HIPAA NOTICE OF PRIVACY PRACTICES
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.
Amavi Aesthetic Surgery PLLC (“Amavi) is required by law to maintain the privacy of your health information and provide you a description of our privacy practices. This notice applies to all Amavi employees, staff, volunteers, students, trainees and others whose conduct, in the performance of work for Amavi, is under the direct control of Amavi, whether or not Amavi pays them. This notice also applies to other healthcare providers that offer clinically integrated healthcare services at Amavi, such as physicians, residents, physician assistants, emergency service providers, and others as part of an Organized Health Care Arrangement. However, this notice only applies to the privacy practices of these healthcare providers when they are providing care at Amavi. It does not apply to the privacy practices of these providers in their own offices or other healthcare settings. Amavi will share your information with these other providers as described in this notice.
Your Rights
You have certain rights when it comes to your health information. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record.
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. We may require you to do this in writing. We will provide you with a copy of your health information or a summary if you prefer. We may charge a reasonable, cost-based fee.
We may deny your request for some of your health information. If we deny your request, we will inform you in writing why we denied it, how you may have the denial reviewed in certain instances, and how you may file a complaint regarding our decision.
Ask us to amend your medical record.
You can ask us to amend health information about you that you think is incorrect or incomplete. We may deny your request, but if we do, we will tell you why in writing.
Request confidential communications
You can ask us to contact you in a specific way (for example, ask us to contact you at work instead of your home) or to send mail to a different address. We will accommodate all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for your treatment, our payment, or our operations. We are not required to agree to your request, but if we don’t agree, we will tell you why in writing. Even if we agree to your request, we may not follow it in an emergency situation. We may also change our decision in the future, but if we do, we will tell you in writing. The change will only apply to your health information we create or receive after we notify you of the change.
If you pay for a service or health care item out-of-pocket and in full, you can ask us not to share that information with your health insurer if it is for a payment or operations purpose. The request must be in writing and we will approve your request unless we are required by law to share that information.
Get a list of those with whom we have shared information
You can ask for a list (accounting) of the times we have shared your health information for up to six years from the date you ask, who we shared it with, when and why. We will include all the disclosures except for those about treatment, payment, health care operations, and certain other disclosures, including any you asked us to make.
We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a copy.
Choose someone to act for you
We may disclose your information to a person named as your medical power of attorney or legal guardian. We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
To ask questions, express concerns, or file a complaint, contact our Practice Manager Amy Circle by mail:
Amavi Aesthetic Surgery
ATTN: Practice Manager
6200 S Syracuse Way, STE 260, Greenwood Village, CO 80111; or via email at amycircle@amavias.com; by phone at 303-381-0919.
You can also file a privacy or civil rights complaint with the U.S. Department of Health and Human Services’ (DHHS) Office for Civil Rights (OCR), electronically through the OCR Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. DHHS, 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201; 1-800-368-1019 or 1-800-537-7697 (TDD). Complaints to the Office for Civil Rights must be filed within 180 days of when you learn of, or should have known about, the violation.
We will not retaliate against you for filing a complaint.
Your Choices
In certain situations, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, let us know.
Reminding you that you have an appointment for care.
Sharing information with your family, close friends, or others involved in your care or payment for your care.
Sharing information for disaster relief purposes with entities authorized to assist in disaster relief efforts.
Providing your religious affiliation to a member of the clergy, such as a priest, rabbi, or pastor.
Contacting you for fundraising efforts. You can tell us not to contact you again by following the instructions we send you when you are contacted.
If you are not able to or do not tell us your preferences (for example, if you are unconscious or do not indicate a preference to us) we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
Our Uses and Disclosures
We are permitted to use or share your health information in the following ways:
To treat you
We can use your health information and share it with other professionals to provide, coordinate and manage your health care and related services. For example, information about your visit may be provided to your primary care physician, with payers for quality management purposes relating to your treatment, or with other providers or organizations to allow you to receive care remotely or have virtual visits with our clinical staff.
For our operations
We can use and share your health information to run our organization, improve your care, and contact you when necessary. For example, we may use your information to review your treatment, evaluate the performance of the staff caring for you, or share with students being trained in the organization.
To bill for your services or other payment reasons
We can use and share your health information to bill and get payment from health plans or other entities. For example, we give information about you to your health insurance plan so it will pay for your services.
Future communications
We may communicate to you via newsletters, mailings, or other means regarding treatment options, health related information, disease-management programs, wellness programs, research projects, or other community based initiatives or activities in which we participate.
Business associates
Some of the services provided to you are performed on our behalf by outside vendors called Business Associates. We will disclose your health information to our Business Associates to allow them to perform these services for us. For example, we may contract with a copy service company to provide you copies of your health record. Business Associates are required by federal law to safeguard your information.
How else can we use or share your health information?
We are allowed or required to share your information in ways that contribute to the public good such as public health and research. We have to meet certain conditions in the law before we can share your information for those purposes.
Help with public health and safety issues.
We can share health information about you for certain public health and safety situations such as: preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; and preventing or reducing a serious threat to anyone’s health or safety.
Research.
We may use or disclose your health information for research studies but only when the researchers meet all federal and state requirements to protect your privacy. You may also be contacted to participate in a research study.
Comply with the law.
We will share information about you if state or federal laws require it, including with the federal Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests.
We can share health information about you with organ procurement, banking or transplantation organizations for the purpose of facilitating organ, eye, or tissue donation and transplantation.
Coroners, medical examiners and funeral directors.
We may share health information with a funeral director as necessary to carry out their duties including arrangements after death, or with coroners and medical examiners to identify the deceased, determine a cause of death, or as otherwise authorized by law.
Workers’ compensation, health oversight and government authorities.
We can use or share health information about you for workers’ compensation claims and with health oversight agencies for activities authorized by law and for special government functions such as military, national security, and presidential protective services.
Law Enforcement.
We may disclose health information to a law enforcement official for purposes such as to respond to a search warrant, identify a suspect, fugitive or missing person, report a death believed to be a result of criminal conduct, or report a crime committed on our property. We may also disclose health information to correctional institutions or law enforcement officials under certain circumstances if you are in custody.
Lawsuits and legal actions.
We may disclose your information in response to a valid court or administrative order. We may also disclose your information in response to certain types of subpoenas, discovery requests, or other lawful processes.
Our Responsibilities
We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us in writing that we can. If you tell us we can, you may change your mind at any time by notifying us in writing. We will notify you promptly if a breach occurs that may have compromised the privacy or security of your health information.
Authorization Required.
In the following cases, we won’t share your information unless you give us written permission:
Marketing purposes, except if we talk with you in person or give you a promotional gift of little value from a company we work with, like a pen or notebook.
Sale of your information.
Most sharing of psychotherapy notes, which are private notes maintained by your psychiatrist or psychologist.
Revisions to this Notice.
We reserve the right to change the terms of this Notice at any time. If we do, the changes will apply to all information we have about you. The new Notice will be available upon request and on our website.
For more information on your rights and our responsibilities:
https://www.hhs.gov/hipaa/for-individuals/notice-privacy-practices/index.html
Treating you fairly.
Amavi Aesthetic Surgery complies with applicable Federal and state civil rights laws and does not or discriminate on the basis of race, color, national origin, language, culture, ethnicity, age, religion, sex, mental or physical disability, sexual orientation, gender expression, gender identity, veteran status, socioeconomic status, or any other characteristic prohibited by federal, state, or local law.