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.
Notice Regarding Privacy of Personal Health Information
Understanding Your Facets Medical Dayspa Health Record Information
Federal regulations developed under the Health Insurance Portability and Accountability Act (HIPAA) requires that Facets Medical Dayspa provide you with this Notice Regarding Privacy of Personal Health Information. The Notice describes (1) how Facets Medical Dayspa may use and disclose your protected health information, (2) your rights to access and control your protected health information in certain circumstances, and (3) Facets Medical Dayspa’s duties and contact information.
I. Protected Health Information
“Protected Health Information” is health information created or received by your health care provider that contains personal information that may be used to identify you, such as demographic data. It includes written or oral health information that relates to your past, present, or future physical or mental health; the provision of health care to you; and your past, present, or future payment for health care.
II. The Use and Disclosure of Protected Health Information in Treatment, Payment, and Health Care Operations
Each time you visit a hospital, a physician, or another health and healing provider, the provider makes a record of your visit. Typically, this record contains your health history, current symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment. This information, often referred to as your medical record, may be used in the course of providing treatment, obtaining payment for treatment, and conducting health care operations.
Treatment. Facets Medical Dayspa may use and disclose your protected health information in the course of the following:
• Basis for planning your care and treatment.
• Means of communication among the many health professionals who contribute to your care.
• Legal document describing the care that you received.
Payment. When needed, Facets Medical Dayspa will use or disclose your protected health information for the following;
• Means by which you or a third-party payer can verify actual services received and billed for
requests by health insurance companies to demonstrate medical necessity, or for utilization
review purposes.
Health Care Operations. Facets Medical Dayspa may use or disclose your protected health information for management and administrative purposes, and to offer quality health care. This may include the following:
• Tool in medical education.
• Source of information for public health officials charged with improving the health of the regions
they serve.
• Tool to assess the appropriateness and quality of care that you received.
• Tool to improve the quality of health care and achieve better patient outcomes.
• Accreditation, certification, licensing, or credentialing activities.
• Reviews and audits such as compliance reviews, medical reviews, legal services, and
maintaining compliance programs.
• Business management and general administrative activities.
Other Uses and Disclosures. As part of treatment, payment, and healthcare operations, Facets Medical Dayspa may also use or disclose your protected health information to: (1) remind you of an appointment or to schedule a phone appointment with one of our health professionals including leaving appointment reminder information on your telephone answering machine; (2) inform you of potential treatment alternatives or options; or (3) communication to your physician and other healthcare professionals after you have left the care of our Facets Medical Dayspa professionals.
Understanding what is in your health records and how your health information is used helps you to:
• Ensure its accuracy and completeness.
• Understand who, what, where, why, and how others may access your health information.
• Make informed decisions about authorizing disclosure to others.
• Better, understand the health information rights detailed below.
III. Your Rights under the Federal Privacy Standard
Although your health records are the physical property of the health care provider who completed it, you have the following rights with regard to the information contained therein:
• Request restriction on uses and disclosures of your health information for treatment, payment,
and health care operations. “Health care operations” consist of activities that are necessary to
carry out the administrative and management duties of the providers. We do not, however, have
to agree to the restriction. If we do, we will adhere to it unless you request otherwise or we give
you advance notice. The right to request restriction does not extend to uses or disclosures
permitted or required under the following sections of the federal privacy regulations:
§ 164.502(a)(2)(i) (disclosures to you), 164.510(a) (for facility directories, but note that you
have the right to object to such uses), or 164.512 (uses and disclosures not requiring a consent
or an authorization). The latter uses and disclosures include, for example, those required by
law, such as mandatory communicable disease reporting. You may also ask us to communicate
with you by alternate means, and if the method of communication is reasonable, we must grant
the alternate communication request. You may request restriction or alternate communications
for treatment, payment, and health care operations.
• Obtain a copy of this notice of information practices. Although we have posted a copy in
prominent locations throughout the facility and on our website, you have a right to a hard copy
upon request.
• Inspect and copy your health information upon request. Again, this right is not absolute. In
certain situations, such as if access would cause harm, we can deny access. You do not have
a right of access to the following:
o Counseling notes. Such notes consist of those notes that are recorded in any medium
by a health care provider who is a mental health professional documenting or analyzing
a conversation during a private, group, joint, or family counseling session and that are
separated from the rest of your medical record.
o Information compiled in reasonable anticipation of or for use in civil, criminal, or
administrative actions or proceedings.
o Protected health information (“PHI”) that is subject to the Clinical Laboratory
mprovement Amendments of 1988 (“CLIA”), 42 U.S.C. § 263a, to the extent that giving
you access would be prohibited by law.
o Information that was obtained from someone other than a health care provider under
a promise of confidentiality and the requested access would be reasonably likely to
reveal the source of the information.
In other situations, we may deny you access, but if we do, we must provide you a review of
our decision denying access. These “reviewable” grounds for denial include the following:
o A licensed healthcare professional, such as your attending physician, has determined,
in the exercise of professional judgment, that the access is reasonably likely to
endanger the life or physical safety of yourself or another person.
o PHI makes reference to another person (other than a health care provider) and a
licensed health care provider has determined, in the exercise of professional judgment
that the access reasonably likely to cause substantial harm to such other person.
o The request is made by your personal representative and a licensed health care
professional has determined, in the exercise of professional judgment, that giving
access to such personal representative is reasonably likely to cause substantial harm
to you or another person.
For these reviewable grounds, another licensed professional must review the decision of
the provider denying access within 60 days. If we deny you access, we will explain why and
what your rights are, including how to seek review. If we grant access, we will tell you what, if
anything, you have to do to get access. We reserve the right to charge a reasonable, cost-
based fee for making copies.
• Request amendment/correction of your health information. We do not have to grant the request if
the following conditions exist:
o We did not create the record. If, as in the case of a consultation report from another
provider, we did not create the record, we cannot know whether it is accurate or not.
Thus, in such cases, you must seek amendment/correction from the party creating the
record. If the party amends or corrects the record, we will put the corrected record into
our records.
o The records are not available to you as discussed immediately above.
o The record is accurate and complete.
If we deny your request for amendment/correction, we will notify you why, how you can attach
a statement of disagreement to your records (which we may rebut), and how you can register
a concern. If we grant the request, we will make the correction and distribute the correction to
those who need it and those whom you identify to us that you want to receive the corrected
information.
• Obtain an accounting of non-routine uses and disclosures, those other than for treatment,
payment, and health care operations. We do not need to provide an accounting for the
following disclosures:
o To you for disclosures of protected health information to you.
o For the facility directory or to persons involved in your care or for other notification
purposes as provided in the federal privacy regulations.
o For national security or intelligence purposes under § 164.512(k)(2) of the federal
privacy regulations (disclosures not requiring consent, authorization, or an opportunity
to object).
o To correctional institutions or law enforcement officials under § 164.512(k)(5) of the
federal privacy regulations (disclosures not requiring consent, authorization, or an
opportunity to object).
o That occurred before April 14, 2003.
We must provide the accounting within 60 days. The accounting must include the following
information:
o Date of each disclosure.
o Name and address of the organization or person who received the protected
health information.
o Brief description of the information disclosed.
o Brief statement of the purpose of the disclosure that reasonably informs you of the basis
for the disclosure or, in lieu of such statement, a copy of your written authorization or
a copy of the written request for disclosure.
The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge
a reasonable, cost-based fee.
• Revoke your consent or authorization to use or disclose health information except to the extent
that we have taken action in reliance on the consent or authorization.
IV. Our Responsibilities under the Federal Privacy Standard
In addition to providing you your rights, as detailed above, the federal privacy standard requires us to take the following measures:
• Maintain the privacy of your health information, including implementing reasonable and
appropriate physical, administrative, and technical safeguards to protect the information.
• Provide you this notice as to our legal duties and privacy practices with respect to individually
identifiable health information that we collect and maintain about you.
• Abide by the terms of this notice.
• Train our personnel concerning privacy and confidentiality.
• Implement a sanction policy to discipline those who breach privacy/ confidentiality or our
policies with regard thereto.
• Mitigate (lessen the harm of) any breach of privacy/confidentiality.
We will not use or disclose your health information without your consent or authorization, except as described in this notice or otherwise required by law.
WE RESERVE THE RIGHT TO CHANGE OUR PRACTICES AND TO MAKE THE NEW PROVISIONS
EFFECTIVE FOR ALL INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION THAT WE MAINTAIN.
IF WE CHANGE OUR INFORMATION PRACTICES, WE WILL MAIL A REVISED NOTICE TO THE
ADDRESS THAT YOU HAVE GIVEN US.
V. How to Get More Information or to Report a Problem
If you believe your privacy rights have been violated, you have the right to forward complaints to the Secretary of the Department of Health and Human Services. Complaints may be provided verbally or in writing. Complaints or questions may be also be directed to our privacy officer. If you have questions and/or would like additional information, you may contact the privacy officer at the following address and telephone number:
Privacy Officer
Facets Medical Dayspa
9623 Windermere Blvd
Suite F
Fishers, Indiana 46037
ATTN: Privacy Officer
Telephone 1-317-595-0400
Effective date: January 1 2006
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