(2022) Disclosure of Health Information Protected under HIPAA


Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Fax: 623.471.5180

Notice of Privacy Practices: Use of Disclosure of Health Information Protected under HIPAA

This document provides a summary of how medical information about you may be used and disclosed and how you can obtain access to this information.

We understand that medical information about you and your health is personal. We are committed to protecting your medical information. It is our policy that the privacy of your protected health information (PHI) be uncompromised while still allowing necessary access to assure that the medical care you receive is appropriated and of the highest possible quality.

We pledge to you that we will protect the confidentiality of information provided to us. Your information will be used in the following manner, know as Treatment, Payment, and Healthcare Operations (TPO):

      1.To provided medical treatment and/or services.
      2. To bill third party payers, when appropriated, for treatment you receive from us.
      3. To facilitate the mechanisms which allow the operation of our facility.

In every use of your information, we will be responsible custodians of your PHI and adhere to the standards set forth in the legislation which created these privacy practices. We recognize that all patients have the right to privacy in matters relating to their health and we will not use your PHI for uses outside of our facility without your express permission.

You have the following rights regarding to the medical information we maintain about you:

      1. To inspect and copy information that may be used to make decisions about your care.
      2. To request restrictions or limitations on the medical information we use or disclose about you for treatment, payment for health care operations. While we are not required to agree to your request, we will do our utmost to comply unless the information is needed to provide emergency treatment.
      3. To amend the PHI we maintain if you believe that the medical information we have about you is incorrect or incomplete.
      4. To request an accounting of disclosures we have made for uses other than our own.
      5. To request confidential communications; i.e., that we communicate with you in a certain manner or at a certain location.
      6. To receive a paper copy of this notice.

All members of our staff are committed to adhering to the conditions set forth in this notice of privacy practices. Any violations will be grounds for disciplinary action. We reserve the right to change this policy in the future; such changes will be available to all patients.

Should you believe that your privacy rights have been violated, you may file a complaint with this facility or with the State oversight department; all complaints must be submitted in writing. You will not be penalized for filing a complaint.

Patient acknowledgement:

I acknowledge receipt of this information regarding my right to PHI privacy. I have received information regarding the providers of care in this organization, a copy of the Patient's Bill of Rights and Responsibilities, information regarding the grievance process and information regarding the infection control process of this organization, and I understand all the information

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