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.

Effective Date of this Notice:

September 28, 2012


Effective Date of Last Revision:

September 28, 2012


This Notice of Privacy Practices describes the practices of Connecticut Skin Institute and applies to the following service delivery sites listed below:

999 Summer St., Suite 305, Stamford, CT 06902

The provision of this notice by one of these entities satisfies the provision requirements of all entities covered by this notice. The entities covered by this notice are referred to, collectively, as the “covered entities.”

Our Commitment to Protect Your Personal Health Information

We understand the importance of privacy, and are committed to maintaining the confidentiality of your medical information. Our office creates and maintains a record of the medical care we provide to you and we may also receive such records from others. These records may contain demographic information or information that relates to your present, past or future physical or mental health and related services. Any information that can be identified with you is called “protected health information.” We may use your protected health information to provide or enable other healthcare providers to provide quality medical care, to obtain payment for services provided to you and to enable us to operate our healthcare facilities.

Our Legal Duty to Protect Your Health Information

A federal regulation known as the HIPAA Privacy Rule requires us to:
Maintain the privacy of your protected health information
Provide you with this Notice which describes our legal duties and privacy practices with respect to your private health information
Comply with the terms of our Notice of Privacy Practices, as currently in effect
This Notice of Privacy Practices describes the ways that we may use and disclose health information about you whether created by us in our practice or received by us from another healthcare provider. This notice also describes your rights and certain duties we have regarding the use and disclosure of your medical information.

Changes to this Notice of Privacy Practices

We reserve the right to make changes to this Notice and to make such changes effective for all protected health information we may already have about you or may create or receive in the future. If and when this notice is changed, we will:

Post the revised Notice of Privacy Practices in our reception area at each office in a prominent location with the new effective date
Provide you with a copy of the revised Notice of Privacy Practices upon your request
Post the revised Notice of Privacy Practices on our website www.ctskindoc.com

How We May Use and Disclose Your Protected Health Information

We May Use and Disclose Your Protected Health Information For Treatment, Payment or Healthcare Operations

We may use and disclose your protected health information to provide treatment to you, to obtain payment for services rendered to you and for healthcare operations.

FOR TREATMENT

We may use and disclose your protected health information to provide medical treatment and to coordinate and manage your healthcare and other related services. For example, your health information may be shared among and between the covered entities, as well as disclosed to other healthcare providers involved in your care such as another physician or healthcare provider who provide services which we do not provide, or a pharmacist who needs your information in order to dispense a prescription to you. We may also disclose your protected health information to providers or facilities who may be involved in your care after you leave our facility or our care.

FOR PAYMENT

We may use and disclose your protected health information so that we can bill and collect payment for the treatment and services provided to you. For billing and payment purposes, your private health information may be shared among and between the covered entities, with your health plan, another health care provider, a third party administrator, collection agency or any party involved in billing, claims management and collection activities. For example, we may inform your health plan about treatment that we intend to provide to you so that we can obtain the appropriate approvals and/or to confirm coverage for your treatment so we can be paid for the services we provide.

FOR HEALTHCARE OPERATIONS

We may use and disclose your protected health information as is necessary while performing business activities which are referred to as “healthcare operations.” Healthcare operations include some of the administrative tasks that allow us to run our practice and improve the quality of care we provide to you. For example, we may use and disclose your protected health information among and between the covered entities, as well as with others for the following health care operations: reviewing and improving the quality of care that we provide our patients; identifying groups of patients who have similar health problems to give them information about treatment alternatives, programs or new procedures; providing training programs for students, trainees, healthcare providers, or non healthcare professionals; cooperating with outside organizations that assess the quality of the care that we provide; cooperating with outside organizations that evaluate, certify, or license healthcare providers or staff in a particular field or specialty; cooperating with various people who review our activities such as accountants, lawyers, and others who assist us with the business management and general administrative activities of our practice, including managing our activities related to complying with the HIPAA Privacy Rule and other legal requirements. Additionally, if another healthcare provider, company, or health plan that is required to comply with the HIPAA Privacy Rule has or once had a relationship with you, we may disclose your protected health information for certain health care operations of that healthcare provider or company.

Communications While In Our Office or From Our Office
APPOINTMENT REMINDERS

We may use or disclose your protected health information to contact or remind you about appointments you have with our practice or appointments we have scheduled for you with other healthcare providers. If you are not home, we may leave this information with the person answering the phone or on your answering machine. We may also utilize electronic means of communication including e-mail and text messaging services.

RECEPTION AREA

We may ask you to sign in when you arrive at our office. We may also call out your name when we are ready to see you.

TREATMENT AREAS

We may use and disclose your health information while communicating and providing healthcare services to you in areas that are shared by patients receiving similar services i.e. MOHS and Cosmetic waiting areas.

TREATMENT ALTERNATIVES AND HEALTH-RELATED BENEFITS AND SERVICES

We may use or disclose your protected health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you.

INCIDENTAL DISCLOSURES

In the process of using your protected health information in the course of treatment, payment and healthcare operations, we may make incidental disclosures. We will take reasonable steps to limit those situations that cannot be reasonably prevented.

Uses and Disclosures of Your Protected Health Information We May Make Without Your Written Authorization Unless You Object

We may use and disclose your protected health information in some situations where you have the opportunity to agree or object. If you do not object, then we may make the following types of uses and disclosures. If you do object, you must notify us in writing by contacting the Privacy Official who is listed in this notice.

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE

Unless you object, we may disclose protected health information about you to a family member, relative, close personal friend, caregiver, neighbor or other person(s) you identify, including clergy, who are involved in your care. These disclosures are limited to information relevant to the person’s involvement in your care or in payment for your care.

DISASTER RELIEF

Unless you object, we may disclose protected health information about you to a public or private organization (like the American Red Cross) assisting in a disaster relief effort. Even if you object, we may still share information about you, if necessary for the emergency circumstances.

Other Uses and Disclosures We Can Make Without Your Written Authorization

We may use and disclose your protected health information in the following situations without your written authorization.

REQUIRED BY LAW

We may use or disclose your protected health information when required to do so by law and will limit our use or disclosure to the relevant requirements of the law. For example, if the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will disclose the information required.

PUBLIC HEALTH ACTIVITIES

We may disclose your protected health information to a public health authority that is authorized by law to collect or receive such information for purposes including preventing or controlling disease, injury, or disability; to report disease, injury, birth, or death; to report child abuse or neglect; to report reactions to medications or problems with products or devices regulated by the federal FDA or other activities related to qualify, safety, or effectiveness of FDA regulated products or activities: to locate and notify persons of recalls of products they may be using; to notify a person who may have been exposed to a communicable disease in order to control who may be at risk of contracting or spreading the disease; or to report to your employer, under limited circumstances, information related primarily to workplace injuries or illness, or workplace medical surveillance.

REPORTING VICTIMS OF ABUSE, NEGLECT OR DOMESTIC VIOLENCE

When authorized by law or if you agree to the report and if we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your protected health information to notify a government authority.

HEALTH OVERSIGHT ACTIVITIES

We may disclose your protected health information to a health oversight agency for oversight activities including, for example, audits, investigations, inspections, licensure and disciplinary activities and other activities conducted by oversight agencies to monitor the health care system, government health care programs, and compliance with certain laws.

JUDICIAL AND ADMINISTRATIVE PROCEEDINGS

We may disclose your protected health information in response to a court or administrative order. We also may disclose protected health information in response to a subpoena, discovery request, or other lawful process that meets the requirements of the HIPAA Privacy Rule.

LAW ENFORCEMENT

We may disclose your protected health information for certain law enforcement purposes, including, but not limited to: reporting certain types of wounds and/or other physical injuries (i.e. gunshot wounds); reports required by law; reporting emergencies or suspicious deaths; complying with a court order, warrant, subpoena, or other legal process; identifying or locating a suspect or missing person, material witness or fugitive; answering certain requests for information concerning crimes, about the victim of crimes; reporting and/or answering requests about a death we believe may be the result of a crime; reporting criminal conduct that took place on our premises; and in emergency situations to report a crime, the location of the crime or victim or the identity, description and/or location of a person involved in the crime.

CORONERS, MEDICAL EXAMINERS, FUNERAL DIRECTORS

We may disclose your protected health information to a coroner or medical examiner for the purpose of identifying you or determining the cause of death and to funeral directors, as authorized by law, so that they may carry out their duties with respect to your funeral arrangements.

ORGAN/EYE OR TISSUE DONATION ORGANIZATIONS

If you are an organ donor, we may release your protected health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.

RESEARCH

Under certain limited circumstances, your protected health information may be used for research purposes if an institutional review board has approved the research. The institutional review board must have established procedures to insure that your protected health information remains confidential.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY

We may use or disclose your protected health information in limited circumstances when necessary to prevent a threat to your health or safety or the health and safety of another person or to the public. This disclosure can only be made to a person who is able to help prevent the threat.

SPECIALIZED GOVERNMENT FUNCTIONS

We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.

WORKERS COMPENSATION

We may use or disclose our protected health information to comply with laws and regulations relating to workers compensation or similar programs established by law that provide benefits for work-related injuries and/or illnesses.

BUSINESS ASSOCIATES

We may disclose your protected health information to our business associates who perform healthcare operations on our behalf under a Business Associate Agreement. These business associates are required to protect the confidentiality of your health information.

Any Other Use or Disclosure of Your Protected Health Information Requires Your Written Authorization

All other uses or disclosures of your protected health information, outside of those listed above, will only be made with your written authorization. The Authorization will describe the particular health information to be used or disclosed and the purpose of the use or disclosure. The Authorization will also specify the name of the person or entity to which the health information is being disclosed, and it will be limited to an expiration date or event. If you sign an authorization allowing us to disclose protected health information about you in a specific situation, you can later revoke (cancel) your authorization in writing. If you cancel your authorization in writing, we will not disclose your protected health information after we receive your cancellation, except for disclosures which were already being processed or made before we received your cancellation.

Disclosure of Psychiatric, Substance Abuse and HIV-Related Information

For uses and disclosures of your protected health information related to care for psychiatric conditions, substance abuse, or HIV-related information, special conditions may apply. For example, we generally may not disclose this specially protected information in response to a subpoena, warrant or other legal process unless you sign a special authorization or if a court orders the disclosure. A general release of your protected health information will not be sufficient for purposes of disclosing psychiatric, substance abuse or HIV-related information.

PSYCHIATRIC INFORMATION

We will not disclose records relating to a diagnosis or treatment of your mental condition between you and a psychiatrist or psychologist without specific written authorization or as required or permitted by law.

HIV-RELATED INFORMATION

HIV-related information will not be disclosed, except under limited circumstances set forth under state or federal law, without your specific written authorization.

SUBSTANCE ABUSE TREATMENT

If you are treated in a substance abuse program, information which could identify you as alcohol or drug-dependent will not be disclosed without your specific authorization except for purposes of treatment or payment or when specifically required or allowed under state or federal law.

Your Individual Rights Regarding Your Protected Health Information

Under federal law, you have certain rights with respect to your protected health information that we maintain. The following is a description of your rights and our duties with respect to enforcing those rights.

THE RIGHT TO ACCESS YOUR PERSONAL PROTECTED HEALTH INFORMATION

Upon written request, you have the right to inspect and receive a copy of your protected health information maintained by our office except under certain limited circumstances. If you request a copy of your medical record, we may charge you a reasonable fee for the copying. Under state law, we will not charge you more than is permitted by the current rate allowed by state law for copies. We may also charge you a reasonable fee for x-rays, mailings and other supplies and labor related to this request. To inspect or request a copy of your protected health information please contact our Privacy Official who is listed in this Notice.

Your request to inspect or receive copies of your protected health information may be denied in certain limited circumstances. If you are denied access to your protected health information, in some cases you will have the right to request a review of this denial. A licensed healthcare professional designated by our practice and who did not participate in the original decision to deny access will perform this review.

THE RIGHT TO REQUEST RESTRICTIONS

You have the right to request restrictions on the protected health information that we may use or disclose for treatment, payment or healthcare operations. Additionally, you can request that we limit the information we disclose about you to those individuals involved in your care or the payment of your services, such as a relative or friend that otherwise are permitted by the Privacy Rule. For example, you could request that we not disclose information about a procedure you had performed by one of our physicians.

To request restrictions, you must submit your request in writing to our Privacy Official who is listed in this Notice. You must tell us what information you want restricted, to whom you want the information restricted, and whether you want to limit our use, disclosure, or both.

We are not required to agree to such a restriction however, if we do agree to the restriction, we will honor that restriction except in the event of an emergency and will only disclose the restricted information to the extent necessary for your emergency treatment.

THE RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS

You have the right to request that we communicate with you concerning your health matters in a certain manner or at a certain location. For example, you can request that we contact you at a certain phone number or a specific address.

You must submit your written request for Confidential Communications to our Privacy Official who is listed in this Notice. You must tell us how and where you want to be contacted (for example, by regular mail to your post office box and not your home).

We will accommodate any request that is reasonable, but may deny the request if you are unable to provide us with appropriate methods of contacting you.

THE RIGHT TO REQUEST AN AMENDMENT

You have the right to request that our office amend your protected health information as long as such information is kept by us. To make this type of request you must submit your request in writing to our Privacy Official listed in this notice and must explain your reasons for the requested amendment.

We may deny your request for amendment if the information: was not created by us (unless you prove the creator of the information is no longer available to amend the record); is not part of the records maintained by us; in our opinion, is accurate and complete; is information to which you do not have a right of access.

If we deny your request for amendment, we will give you a written denial notice. The denial notice will explain the reason for the denial, your individual right to submit a written statement disagreeing with the denial, and how to file such a statement. A copy of the disagreement statement will be attached to your medical record.

THE RIGHT TO AN ACCOUNTING OF DISCLOSURES

You have the right to request an accounting (a report) of certain disclosures of your protected health information made by our medical practice or made by others on our behalf. You may ask for disclosures made up to six years. We are not required to include disclosures: made for treatment, payment, or health care operations; made directly to you, that you authorized, or those which are made to individuals involved in your care; allowed by law when the use or disclosure relates to certain government functions or in other law enforcement custodial situations, and/or; occurred prior to April 14, 2003 (the HIPAA Privacy Rule compliance deadline).

Requests for an accounting of disclosures must be submitted in writing to the Privacy Official listed in this Notice. The request must state the time period for which you would like the accounting. The accounting will include the disclosure date, the name and address (if known) of the person or entity that received the information, a brief description of the information disclosed, and a brief statement of the purpose of the disclosure. If you request a listing of disclosures more than once within a 12-month period, we will charge you a reasonable fee for the accounting. The first accounting, within a 12-month period, is provided to you at no charge. We will inform you of the costs involved in the event that you wish to withdraw your request.

THE RIGHT TO A PAPER COPY OF THIS NOTICE

You have the right to obtain a paper copy of this Notice at any time. You are entitled to a paper copy of this Notice even if you have previously agreed to receive this Notice electronically. You may request a copy of this Notice by contacting our office in writing or by telephone. In addition, you may obtain a copy of this Notice at our website, www.ctskindoc.com.

Complaints

If you believe that your privacy rights have been violated, you may file a complaint in writing with our office or with the government.

To file a complaint with our office, please contact our privacy official at the address and telephone number listed below.

To file a complaint with the government, please contact:

Office for Civil Rights
U.S. Department of Health and Human Services
JFK Federal Building-Room 1875
Boston, MA 02203
You will not be retaliated against for filing a complaint.

Contact Information

If you have any questions about this Notice, please contact our Privacy Official at the following address and telephone number:

Privacy Official/Office Manager
Connecticut Skin Institute
999 Summer Street, Suite 305
Stamford, CT 06905
(203) 428-4440


Disclaimer:
*Results may vary depending on the individual.