Patient Privacy Policy

This notice describes how medical information, about you, may be used and disclosed and how you can get access to this information.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
• Our Uses and Disclosures

We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and government requests
• Respond to lawsuits and legal actions

Our responsibilities:

1. Provide an electronic or paper copy of your medical record upon request. 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 will provide a copy or a summary, of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
   Ask us to correct your medical record: You can ask us to correct health information, about you, that you think is incorrect or incomplete. We may say “no†to your request, but we will tell you why, in writing, within 60 days.
2. Request confidential communications: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
3. Ask us to limit what we use or share: You can ask us not to use, or share, certain health information for treatment, payment, or our operations. We are not required to agree, to your request, and we may say “no†if it would affect your care.
   If you pay for a service or a health care item, out-of-pocket in full, you can ask us not to share that information, for the purpose of payment or our operations, with your health insurer. We will say “yes,†unless a law requires us to share that information.
4. Get a copy of this privacy notice: You can ask for a paper copy of this notice, at any time, even if you have agreed to receive the notice electronically.
5. Choose someone to act for you:If you have given someone medical power of attorney, or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority, and can act for you, before we take any action.
6. File a complaint: If you believe your privacy rights have been violated, you may file a complaint, with the hospital, by contacting the Secretary of Department of Health and Human Services, Office of Civil Rights, 200 Independence Ave, SW, Humphrey Building, Mail Stop Room 506F, Washington, DC 20201.

Your Choices

For certain health information, 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, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
• If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and 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.

In these cases, we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
• Fund-raising

Our Uses and Disclosures

We typically use or share your health information in the following ways:

• Treat you
• Contact you
• Bill for services

Restriction of Release of Medical Information for Self-Payment Services.

You have the right to request a restriction, of the release of your medical information, for a particular date(s) of service. The restriction prohibits us from forwarding medical information, relating to the service(s), to your health insurance company. You must make the request, and pay for the services in full, before they are rendered.

Other ways we use or share your health information:

• Public health and research
• Help with public health and safety issues
• To comply with the law
• Respond to lawsuits and legal actions

Our responsibilities:

We are required, by law, to maintain the privacy and security of your protected health information.

We will let you know, promptly, if a breach occurs that may have compromised the privacy or security of your information.

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 we can in writing. If you tell us we can, you may change your mind at any time. Let us know, in writing, if you change your mind.

If you have questions, about this notice, please contact:

Cosmetic and Reconstructive Surgery Associates of Connecticut
Attention: Privacy Officer
Four Corporate Drive
Suite 484
Shelton , CT 06484
203-935-8160

Changes to the terms of this Notice:

We can change the terms, of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our Web site, and we will mail a copy to you.

For more information, regarding the Notice of Privacy Practices, please visit: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Effective Date: January 1, 2015
Sources: United States Department of Health and Human Services, Griffin Hosptial