NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
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.
Plastic Surgical Associates is required by law to
maintain the privacy of your medical information and to
provide you with notice of its legal duties and privacy
practices with respect to this information. The purpose
of this notice is to provide you with that information.
Any information that is about your health, the health
care you receive, or payment for that care is considered
confidential and protected by the Practice. We are
required to abide by the terms of the notice that is
currently in effect at the time your medical information
is used or disclosed.
We reserve the right to change the terms of this notice
and to make the new notice provisions effective for all
medical information that we maintain. We will post a
copy of the current notice in our office. In addition,
each time you come to the Practice for treatment or
health care services, you may request a copy of the
current notice in effect.
SECTION A – We may use and disclose your
medical information for purposes of treatment, payment
and health care operations.
The following is a description and example of the ways
in which we may use and disclose your medical
For Treatment: We may provide medical
information about you to health care providers, other
Practice personnel, or third parties who are involved in
the provision, management or coordination of your care.
• Health care Professionals: Your medical
information will be shared among physicians and
nurses involved in your care.
• Appointment Reminders: We may use and disclose
medical information to provide appointment reminders
or information about treatment alternatives or other
For Payment: We may use or
disclose your medical information so that we can collect
or make payment for the health care services you receive
or are going to receive. For example:
• Insurance: If you participate in a health
insurance plan, we will disclose necessary
information to that plan to obtain preauthorization,
if required, or payment for your care.
We may also disclose your medical information to
another health care provider, a health plan, or a
health care clearinghouse for the payment activities
of that entity.
For Health Care Operations:
We may use or disclose your medical information for our
activities and operations. These uses and disclosures
are necessary to run our practice and to make sure that
all of our patients receive quality care. For example:
• Quality Improvement: We may use or disclose
your medical information to review quality of care
or competence of health care providers.
• Sale: We may need to disclose your medical
information if we ever sell or transfer our
For quality-related or fraud and abuse activities, if
you have or had a relationship with another health care
provider, a health plan, or a health care clearinghouse,
we may also disclose your medical information to that
entity for those types of health care operations.
SECTION B – We may use or disclose your medical
information without your written authorization.
I. The following is a description of ways in which we
may use and disclose your information for which an
authorization or an opportunity to agree or object is
As Required By Law: We may use or disclose
your medical information to the extent required by law,
provided that the use or disclosure complies with and is
limited to the relevant requirements of such law.
Public Health Activities: To the extent
authorized or required by law, we may disclose your
medical information to a public health authority to
report a birth, death, disease or injury, as part of a
public health investigation, or to report child or adult
abuse, or domestic violence.
To the extent authorized or required by the Food and
Drug Administration (“FDA”), we may disclose your
medical information to a person or organization
authorized to report adverse events, track products,
enable product recalls, repairs, or replacement, and/or
conduct post marketing surveillance. This means we may
disclose to non-governmental persons information about
the quality, safety and effectiveness of FDA regulated
products and activities.
Victim of Abuse, Neglect or Domestic Violence:
If we believe you have been a victim of abuse, neglect
or domestic violence, we may disclose your medical
information to a government authority. We will make this
disclosure if it is necessary to prevent serious harm to
you or other potential victims, you are unable to agree
due to your incapacity, you agree to the disclosure, or
when required by law.
Health Oversight Activities: We may
disclose medical information to a health oversight
agency for activities authorized by law. These oversight
activities include but are not limited to, audits,
investigations, inspections, and licensure. These
activities are necessary for appropriate oversight of
the health care system, government benefit and
regulatory programs, and compliance with civil rights
Judicial and Administrative Proceedings:
We may disclose medical information about you as
required by a court or administrative order, or under
certain circumstances in response to a subpoena,
discovery request or other legal process.
Law Enforcement: We may release medical
information to law enforcement officials as required by
the law. Under limited circumstances we may release your
medical information to report a crime or in response to
a court order, grand jury subpoena, warrant, or
Decedents: Consistent with applicable law,
we may release medical information to a coroner, medical
examiner, or funeral director.
Organ, Eye and Tissue Donation: For the
purpose of facilitating organ, eye or tissue donation
and transplantation, we may use or disclose medical
information to organizations that engage in procurement,
banking, or transplantation of cadaveric organ, eye or
Research: If a researcher has obtained the
required waiver, from the Institutional Review Board or
the Privacy Board, and has demonstrated that the
information is necessary to the research and possesses a
minimal risk of inappropriate use or disclosure, we may
use and disclose medical information about you for
research purposes. If a researcher has not obtained the
required waiver, we will not disclose your medical
information without your written authorization, other
than in a limited data set as described below.
Limited Data Set: For purposes of
research, public health, or health care operations, it
may be necessary to use or disclose some of your medical
information for activities or to persons we are not
otherwise authorized to give your information to. In
this situation, we may use your medical information to
create a limited data set in which certain required
direct identifiers (such as your name) have been
removed. We will disclose the information in the limited
data set for these purposes only if we have obtained
satisfactory assurances from the recipient that the
recipient will only use or disclose the information for
To Avert a Serious Threat to Health or Safety:
We may use and disclose medical information about you
when we believe in good faith disclosure is necessary to
prevent a serious threat to your health and safety or
the health and safety of the public or another person.
Specialized Government Functions: Medical
information may be disclosed for military and veterans
affairs, for national security and intelligence
activities, or for correctional activities.
Workers’ Compensation: We may release
medical information about you as necessary to comply
with laws relating to workers’ compensation or similar
programs that are established by the law to provide
benefits for work-related injuries or illness without
regard to fault.
Business Associates: We may disclose your
information to a person or organization that performs a
function or activity on behalf of the Practice that
involves the use or disclosure of protected health
information, such as a billing services company. In
addition, no later than April 14, 2004, if a business
associate is not a person or organization that we are
otherwise permitted to disclose medical information to,
we will only use or disclose your information to that
person or organization if we have obtained adequate
assurances that the business associate will
appropriately safeguard the information.
Personal Representative: We may disclose
your information to a person who has the authority,
under the law, to act on your behalf in making decisions
related to health care.
II. The following is a description of ways in which we
may use and disclose your information after we have
given you an opportunity to object. We will attempt to
obtain your permission prior to making a disclosure for
these purposes. This permission may be oral. If we are
unable to obtain your permission because you are
incapacitated or we are unable to reach you, we may use
or disclose some or all this information, if (1) based
on our professional judgement use or disclosure is in
your best interest or (2) use or disclosure of this
information is consistent with your previously expressed
Individuals Involved in Your Care or Payment for
Your Care: We may release relevant medical
information about you to a friend or family member who
is involved in your medical care. We may also notify
these individuals of your location, general condition,
Disaster Relief: We may disclose medical
information about you to an entity assisting in a
disaster relief effort so that your family can be
notified about your condition, status and location.
SECTION C – We may use or disclose your medical
information for other purposes once we have obtained
your written authorization.
Other uses and disclosure of medical information not
covered by this notice or the laws that apply to us will
be made only with your written authorization. You may
revoke this authorization, in writing, at any time.
However, this revocation will not apply to the extent we
have taken action in reliance on that authorization. In
addition, if the authorization was obtained as a
condition of obtaining insurance coverage, the insurer
will have a right to contest a claim under the policy.
SECTION D – Your rights regarding medical
information about you
Right to Request Restrictions: You have
the right to request a restriction or limitation on the
medical information we disclose about you for treatment,
payment, or health care operations. You also have the
right to request a limit on the medical information we
disclose about you for notification purposes or to
someone who is involved in your care or the payment of
your care, like a family member or friend.
We are not required to agree to your request. If we do
agree, we will comply with your request unless the
information is needed to provide you emergency
To request a restriction, you must make your request in
writing to our Privacy Officer, our Practice Manager.
The requested restriction will not be effective unless
and until it has been reviewed and approved by the
Privacy Officer. For purposes of ensuring proper
documentation, we may require that you make your request
using a form that we give you.
We may terminate an agreed upon restriction without your
consent. In that situation, the restriction will only
apply to protected health information created or
received before you were informed of the termination of
The Right to Receive Confidential Communications:
You have the right to request that we
communicate with you about medical matters in a certain
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 our Privacy Officer. We will not ask you
the reason for your request. We will accommodate all
reasonable requests. Your request must specify how or
where you wish to be contacted. To comply with this
request we may ask you to (1) provide information as to
how payment will be handled and (2) specify an
alternative method of contact. For purposes of ensuring
proper documentation, we may require that you make your
request using a form that we give you.
Right to Inspect and Copy: You have the
right to inspect and obtain a copy of most of your
medical information maintained at the Practice; you must
submit your request in writing to our Privacy Officer.
For purposes of ensuring proper documentation, we may
require that you make your request using a form that we
give you. 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.
We may deny your request to inspect and obtain a copy in
certain limited circumstances. If you are denied access,
you may have the right to request that the denial be
reviewed. Another licensed health care professional
chosen by the Practice will review your request and the
denial. The person conducting the review will not be the
person who denied your request. We will comply with the
outcome of the review.
Right to Amend: If you feel that medical
information we have about you is incorrect or
incomplete, you may ask us to amend the information. You
have the right to request an amendment for as long as
the information is kept by the Practice. To request an
amendment, your request must be made in writing and
submitted to our Privacy Officer. In addition, you must
provide a reason that supports your request. For
purposes of ensuring proper documentation we may require
that you make your request using a designated form.
We may deny your request for an amendment if it is not
in writing or does not include a reason to support the
request. In addition we may deny your request if you ask
us to amend information that (1) was not created by us;
(2) is not part of the medical information kept by or
for the Practice; (3) is not part of the information
which you would be permitted to inspect and copy; or (4)
is accurate and complete.
Right to an Accounting of Disclosures: You
have the right to request an accounting of certain
disclosures. This is a list of the disclosures we made
of medical information about you. You have the right to
request an accounting of certain disclosures by Plastic
Surgical Associates that were made after April 14, 2003
and for a period of time less than six years from the
date of your request. To request an accounting you must
submit a written request to our Privacy Officer. Your
request should indicate in what form you want the list
(for example, on paper, electronically). We will comply
with your request within sixty (60) days or we will
provide you with an explanation for the delay. The first
list you request within a 12-month period will be free.
For additional lists, we may charge you for the costs of
providing the list. We will notify you of the cost
involved and you may choose to withdraw or modify your
request at that time before any costs are incurred.
The right to an accounting does not apply to all
disclosures. For example, you do not have a right to an
accounting of disclosures pursuant to an authorization,
disclosures to carry out treatment, payment, or health
care operations, or disclosures of a limited data set.
Right to a Paper Copy of This Notice: You have
the right to a paper copy of this notice. You may ask us
to give you a copy of this notice at any time. Even if
you have agreed to receive this notice electronically,
you are still entitled to a paper copy of this notice.
You may view an electronic copy of this notice on our
website, www.plastic-surgical-assoc.com. To obtain a
paper copy of this notice, you may ask for a copy at
registration when you visit the Practice for services,
or you may contact our Privacy Officer.
Complaints: If you believe your privacy
rights have been violated, you may file a complaint with
the Practice or with the Secretary of the Department of
Health and Human Services. To file a complaint with the
Practice, you must submit complaint in writing to our
Privacy Officer at:
Plastic Surgical Associates
4815 Liberty Avenue, Suite 235
Pittsburgh, PA 15224
You will not be retaliated against for filing a
Questions? For further information
about matters covered by this notice you may contact our
Privacy Officer at the above address or by telephone at:
412-681-5995 or 412-572-6164.