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.
AMA Privacy Officer: Dahlia Milgrom Email: firstname.lastname@example.org Tel: 949-428-4500
This Privacy Notice (“Notice”) applies to AMA Regenerative Medicine & Skincare, its affiliates, and its employees. AMA Regenerative Medicine & Skincare will disclose patients’ protected health information as needed to carry out treatment, payment, and health care operations as allowed by law. We are mandated by law to protect the privacy of our patients’ protected health information and to give patients with notice of our legal responsibilities and privacy policies regarding protected health information. We are expected to follow the terms of this Notice for the duration of its validity.
We reserve the right to modify the provisions of this Notice as needed and to implement a new notice of privacy practices for all protected health information stored by AMA Regenerative Medicine & Skincare. In the event of a breach of your unprotected protected health information, we are compelled to notify you. We are also required to notify you that a state law provision relating to the privacy of your health information may be more strict than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”). A copy of any amended Notice of Privacy Practices or information relevant to a specific State statute can be acquired by mailing a request to the Privacy Officer at the address listed above.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
Authorization and Consent: Except as specified below, we will not use or disclose your protected health information for any purpose other than treatment, payment, or health care operations unless you have signed a form allowing such use or disclosure or have given consent by way of video recording or voluntarily appearing in our patient testimonial videos. You have the right to revoke such authorization in writing (or just call us), with such revocation effective once we actually receive the writing; however, such revocation shall not be effective to the extent that we have taken any action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, and other law gives the insurer the right to contest a claim under the policy or the policy itself. If at any time you wish for a testimonial video featuring you to be taken down, email us at email@example.com or call us and we will do so immediately.
Uses and Disclosures for Treatment: We shall use and disclose your protected health information only as needed for your treatment. Doctors, nurses, and other professionals participating in your care will consult your medical record and information you provide regarding your symptoms and reactions to your treatment plan, which may include procedures, drugs, tests, medical history, and so on.
Uses and Disclosures for Payment: We shall use and disclose your protected health information for payment purposes only. We may also use your information to prepare a bill for you or the person in charge of your payment.
Uses and Disclosures for Health Care Operations: We shall use and disclose your protected health information for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, and so on. We may, for example, use and disclose your protected health information to improve clinical treatment and patient care. We will always take every step possible to conceal your identity.
Individuals Involved In Your Care: We may release your protected health information to designated family, friends, and others involved in your care or payment for your care from time to time in order to enable that person’s engagement in caring for you or paying for your care. If you are unavailable, incapacitated, or in the midst of an emergency medical condition, and we determine that a limited disclosure may be in your best interests, we may share limited protected health information with such others without your consent. If you are unavailable, incapacitated, or in the midst of an emergency medical condition, and we determine that a limited disclosure may be in your best interests, we may share limited protected health information with such others without your consent. We may also reveal limited protected health information to a governmental or private body authorized to assist in disaster relief operations in order for that agency to find a family member or other individuals involved in some area of your care.
Appointments and Services: We may contact you to give appointment updates or information about your treatment, as well as other health-related perks and services that you may find useful. You have the right to request, and we shall facilitate, communications about your protected health information from us via alternate means or at alternative places. For example, if you do not want appointment reminders left on voice mail or emailed to a certain address, we will accommodate reasonable requests. You must give an adequate replacement address or form of contact with such a request. You also have the right to request that we not send you any further marketing materials, and we will do our best to comply. Such requests must be made in writing, including your name and address, and sent to the Privacy Officer at the address listed above or below.
Research: We may use and disclose your protected health information for research purposes in restricted circumstances. In all circumstances where your express permission is not obtained, your privacy will be secured by strong confidentiality standards imposed by an Institutional Review Board that oversees the research or by representations made by the researchers that limit their use and dissemination of your information.
Fundraising: We may contact you for fundraising purposes using the information you provide and with your permission. We may share your contact information with a linked charity so that they can contact you for comparable objectives. If you do not want us or the foundation to contact you for fundraising purposes, please write to the Privacy Officer at the address below.
Marketing: We must acquire your permission before using or disclosing your protected health information for marketing purposes, unless the communication is (1) face-to-face with you or (2) a promotional gift of minor value. We will never sell your information to a 3rd party.
Other Uses and Disclosures: We are permitted and/or obligated by law to make the following further uses and disclosures of your protected health information without your agreement or authorization:
- Any lawful purpose
- Public health activities such as required reporting of immunizations, disease, injury, birth and death, or in connection with public health investigations
- If we suspect child abuse or neglect; if we believe you are a victim of abuse, neglect, or domestic violence
- To the Food and Drug Administration to report adverse events, product defects, or to participate in product recalls;
- To a government oversight agency undertaking audits, investigations, civil or criminal procedures
- To a court or administrative subpoena or discovery request
- To law enforcement officers as required by law if we believe you have been the victim of abuse, neglect, or domestic violence. We will only disclose this information if you agree or if needed or authorized by law
- To coroners and/or funeral directors in accordance with the law
- If necessary to arrange an organ or tissue donation from you or a transplant for you
- If you are a member of the military, we may also release your protected health information for national security or intelligence activities
- To workers’ compensation agencies in accordance with the law
RIGHTS THAT YOU HAVE REGARDING YOUR PROTECTED HEALTH INFORMATION:
Access to Your Protected Health Information: Much of the protected health information that we keep on your behalf is accessible to you for copying and/or inspection. You may seek a copy of protected health information that we keep in any electronic designated record set in a suitable electronic format, if it is readily producible. Access requests must be submitted in writing and signed by you or your legal agent. Your online portal also contains your information. For your protected health information, you will be charged a reasonable copying fee as well as actual postage and supply expenses. You will be charged a copying and delivery fee if you request extra copies.
Amendments to Your Protected Health Information: You have the right to request that any protected health information we have on file for you be rectified or corrected in writing. We are not bound to make requested changes, but we will carefully evaluate each suggestion. All change requests must be in writing, signed by you or your legal representative, and include the grounds for the request. If an amendment or correction request is submitted, we may notify others who collaborate with us if we believe it is essential.
Accounting for Disclosures of Your Protected Health Information: You have the right to an accounting of certain disclosures of your protected health information made by us after April 14, 2003. Requests must be in writing and signed by you or your authorized agent. The first accounting in any 12-month period is free; each subsequent accounting requested during the same 12-month period will be charged a cost. The charge will be communicated to you at the time of your request.
Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to request restrictions on how your protected health information is used and disclosed for treatment, payment, or health care operations. We are not obligated to accede to most limitation requests, but we will make every effort to meet reasonable requests when possible. You do, however, have the right to limit disclosure of your protected health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the protected health information pertains solely to a health care item or service for which you have paid AMA Regenerative Medicine & Skincare in full. If we agree to any discretionary limits, we have the right to remove them as we see fit. If we remove a restriction established in accordance with this paragraph, we will tell you. You also have the right to revoke any restriction, in writing or orally, by stating your desire to the official in charge of medical records.
Right to Notice of Breach: We take the confidentiality of our patients’ information very seriously, and we are required by law to preserve the privacy and security of your protected health information by implementing suitable precautions. In the case of a breach involving or possibly involving your unsecured health information, we will notify you and advise you on the steps you may need to take to protect yourself.
For Further Information: If you have any questions, require further information, or wish to make a request in response to this Notice, please contact:
AMA Privacy Officer: Dahlia Milgrom Email: firstname.lastname@example.org Tel: 949-428-4500
Complaints: Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed above.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:
Office for Civil Rights
U.S. Department of Health & Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
(415) 437-8310 : (415) 437-8311 (TDD) : (415) 437-8329 (FAX) : OCRMail@hhs.gov
You will not be penalized in any way for filing a complaint.