and in emergency circumstances, t reprt a crime; the lcatin f the crime r victims; r the identity, descriptin r lcatin f the persn wh cmmitted the crime. Crners, Medical Examiners and Funeral Directrs. We may release medical infrmatin t a crner r medical examiner. This may be necessary t identify a deceased persn r determine the cause f death. We may als release medical infrmatin abut patients f the Prvider t funeral directrs as necessary t carry ut their duties. Natinal Security and Intelligence Activities. We may release medical infrmatin abut yu t authrized federal fficials fr intelligence, cunterintelligence, and ther natinal security activities authrized by law. Prtective Services fr the President and Others. We may disclse medical infrmatin abut yu t authrized federal fficials s they may prvide prtectin t the President, ther authrized persns r freign heads f state r cnduct special investigatins. Inmates. If yu are an inmate f a crrectinal institutin r under the custdy f a law enfrcement fficial, we may release medical infrmatin abut yu t the crrectinal institutin r law enfrcement fficial. This release wuld be necessary fr the institutin t prvide yu with health care, t prtect yur health and safety r the health and safety f thers, r fr the safety and security f the crrectinal institutin. Page 4 f 7 Cpyright 2013 Stericycle, Inc. All rights reserved. HIPAA Cmpliance Prgram
Sectin E: Yur Rights Regarding Medical Infrmatin Abut Yu Yu have the fllwing rights regarding medical infrmatin we maintain abut yu: Right t Access, Inspect and Cpy. Yu have the right t access, inspect and cpy the medical infrmatin that may be used t make decisins abut yur care, with a few exceptins. Usually, this includes medical and billing recrds, but may nt include psychtherapy ntes. If yu request a cpy f the infrmatin, we may charge a fee fr the csts f cpying, mailing r ther supplies assciated with yur request. We may deny yur request t inspect and cpy medical infrmatin in certain very limited circumstances. If yu are denied access t medical infrmatin, in sme cases, yu may request that the denial be reviewed. Anther licensed health care prfessinal chsen by the Prvider will review yur request and the denial. The persn cnducting the review will nt be the persn wh denied yur request. We will cmply with the utcme f the review. Right t Amend. If yu feel that medical infrmatin we have abut yu is incrrect r incmplete, yu may ask us t amend the infrmatin. Yu have the right t request an amendment fr as lng as the infrmatin is kept by r fr the Prvider. In additin, yu must prvide a reasn that supprts yur request. We may deny yur request fr an amendment if it is nt in writing r des nt include a reasn t supprt the request. In additin, we may deny yur request if yu ask us t amend infrmatin that: Was nt created by us, unless the persn r entity that created the infrmatin is n lnger available t make the amendment; Is nt part f the medical infrmatin kept by r fr the Prvider; Is nt part f the infrmatin which yu wuld be permitted t inspect and cpy; r Is accurate and cmplete. Right t an Accunting f Disclsures. Yu have the right t request an Accunting f Disclsures. This is a list f the disclsures we made f medical infrmatin abut yu. Yur request must state a time perid which may nt be lnger than six years and may nt include dates befre April 14, 2003. Yur request shuld indicate in what frm yu want the accunting (fr example, n paper r electrnically, if available). The first accunting yu request within a 12 mnth perid will be cmplimentary. Fr additinal lists, we may charge yu fr the csts f prviding the list. We will ntify yu f the cst invlved and yu may chse t withdraw r mdify yur request at that time befre any csts are incurred. Right t Request Restrictins. Yu have the right t request a restrictin r limitatin n the medical infrmatin we use r disclse abut yu fr payment r healthcare peratins. Yu als have the right t request a limit n the medical infrmatin we disclse abut yu t smene wh is invlved in yur care r the payment fr yur care, like a family member r friend. In yur request, yu must tell us what infrmatin yu want t limit, whether yu want t limit ur use, disclsure r bth, and t whm yu want the limits t apply. We are nt required t agree t these types f request. We will nt cmply with any requests t restrict use r access f yur medical infrmatin fr treatment purpses. Yu als have the right t restrict use and disclsure f yur medical infrmatin abut a service r item fr which yu have paid ut f pcket, fr payment (i.e. health plans) and peratinal (but nt treatment) purpses, if yu have cmpletely paid yur bill fr this item r service. We will nt accept yur request fr this type f restrictin until yu have cmpletely paid yur bill (zer balance) fr this Page 5 f 7 Cpyright 2013 Stericycle, Inc. All rights reserved. HIPAA Cmpliance Prgram
item r service. We are nt required t ntify ther healthcare prviders f these restrictins, that is yur respnsibility. Right t Receive Ntice f a Breach. We are required t ntify yu by first class mail r by email (if yu have indicated a preference t receive infrmatin by email), f any breaches f Unsecured Prtected Health Infrmatin as sn as pssible, but in any event, n later than 60 days fllwing the discvery f the breach. Unsecured Prtected Health Infrmatin is infrmatin that is nt secured thrugh the use f a technlgy r methdlgy identified by the Secretary f the U.S. Department f Health and Human Services t render the Prtected Health Infrmatin unusable, unreadable, and undecipherable t unauthrized users. The ntice is required t include the fllwing infrmatin: a brief descriptin f the breach, including the date f the breach and the date f its discvery, if knwn; a descriptin f the type f Unsecured Prtected Health Infrmatin invlved in the breach; steps yu shuld take t prtect yurself frm ptential harm resulting frm the breach; a brief descriptin f actins we are taking t investigate the breach, mitigate lsses, and prtect against further breaches; cntact infrmatin, including a tll-free telephne number, e-mail address, Web site r pstal address t permit yu t ask questins r btain additinal Infrmatin. In the event the breach invlves 10 r mre patients whse cntact infrmatin is ut f date we will pst a ntice f the breach n the hme page f ur website r in a majr print r bradcast media. If the breach invlves mre than 500 patients in the state r jurisdictin, we will send ntices t prminent media utlets. If the breach invlves mre than 500 patients, we are required t immediately ntify the Secretary. We als are required t submit an annual reprt t the Secretary f a breach that invlved less than 500 patients during the year and will maintain a written lg f breaches invlving less than 500 patients. Right t Request Cnfidential Cmmunicatins. Yu have the right t request that we cmmunicate with yu abut medical matters in a certain way r at a certain lcatin. We will nt ask yu the reasn fr yur request. We will accmmdate all reasnable requests. Yur request must specify hw r where yu wish t be cntacted. Right t a Paper Cpy f This Ntice. Yu have the right t a paper cpy f this Ntice. Yu may ask us t give yu a cpy f this Ntice at any time. Even if yu have agreed t receive this Ntice electrnically, yu are still entitled t a paper cpy f this Ntice. Yu may btain a cpy f this Ntice at ur website. www.renewderm.cm T exercise the abve rights, please cntact the individual listed at the tp f this Ntice t btain a cpy f the relevant frm yu will need t cmplete t make yur request. Sectin F: Changes t This Ntice We reserve the right t change this Ntice. We reserve the right t make the revised r changed Ntice effective fr medical infrmatin we already have abut yu as well as any infrmatin we receive in the future. We will pst a cpy f the current Ntice. The Ntice will cntain n the first page, in the tp right hand crner, the effective date. In additin, each time yu register at the Prvider fr treatment r health care services as an utpatient, we will ffer yu a cpy f the current Ntice in effect. Page 6 f 7 Cpyright 2013 Stericycle, Inc. All rights reserved. HIPAA Cmpliance Prgram
Sectin G: Cmplaints If yu believe yur privacy rights have been vilated, yu may file a cmplaint with the Prvider r with the Secretary f the Department f Health and Human Services; http://www.hhs.gv/cr/privacy/hipaa/cmplaints/index.html T file a cmplaint with the Prvider, cntact the individual listed n the first page f this Ntice. All cmplaints must be submitted in writing. Yu will nt be penalized fr filing a cmplaint. Sectin H: Other Uses f Medical Infrmatin Other uses and disclsures f medical infrmatin nt cvered by this Ntice r the laws that apply t us will be made nly with yur written permissin. If yu prvide us permissin t use r disclse medical infrmatin abut yu, yu may revke that permissin, in writing, at any time. If yu revke yur permissin, we will n lnger use r disclse medical infrmatin abut yu fr the reasns cvered by yur written authrizatin. Yu understand that we are unable t take back any disclsures we have already made with yur permissin, and that we are required t retain ur recrds f the care that we prvided t yu. Sectin I: Organized Healthcare Arrangement The Prvider, the independent members f its Medical Staff (including yur physician), and ther healthcare prviders affiliated with the Prvider have agreed, as permitted by law, t share yur health infrmatin amng themselves fr purpses f treatment, payment r health care peratins. This enables us t better address yur healthcare needs. Revisin Date: September 21, 2013, t be cmpliant with HIPAA Omnibus Privacy Rules. Original Effective Date: September 1, 2008. Page 7 f 7 Cpyright 2013 Stericycle, Inc. All rights reserved. HIPAA Cmpliance Prgram