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.

 
Protecting your privacy

Protecting your privacy and your medical information is at the core of our business. We recognize our obligation to keep your information secure and confidential whether on paper or the internet. At Pediatric Plastic Surgery Institute (hereafter referred to as "the Practice"), privacy is one of our highest priorities.

Keeping your information

Keeping the medical and health information we have about you secure is one of our most important responsibilities. We value your trust and will handle your information with care. Our employees access information about you only when necessary to provide treatment, verify eligibility, obtain authorization, process claims and other wise met your needs. We may also access information about you when considering a request from you or when exercising our rights under the law or any agreement with you.

We safeguard information during all business practices according to established security standards and procedures, and we continually assess new technology for protecting information. Our employees are trained to understand and comply with these information principles.

 
Working to meet your needs through information

In the course of doing business, we collect and use various types of information, like name and address and claim information. We use this information to provide service to you, to process your claims, and to bring you health information that might be of interest to you.

 
Keeping information accurate

Keeping your health information accurate and up-to-date is very important. If you believe the health information we have about you is incomplete, inaccurate or not current, please call or write us at the telephone numbers or addresses listed below. We take appropriate action to correct any erroneous information as quickly as possible through a standard set of practices and procedures.

 
How and why information is shared

 
We limit who receives information and what type of information is shared.

• Sharing information with the Practice. We share information within our company to deliver you the health care services and the related information and education programs specified in your plan.

• Sharing information with companies that work for us. To help us offer you our services, we may share information with companies that work for us, such as claim processing and mailing companies and companies that deliver health education and information directly to you. These companies act on our behalf and are obligated contractually to keep the information that we provide them confidential.

• Other. Patient-specific personally identifiable data is released only when required to provide a service for you and only to those with a need to know, or with your consent. Data is released with the condition that the person receiving the data will not release it further, unless you give permission.

If we receive a subpoena or similar legal process demanding release of any information about you, we will attempt to notify you (unless we are prohibited from doing so). Except as required by law or as described above, we do not share information with other parties, including government agencies.

The practice does not share any customer information with third-party marketers who offer their products and services to our patients.

Count on our commitment to your privacy

You can count on us to keep you informed about how we protect your privacy and limit the sharing of information you provide to us-whether it’s at our office, over the phone or through the internet.

Pediatric Plastic Surgery Institute

9101 N. Central Expressway, Suite 595

Dallas, Texas 75231

469-375-3838

 

Patient Consent and Acknowledgment of Receipt of Privacy Policy

I understand that as part of the provision of healthcare services, Pediatric Plastic Surgery Institute creates and maintains health records and other information describing among other things, my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.

I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their Notice of practices and prior to implementation will mail a copy of any revised notice t the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I  have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations (quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical review, legal services, and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested.

By signing this form, I consent to the use and disclosure of protected health information about me for the purpose of treatment ,payment and health care operations. I have the right to revoke this consent, in writing, except where disclosures have already been made in reliance on my prior consent.

 
This consent is given freely with the understanding that:

1. Any and all records whether written or oral or in electronic formation, are confidential and cannot be disclosed for reasons outside of treatment, payment or health care operations without my prior written authorization, except as otherwise provided by law.
2. A photocopy or fax of this consent is as valid as the original.
3. I have the right to request that the use of my Protected Health Information, which is used tor disclosed for the purpose of treatment, payment or health care operations be restricted. I also understand that the Practice and I must agree to any restrictions on the use and disclosure of my Protected Health information that I request in writing, and, when I request in writing, agree to terminate any restrictions on the use and disclosure of my Protected health Information which have been previously agreed upon.