THE CENTER FOR FACIAL PLASTIC & LASER SURGERY

Our HIPPA- Privacy Policy

The Forum @ Ballantyne

Commons, 11220 Elm Lane, Suite 101, Charlotte, NC 28277

TO OUR PATIENTS: NOTICE OF PRIVACY PRACTICES

This notice describes how health information about you, as a patient of The
Center for Facial Plastic Surgery, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the
Health Insurance Portability and Accountability Act of 1996, (HIPAA).

OUR COMMITMENT TO YOUR PRIVACY

The Center for Facial Plastic & Laser Surgery is dedicated to maintaining the privacy
of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the followingimportant information.

USES AND DISCLOSURE OF YOUR HEALTH INFORMATION IN CERTAIN SPECIAL
CIRCUMSTANCES

The following circumstances may require us to use or disclose your health
information:

  • To public health authorities
    and health oversight agencies that are authorized by law to collect information.
  • Lawsuits and similar
    proceedings in response to a court or administrative order.
  • If required to do so by a
    law enforcement official.
  • When necessary to reduce or
    prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
  • If you are a member of U.S.
    or foreign military forces (including veterans) and if required by the appropriate authorities.
  • To federal officials for
    intelligence and national security activities authorized by law.
  • To correctional institutions
    or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
  • For Workers Compensation or
    similar programs.

YOUR RIGHTS REGARDING YOUR HEALTH
INFORMATION

  • Communications: You can request that Center
    for The Facial Plastic Surgery communicate with you about your health and related issues in a particular manner or
    at a certain location. For instance, you may ask that we contact you at home, rather
    than at work. We will accommodate reasonable requests.
  • You can request a restriction in our use or
    disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are
    not required to agree to your request; however, if we do agree, we are bound by our
    agreement except when otherwise required by law, in emergencies, or when the
    information is necessary to treat you.
  • You have the right to inspect and obtain a
    copy of the health information that may be
    used to make decisions about you, including patient medical records and billing records,
    but not including psychotherapy notes. You must submit your request in writing to: The
    Center for Facial Plastic & Laser Surgery, 11220 Elm Lane, Suite 101,
    Charlotte, NC 28277    , ATTN: Helen Mundy.
  • You may ask us to amend your health
    information if you believe it is incorrect or
    incomplete, and as long as the information is kept by or for our practice. To request and
    amendment, your request must be made in writing and submitted to: The Center for
    Facial Plastic & Laser Surgery, 11220 Elm Lane, Suite 101, Charlotte, NC 28277, ATTN: Helen Mundy.

You must provide us with a reason that
supports your request for the amendment.

  • Right to a copy of this notice. You are
    entitled to receive a copy of the Notice of Privacy
    Practices. You may ask us to give you a copy of this Notice at any time. To obtain a
    copy of this notice, contact our front desk receptionist.
  • Right to file a complaint. If you believe
    that your privacy rights have been violated, you
    may file a complaint with our practice or with the Department of Health and Human
    Services. To file a complaint with our practice, contact: The Center for Facial Plastic & Laser Surgery, 11220 Elm Lane, Suite 101, Charlotte, NC 28277, ATTN:
    Helen Mundy.

All complaints must be submitted in
writing. You will not be penalized or otherwise retaliated
against for filing a complaint.

  • Right to provide an authorization for other
    uses and disclosures. Our practice will obtain
    your written authorization for uses and disclosures that are not identified by this notice
    or permitted by applicable law.

If you have any questions regarding this
notice or our health information privacy policies, please
contact: The Center for Facial Plastic & Laser Surgery, 11220 Elm Lane, Suite
101, Charlotte, NC 28277, ATTN: Helen Mundy.

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