CHEYENNE SKIN CLINIC
AND
CENTER FOR DERMATOLOGIC SURGERY
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ THIS NOTICE CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
Our goal at Cheyenne Skin Clinic and Center for Dermatologic Surgery is to take appropriate steps to attempt to safeguard any medical or other personal information that is provided to us. We are required to:
• Maintain the privacy of medical information provided to us.
• Provide notice of our legal duties and privacy practices.
• Abide by the terms of our Notice of Privacy Practices currently in effect.
This notice describes the practices of our employees and staff as well as:
All entities associated with Cheyenne Skin Clinic and Center for Dermatologic Surgery to include any additional individuals, affiliated entities, entities associated as organized health care arrangements, or any other individuals or entities, sites, and locations will follow the terms of this notice. In addition,these individuals, entities, sites, and locations may share medical information
with each other for the treatment, payment, or health care operations purposes described in this notice.
In the ordinary course of receiving treatment and health care services from us, you will be providing us with personal information, such as:
· Your name, address, and phone number
· Information relating to your medical history
· Your insurance information and coverage
· Information concerning your doctor, nurse or other medical providers.
In addition, we will gather certain medical information about you and will create a medical record of the care that is provided for you. Some information may also be provided to us by other individuals or organizations that are part of your “circle of care”, such as your referring physician, your other doctors, your health plan, and close friends or family members.
We may use and disclose personal and identifiable health information about you in different ways. All of the ways in which we may use and disclose information will fall within one of the following categories, but not every use or disclosure in a category will be listed.
Treatment: We will use health information about you to furnish services and supplies to you, in accordance with our policies and procedures. For example, we will use your medical history, such as “family history of skin cancer”, to assess your health and perform pathological services.
Payment: We will use and disclose health information about you to bill for our services and to collect payment from you or your insurance company. For example, we may need to give a payer information about your current medical conditions so that it will pay us for the pathological services that we have furnished to you. We may need to inform your payer of these findings in order to obtain prior approval or to determine whether the service is covered.
Health Care Operations: We may use and disclose information about you for the general operation of our business. For example, we sometimes arrange for accreditation organizations, auditors or consultants to review our practice and evaluate our operations.
Public Policy Uses and Disclosures: There are 16 types of public-good uses and disclosures that the HIPAA Privacy Rule permits, provided applicable conditions are met. They are:
You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail.
Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment or that you should schedule an appointment.
Treatment Alternatives: We may use and disclose your personal health information in order to tell you about or recommend possible treatment options, alternative or health-related services that may be of interest to you.
We are required to obtain written authorization from you for any other uses and disclosures of medical information other than those described above. If you provide us with such permission, you may revoke that permission in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by your written authorization. We will be unable to take back any disclosures already made based upon your original permission.
INDIVIDUAL RIGHTS
You have the right to ask for restrictions on the ways in which we use and disclose your medical information beyond those imposed by law. We will consider your request, but we are not required to accept it.
Except under certain circumstances, you have the right to inspect and copy medical billing records for yourself. If you ask for copies of this information, we may charge you a fee for copying and mailing.
If you believe the information in your records is incorrect or incomplete, you have the right to ask us to correct the existing information or correct the missing information. Under certain circumstances, we may deny your request.
You have a right to ask for a list of instances when we have used or disclosed your medical information for reasons other than your treatment, payment for services, our health care operations, or disclosures you have given us authorization to make. If you ask for this information from us more than once every twelve months, we may charge you a fee.
To exercise any of your rights, please contact us in writing at:
Cheyenne Skin Clinic
123 Western Hills Blvd.
Cheyenne , Wyoming 82009
Attn: Privacy Officer
We reserve the right to make changes to this notice at any time. We service the right to make the revised notice effective for personal health information we have about you as well as any information we receive in the future. In the event there is a material change to this Notice, the revised Notice will be posted. In addition, you may request a copy of the revised Notice at any time.
COMPLAINTS/COMMENTS:
If you have any complaints concerning our Privacy Policy, you may contact the Secretary of the Department of Health and Human Services, at 200 Independence Avenue, S.W. , Room 509F, HHH Building , Washington , D.C. 20201 (e-mail: ocrmail@hhs.gov ). You may also contact our Privacy Officer, Teresa Lake at Cheyenne Skin Clinic, 123 Western Hills Blvd. , Cheyenne , Wyoming 82009 (307)635-0226.
This Privacy Policy is effective March 1, 2003 .