Statement of Privacy Practices

Our Statement of Privacy Practices is currently in effect and provides information about the use and disclosure of protected health information by La Belle Vie Cosmetic Surgery Center and our employees. It is applicable in all instances wherein individually identifiable health information is col- lected from you and services are provided for you. Our Statement:

1. Defines your rights and our obligations when using your health Information
2. Informs you about laws that provide special protections
3. Explains how your protected health information is used and how, under certain circum-stances, it may be disclosed
4. Tells you how changes in this statement will be made available to you

In synopsis form, you have a right to:

1. Request restricted use of your health information. (Please understand that we may not agree to your request)
2. Request that we not disclose to your health plan of services for which you self-pay in full
3. Request that we communicate with you by alternate methods
4. Review and receive copies of your personal health record
5. Request for amendments and/or changes be made to your record
6. Request an accounting of disclosures of your health information
7. File complaints related to failure to protect of privacy of your healthinformation
8. Direct us not to share information with your family members
9. Request that you not be listed in/on our facility directory

It is important that you know not only that we limit requests for your personal information to that needed to provide quality health care, implement payment activities, and conduct normal health practice operations, but understand what “Protected Healthcare Information” is. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, and/or any personal information that is unique to you.

While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.

Use and Disclosure of your PHI

As stated above we may, under allowed circumstances use and disclose protected health infor- mation (PHI) without your specific authorization. Examples of such instances are included below:

Treatment

We may use and disclose your PHI to provide treatment. For example, we can:

1. Use your information to find out whether certain tests, therapies, and medicines should be ordered
2. Provide your information to staff members to better understand what your healthcare needs are how to evaluate your response to treatment
3. Disclose your PHI to another one of your treatment providers in the in order to provide you with the best possible health care

Payment

We may use your health information for payment purposes. Such instances may include:

1. Preparation of claims for payment of services
2. Billing your insurance directly, including information that identifies you, as well as your diagnosis, the procedures performed, and supplies used so that we can be paid for the treatment provided
3. Collection activities (if necessary) to obtain payment for services

Health Care Operations

We may use and disclose your health information to support the daily activities related to health care. Examples include:

1. Use and disclosure to monitor and improve our health services
2. Use by authorized staff to review at portions of your record to perform administrative activities

Train Staff and Students

We may use and disclose your information to teach and train staff how to review patient health information.

Contact You for Information

Your PHI may also be used to contact you. In example, we may call you or send you a letter to remind you about your appointment, provide test results, inform you about treatment options, or advise you about other health-related benefits and services.

Business Associates

Your PHI may be used by the La Belle Vie Cosmetic Surgery Center and dis- closed to individuals, organizations, or companies that us or to comply with our legal obligations as described in this Notice. An example is disclosure of your PHI to consultants, attorneys or third parties to assist in our business activities. All such entities must sign a Business Associate Agreement to protect the confidentiality of your private information.

Your PHI may also be used to contact you. In example, we may call you or send you a letter to remind you about your appointment, provide test results, inform you about treatment options, or advise you about other health-related benefits and services.

Disclosure to Family, Friends, or Others. You may object to our disclosing your general health condition (“good”, “fair”, “critical”, etc.) to an individual, or individuals, you have identified who have an active interest in your care, payment for your health care, or who may need to notify others about your general condition, location, or death. If you do not so indicate, we will use our best professional judgment to provide relevant protected health information to your family member, friend, or another identified person.

The right to request restricted use

You may request in writing that we not use or disclose your information for treatment, payment, and/or operational activities except when authorized by you, when required by law, or in emergency circumstances. We are not legally required to agree to your request. If you request that we restrict the use of your private information, we will provide you with written notice of our decision about your request.

The right to request non-disclosure to health plans

You have the right to request in writing that health care items or services for which you self-pay for in full in advance of your visit not be disclosed to your health plan.

The right to receive confidential communications

You have the right to request that we communicate with you about medical matters in a particular way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the address above. We will grant all reasonable requests. Your request must specify how or where you wish to be contacted.

The right to inspect and receive copies

In most cases, you have the right to inspect and receive a copy of certain health care information including certain medical and billing records. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

The right to request an amendment to your record

If you believe that information in your record is incorrect or that important information is missing, you have the right to request in writing that we make a correction or add information. In your request for the amendment, you must give a reason for the amendment. We are not required to agree to the amendment of your record, but a copy of your request will be added to your record.

The right to know about disclosures

You have the right to receive a list of instances in which we have disclosed your health information. Certain instances will not appear on the list, such as disclosures for treatment, payment, or health care operations or when you have authorized the use or disclosure. Your first accounting of disclosures in a calendar year is free of charge. Any additional request within the same calendar year requires a processing fee.

The right to make complaints

If you believe that we have violated your privacy, or you disagree with a decision we made about access to your records, you may file a complaint directly to Dr. Mangubat using the contact information above. Neither Dr. Mangubat, nor any employee of La Belle Vie Cosmetic Surgery Center will retaliate against anyone for filing a complaint.

You May Also Contact

U.S. Department of Health and Human Services, Office for Civil Rights: 2201 Sixth Avenue – Mail Stop RX-11 Seattle, WA 98121-1831 206-615-2290; 206-615-2296 (TTY) 206-615-2297 (fax) Toll free: 1-800-362-1710; 1-800-537-7697 (TTY)

If it is found that your patient information is used or disclosed in a manner that is not consistent with the practices described in this notice, La Belle Vie Cosmetic Surgery Center will fully investigate the matter to assess if there was a breach in the protection of your PPE.

The assessment will be conducted to determine whether the information that was used or disclosed has significant risk of physical, financial, or reputational harm to you. If so, La Belle Vie Cosmetic Surgery Center will notify you and Health and Human Services in writing.

We are required by law to protect the privacy of your information, to provide this Statement of Pri- vacy Practices and to follow the privacy practices that are described herein. We reserve the right to change the privacy practices described and the right to make the revised or changed State ment effective for protected health information we already have as well as any information we may receive in the future.

We have posted a copy of our current Statement for your review and reference. Additionally, each time you visit our office for treatment or health care services, you may request a copy of our current Statement of Privacy Practices. An electronic version of the notice is available here.