Patient Notice of Privacy Practices — v1

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Medical services are provided by Corinne Aesthetics PC, with management by Corinne Aesthetics LLC. References to the Practice mean Corinne Aesthetics PC.

Patient terms | Patient privacy notice | Arbitration agreement

Privacy contact and information sharing

Medical services are provided by Corinne Aesthetics PC (the Practice), with management by Corinne Aesthetics LLC. Management does not have unrestricted access to patient information; access must comply with applicable law and safeguards.

Corinne Aesthetics LLC handles marketing, sales, administration and bookkeeping for Corinne Aesthetics PC. SalesMD handles sales outreach and bookings and can also access treatment details or medical records. Access must be appropriate for the purpose and comply with applicable law and safeguards. These descriptions do not authorize medical-information marketing or either company’s own unrelated marketing. Any required authorization must be obtained separately.

Privacy and records contact: Main Office, administered through Corinne Aesthetics LLC for Corinne Aesthetics PC. Telephone: (805) 765-3539. Email: [email protected].

For privacy questions, record requests, corrections, confidential communication requests, restrictions, authorization withdrawal or complaints, email [email protected]. Please do not include medical details, identification documents or payment-card information in your initial email. We will explain the appropriate process for your request.

Corinne Aesthetics PC: 123 Hodencamp Rd, Suite 106, Thousand Oaks, CA 91360.

We use patient information for care, scheduling, payment administration and practice operations. In addition to the support companies identified above, operational software providers process information for Corinne, such as storing records or supporting scheduling, communications and payments. Information shared for these functions remains subject to applicable confidentiality requirements and safeguards; this operational sharing does not authorize recipients to use patient information for their own unrelated marketing. Information may also be shared with providers involved in your care or where legally required or permitted, as described below. This notice does not itself authorize optional advertising disclosures.

Promotional communications and Google advertising measurement use separate optional choices. Choosing one does not authorize the other. Google measurement, if separately authorized and otherwise permitted, is limited to the ad click identifier, booking or payment occurrence, event date/time, a coded reference and the authorized transaction amount. It excludes names, contact details, medical record numbers, treatment names, diagnoses, clinical notes and payment-card details. It is not anonymous and may reveal that services, including medical services, were obtained. The full separate authorization governs the scope; acknowledging this notice grants no advertising permission. Customer Match and customer audience lists are not authorized by this notice.

About this notice

This notice will tell you about the ways in which we may use and disclose medical information about you. It also describes our obligations regarding the use and disclosure of medical information, your rights, and how you can access this information. Please review it carefully.

Understanding Your Health Record/Information

We keep a record of the care and services you receive. This notice applies to those records and to Corinne Aesthetics PC, its staff and providers involved in your care. We protect your medical information and may share it for care, payment administration and practice operations as described in this notice.

Your Health Information Rights

You may request access to your records, copies, corrections, confidential communications, restrictions on information sharing, and an accounting of disclosures where applicable law provides that right. Contact [email protected] to submit a written request. You may request a paper copy of this notice.

For patient access requests governed by California Health and Safety Code section 123110, inspection is generally available within five working days after receipt of a written request, and requested copies are generally provided within 15 days. Specific lawful exceptions and alternative-summary procedures may apply. Reasonable verification of identity or representative authority may be required for record requests; this is separate from routine appointment intake and must not improperly delay access.

Any fees must be permitted by applicable law. We will explain applicable charges and any right to free copies before charging you. A request to inspect records does not authorize removing or altering the original record. We do not claim a general right to delete or withhold information merely because it is considered harmful. Any lawful access limitation must follow the applicable grounds, notice and review procedures.

You may request correction of inaccurate or incomplete information. We will respond under applicable law; a correction request does not automatically require deletion of the original record. You may request a different communication method or location and restrictions on sharing. We will explain whether a requested restriction must be honored or can be agreed to. Where HIPAA applies, an eligible request to restrict disclosure to a health plan for an item or service paid out of pocket in full must be honored unless disclosure is required by law.

You may withdraw an authorization in writing at [email protected], subject to disclosures or other action already taken in reliance on it. Receipt of this notice is not an authorization for optional advertising disclosures.

Our Responsibilities

In addition to the responsibilities set forth above, Practice is also required to:

Maintain the privacy of your health information;
Subject to certain exceptions under the law, provide notice of any unauthorized acquisition, access, use, or disclosure of your protected health information, to the extent it was not otherwise secured;
Provide you with a notice as to our legal duties and privacy practices with respect to information we maintain about you;
Abide by the terms of this notice; and
Notify you if we are unable to agree to a requested restriction on certain uses and disclosures.
We reserve the right to change our practices and to make new provisions effective for all protected health information we maintain, including information created or received before the change is implemented. Should our information practices change, we are not required to notify you, but we will have the revised notice available upon your request at Practice.

Uses and Disclosures of Medical Information That Do Not Require Your Authorization

The following categories describe different ways that Practice may use and disclose medical information without your authorization. We will explain what we mean for each category of uses or disclosures, but not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information without your authorization should fall within one of the categories. We will use your health information for treatment.

For example: We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. We may share your medical information to coordinate different treatments, such as prescriptions, lab work, or X-rays. We also may provide your physician or a subsequent health care provider with copies of various reports to assist in treating you once you are discharged from care at Practice.
We will use your health information for payment.

For example, we use information to administer your self-pay account, process payments and address billing questions. This notice does not provide blanket authorization to send your medical records to an insurer.
We will use your health information for regular health care operations.

For example: We may use the information in your health record to assess the care and outcome in your case and others like it. We will then use this information to continually improve the quality and effectiveness of the health care and services we provide.
We will use and disclose your health information as otherwise allowed by law.

Examples of those uses and disclosures follow:

When We Need Your Written Authorization

We will not use or disclose your health information without your written authorization, except as described in this notice. Additional circumstances that might require your written authorization are uncommon, but an example is uses and disclosures for marketing purposes.

For More Information or to Report a Problem: If you have questions and would like additional information, email [email protected]. If you believe your privacy rights have been violated, email [email protected]. You may also complain to the appropriate regulator, including HHS where HIPAA applies. We will not retaliate for filing a complaint. We may change or update our policies contained in this notice at any time and apply any policy revisions to all the protected health information we maintain. If/when we change our notice, we will post the new notice at each practice location where it can be seen.

If you have any questions or concerns regarding your health information and records, please contact us. Thank you.

Notice of Privacy Practices Acknowledgment

I, the undersigned, understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand, however, that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly to Corinne Aesthetics PC;
Administer your self-pay account and payments; and
Conduct normal health care operations, such as quality assessments and physician certifications.
I acknowledge that I have been provided the Notice of Privacy Practices which contains a more complete description of the uses and disclosures of my health information. I understand that this facility has the right to change its Notice of Privacy Practices from time to time, and that I may contact Practice at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing restrictions on how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that Practice is not required to agree to the restrictions I request, but is bound to abide by such restrictions to which it has agreed.

Information may be shared for care and practice administration as described in this notice and permitted by applicable law. This acknowledgment is not blanket authorization to release records to an insurer or for optional advertising.

HIPAA Compliance Document

We are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights related to your protected health information.

This Notice is effective May 31st, 2017, and applies to all protected health information as defined by federal regulation.

Uses and Disclosures

We use your health information to document and plan treatment, progress, planning, etc. We use your health information for payment. For instance, we use information to administer your self-pay account and payments; this notice does not automatically authorize an insurance disclosure. We use your health information for regular health operations. For example, our compliance officer regularly chooses medical records for audits. This practice ensures that we are constantly working towards improved quality and effectiveness. There are services provided in our organization through contacts with business associates. Examples include outside labs, X-ray, and transcription services. We may use or disclose information to notify or assist in notifying a family member, personal representative, or other person responsible for your care, your location, and general condition. The following are examples of other purposes for which your provider of services is permitted or required to disclose confidential information without the individual's written authorization: Uses and disclosures for public health activities; Reporting victims of abuse, neglect, or domestic violence; Disclosures for judicial and administrative proceedings; Disclosures for law enforcement purposes; Uses and disclosures for cadaveric organ, eye or tissue donation purposes; Disclosures to avert a serious threat to health or safety; and Uses and disclosures for specialized government functions.

Separate Statements for Certain Uses or Disclosures

The provider of services may contact patients with appointment reminders, requests for the patient to contact the office staff for appointments, notices, and letters concerning medical findings. The provider of services may also contact the patient about treatment alternatives or other health-related benefits and services that may be of interest to the individual.

Additional information about your rights

The rights, record-access deadlines, fees and limitations are described in Your Health Information Rights above. You may have additional rights under applicable law.

HIPAA Privacy Notice

The provider of services is required by law to maintain the privacy of confidential information and provide individuals with notice of its legal duties and privacy practices with respect to such information; The provider of services is required to abide by the terms of this Notice; and the provider of services reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all confidential information that it maintains. Revisions to this Notice will be posted in the patient waiting area.

Complaints

Email privacy complaints to [email protected]. We will not retaliate for raising a privacy concern or exercising applicable rights. You may also contact the Medical Board of California about patient-record access or other matters within its jurisdiction, and the HHS Office for Civil Rights where HIPAA applies.

Acknowledging receipt of this notice confirms that you received it and had an opportunity to review it; it is not consent to treatment or authorization for optional advertising disclosures.