Gonyon Cosmetic and Plastic Surgery Notice of Privacy Practices

HIPAA Privacy Policies & Procedures

I PURPOSE

Provide guidance to Gonyon Cosmetic and Plastic Surgery regarding the distribution and maintenance of Gonyon Cosmetic and Plastic Surgery’s notice of privacy practices.  This includes guidance for direct care providers regarding obtaining acknowledgement of receipt by the patient and the health plan requirement to re-notify members of the availability of the notice of privacy practices. 

II POLICY

It is the policy of Gonyon Cosmetic and Plastic Surgery  to develop a notice of privacy practices (NPP) for patients and plan members, distribute the NPP to all patients receiving services, periodically review the NPP to determine if the NPP continues to be accurate and, notify patients and plan members if any major changes are made in the NPP.

III GUIDING STANDARDS

Gonyon Cosmetic and Plastic Surgery NPP adheres to the following:

  1. Plain Language.  Gonyon Cosmetic and Plastic Surgery has written the notice in plain language.
  2. Header.  Gonyon Cosmetic and Plastic Surgery has included prominent and specific language in the NPP that informs the patient and the member that the NPP contains information about a patient or plan member’s privacy rights and how medical information will be treated by Gonyon Cosmetic and Plastic Surgery
  3. Describe Uses and Disclosures.  Gonyon Cosmetic and Plastic Surgery has separately described all uses and disclosures of PHI that Gonyon Cosmetic and Plastic Surgery’s workforce is permitted or required to make with and without authorization. Gonyon Cosmetic and Plastic Surgery has also clearly stated that if other law, including state law, prohibits or materially limits the ability to make a use or disclosure that would otherwise be permitted under HIPAA, Gonyon Cosmetic and Plastic Surgery will only make the uses and disclosures permitted under the more stringent law. 
  4. List Other Activities.  Gonyon Cosmetic and Plastic Surgery has listed any or all of the following activities in Gonyon Cosmetic and Plastic Surgery’s  NPP where Gonyon Cosmetic and Plastic Surgery intends to contact individuals, unless Gonyon Cosmetic and Plastic Surgery receives financial remuneration, for: 
    1. providing appointment and refill reminders,
    2. for treatment, case management, care coordination
    3. communicate about a drug or biologic currently prescribed (as long as any financial remuneration received is reasonably related to the cost of the communication)
    4. describing or recommending treatment alternatives, providing information about health-related benefits, products and services that may be of interest to the individual,
    5. describing plan benefits.
  5. Separate Statements Required.  Gonyon Cosmetic and Plastic Surgery must provide a separate statement for   each of the following activities in Gonyon Cosmetic and Plastic Surgery  NPP that Gonyon Cosmetic and Plastic Surgery intends to  engage in: 
    1. for a health plan or health insurance issuer if PHI may be disclosed to a plan sponsor,
    2. for a health plan that will use or disclose PHI  for underwriting purposes, state that it is prohibited from using or disclosing PHI that is genetic information for such purposes
    3. fundraising communications, with the right to opt out . 
  1. Authorized Uses and Disclosures.  Gonyon Cosmetic and Plastic Surgery has stated that all other uses and disclosures will be made only with the individual’s authorization and that the individual has the right to revoke such authorization.
  2. Describe Individual Rights. Gonyon Cosmetic and Plastic Surgery has described individual’s rights under HIPAA and how individuals may exercise those rights as follows:
    1. The right to request restrictions on certain uses and disclosures, including a statement that Gonyon Cosmetic and Plastic Surgery is not required to agree to a requested restriction EXCEPT when a disclosure to a health plan is for 1) carrying out payment or health care operations and is not otherwise required by law, and 2) the PHI pertains solely to a health care item or service for which the requester has paid in full, All restrictions must be documented. The right to receive confidential communications of PHI
    2. The right to inspect and copy PHI
    3. The right to request amendments PHI
    4. The right to an accounting of disclosures or access report of PHI
    5. The right of an individual, including one who has agreed to receive the notice electronically, to obtain a paper copy of the notice upon request
  3. Describe Gonyon Cosmetic and Plastic Surgery’s Duties.  Gonyon Cosmetic and Plastic Surgery has stated that Gonyon Cosmetic and Plastic Surgery is are required by law to maintain the privacy of PHI, to provide a notice of their legal duties and privacy practices, and to abide by the terms of the notice currently in effect.  Additionally, Gonyon Cosmetic and Plastic Surgery has stated that Gonyon Cosmetic and Plastic Surgery reserves the right to change Gonyon Cosmetic and Plastic Surgery’s privacy practices and apply the revised practices to PHI previously created or received and has described how Gonyon Cosmetic and Plastic Surgery will provide individuals with a revised notice.
  4. Notify of Privacy Breaches: A statement that Gonyon Cosmetic and Plastic Surgery is required by law to maintain the privacy of PHI, provide individuals with notice of its legal duties and privacy practices with respect to PHI, and to notify affected individuals following a breach of unsecured PHI;
  5. Explain How to Make Complaints.  Gonyon Cosmetic and Plastic Surgery has informed individuals about how they can lodge complaints with the Gonyon Cosmetic and Plastic Surgery’s privacy officer or the Secretary of the U.S. Department of Health and Human Services if they believe their privacy rights have been violated and included a statement that the individual will not suffer retaliation for filing a complaint.
  6. Identify Contact Person.  Gonyon Cosmetic and Plastic Surgery has identified a point of contact Kayla COO 970-624-7979 where the individual can obtain additional information about any of the matters identified in the notice.
  7. Effective Date.  Gonyon Cosmetic and Plastic Surgery has included the date the notice went into effect. 

If Gonyon Cosmetic and Plastic Surgery revises Gonyon Cosmetic and Plastic Surgery’s privacy practices in a way that is inconsistent with Gonyon Cosmetic and Plastic Surgery’s NPP (in effect at the time), Gonyon Cosmetic and Plastic Surgery will revise the notice accordingly.  The revised privacy practices will not be implemented prior to the effective date of the revised notice.  Gonyon Cosmetic and Plastic Surgery will apply the revised practices to only that PHI is created or received under the revised notice.

Gonyon Cosmetic and Plastic Surgery will attempt to obtain a signed acknowledgement form from the patient when the NPP is provided the payment.  If the patient refuses to sign the acknowledgement form, it will be noted in the patient’s record.

Gonyon Cosmetic and Plastic Surgery , acting as a health plan will notify plan members of the availability of the NPP at least once every three years.  Notice will be provided via Gonyon Cosmetic and Plastic Surgery’s web site and via newsletter to plan members.

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IV PROCEDURE

  1. Gonyon Cosmetic and Plastic Surgery or a member of Gonyon Cosmetic and Plastic Surgery’s  workforce will provide the NPP upon request of any person.  The requestor does not have to be a current patient or enrollee.  The notice is a public document that people can use in choosing practitioners.
  2. The NPP will be provided to all Gonyon Cosmetic and Plastic Surgery patients upon the patient’s first visit or receipt of services.
  3. In an emergency treatment situation, Gonyon Cosmetic and Plastic Surgery or a member of Gonyon Cosmetic and Plastic Surgery’s workforce will provide the notice as soon as reasonably practicable after the emergency. 
  4. [if Gonyon Cosmetic and Plastic Surgery is a medical/insurance plan] Gonyon Cosmetic and Plastic Surgery will provide plan members a copy of the NPP upon enrollment and notify all plan members once every three years of the availability of the NPP.
  5. Gonyon Cosmetic and Plastic Surgery” will prominently post a copy of the NPP statement at all points of patient access to alert patients, plan members and other individuals that the NPP is available.
  6. Gonyon Cosmetic and Plastic Surgery or a member of Gonyon Cosmetic and Plastic Surgery’s workforce will make an additional copy of the NPP available on site for individuals to take on request. 
  7. In the event of a revision to the notice, Gonyon Cosmetic and Plastic Surgery will promptly post the revision, make it available upon request on site, and begin distributing it at the provision of care to new patients, returning patients or to patients who have not yet received a notice from your office as well as all plan members. 
  8. In the event of a revision to the notice, [if Gonyon Cosmetic and Plastic Surgery is a medical/insurance plan] Gonyon Cosmetic and Plastic Surgery will prominently post the change or its revised notice on its web site with  the effective date and provide the revised notice, or information about the change and how to obtain the revised notice, in its next annual mailing to plan members. If the notice is not posted, Gonyon Cosmetic and Plastic Surgery must provide the revised notice, or information about the change and how to obtain the revised notice, to plan members  within 60 days of the revision.
  9. Gonyon Cosmetic and Plastic Surgery has made Gonyon Cosmetic and Plastic Surgery’s NPP available on Gonyon Cosmetic and Plastic Surgery’s web site and the NPP is prominently posted. 
  10. Gonyon Cosmetic and Plastic Surgery will retain copies of every version of NPP issued for a minimum of six years.
  11. All Gonyon Cosmetic and Plastic Surgery direct care providers make an effort to obtain the patient’s written acknowledgment that he or she received a copy of NPP on the patient’s first visit to the office.  See Notice of Privacy Practices Acknowledgement form.

DEFINITIONS:

Gonyon Cosmetic and Plastic Surgery Privacy Officer: the individual appointed by Gonyon Cosmetic and Plastic Surgery to be the HIPAA Privacy Officer under s. 164.530(a)(1) of the HIPAA Privacy Rule.

HIPAA: Health Insurance Portability and Accountability Act of 1996

Electronic Protected Health Information (ePHI): Electronic health information or health care payment information, including demographic information collected from an individual, which identifies the individual or can be used to identify the individual. ePHI does not include students records held by educational institutions or employment records held by employers, or records for persons deceased for over 50 years.

Individually Identifiable Health Information (IIHI): Information that is a subset of health information, including genetic information and demographic information collected from an individual, and:

  • Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
  • Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and
  • That identifies the individual; or
  • With respect to which there is a reasonable basis to believe the information can be used to identify the individual.

Protected Health Information (PHI): Individually identifiable health information or health care payment information maintained or transmitted in any medium, including demographic information collected from an individual, which identifies the individual or can be used to identify the individual. PHI does not include students records held by educational institutions or employment records held by employers, or records for persons deceased for over 50 years.

Related Policies:

Reference:

Gonyon Cosmetic and Plastic Surgery Confidentiality Agreement

HIPAA Final Privacy Rule, 45 CFR Parts 160 and 164, Department of Health and Human Services, http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/privruletxt.txt, August 14, 2002.

HIPAA Omnibus Rule, revisions to 45 CFR Parts 160, and 164, Department of Health and Human Services, http://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdf, January 25, 2013.