NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES
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.
SCULPTED MD is required to maintain the privacy of your health information and to provide you with a notice of its legal
duties and privacy practices. We will not use or disclose your health information except as described in this Notice. This
Notice applies to all of the medical records generated by SCULPTED MD, as well as records we receive from other
providers.
USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION IN TREATMENT, PAYMENT & HEALTH CARE OPERATIONS
Treatment: SCULPTED MD may use and disclose your protected health information in the course of providing or
managing your health care as well as any related services. For the purpose of treatment, we may coordinate your health care
with a third party. For example, we may disclose your protected health information to a pharmacy to fulfill a prescription for
medication, to a radiology facility to order an X-ray, or to another physician who is assisting in your health care. In addition,
we may disclose protected health information to other health care providers related to the treatment provided by those other
providers.
Payment: When needed, SCULPTED MD will use or disclose your protected health information to obtain payment
for its services. Such uses or disclosures may include disclosures to your health insurer to get approval for a recommended
procedure or to determine whether you are eligible for benefits or whether a particular service is covered under your health
plan. When obtaining payment for your health care, we may also disclose your protected health information to your
insurance company to demonstrate the medical necessity of the care or for utilization review when required to do so by your
insurance company. Finally, we may also disclose your protected health information to another provider where that provider
is involved in your care and requires the information to obtain payment.
Operations: SCULPTED MD may use or disclose your protected health information when needed for the
practice’s health care operations for the purposes of management or administration of the practice and for offering quality
health care services. Health care operations may include: (1) quality evaluations and improvement activities; (2) employee
review activities and training programs; (3) accreditation, certification, licensing, or credentialing activities; (4) reviews and
audits such as compliance reviews, medical reviews, legal services, and maintaining compliance programs; and (5) business
management and general administrative activities. For instance, we may use, as needed, protected health information of
patients to review their treatment course when making quality assessments regarding ophthalmologic care or treatment. In
addition, we may disclose your protected health information to another provider or health plan for their health care
operations.
Other Uses and Disclosures: As part of treatment, payment, and health care operations, SCULPTED MD may also
use or disclose your protected health information to: (1) remind you of an appointment; (2) inform you of potential treatment
alternatives or options; or (3) inform you of health-related benefits or services that may be of interest to you.
USES & DISCLOSURES TO WHICH YOU MAY OBJECT
Family/Friends: SCULPTED MD may disclose your protected health information to a friend or family member
who is involved in your medical care. We may also give information to someone who helps pay for your care. In addition,
we may disclose protected health 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. If you have any objection to the use and disclosure of your protected
health information in this manner, please tell us.
USES & DISCLOSURES THAT ARE REQUIRED OR PERMITTED WITHOUT YOUR AUTHORIZATION
Research: Under certain circumstances, SCULPTED MD may use and disclose your protected health information
to approved clinical research studies. While most clinical research studies require specific patient consent, there are some
instances where a retrospective record review with no patient contact may be conducted by such researchers. For example,
the research project may involve comparing the health and recovery of patients who received one medication for their
medical condition to those who received a different medication for that same condition.
Regulatory Agencies: SCULPTED MD may disclose your protected health information to government and certain
private health oversight agencies, e.g., the Department of Public Health and Environment or the Board of Medical Examiners,
for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations and inspections.
These activities are necessary to monitor compliance with the requirements of government programs.
Law Enforcement/Litigation: SCULPTED MD may disclose your protected health information for law
enforcement purposes as required by law or in response to a court order or other process in litigation.
Public Health: As required by law, SCULPTED MD may disclose your protected health information to public
health or legal authorities charged with preventing or controlling disease, injury or disability. For example, we are required
to report the existence of a communicable disease, such as acquired immune deficiency syndrome ("AIDS"), to the
Department of Public Health and Environment to protect the health and well-being of the general public.
Workers’ Compensation: SCULPTED MD may release protected health information about you for workers'
compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Military/Veterans: SCULPTED MD may disclose your protected health information as required by military
command authorities, if you are a member of the armed forces.
Organ Procurement Organizations: To the extent allowed by law, SCULPTED MD may disclose your protected
health information to organ procurement organizations and other entities engaged in the procurement, banking or
transplantation of organs for the purpose of tissue donation and transplant.
As Otherwise Required or Permitted By Law: SCULPTED MD will disclose your protected health information in
any situation in which such disclosure is required by law (e.g., child abuse, domestic abuse) or any other use permitted under
HIPAA, its amendments or regulations.
USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION:
Other than the circumstances described above, SCULPTED MD will not disclose your protected health information
unless you provide written authorization. An authorization is specifically required in most situations involving uses or
disclosures of protected health information for marketing purpose, for the sale of protected health information, or for
psychotherapy purposes. You may revoke your authorization in writing at any time except to the extent that we have already
taken action in reliance upon the authorization.
YOUR RIGHTS RELATED TO YOUR HEALTH INFORMATION:
Although all records concerning your treatment obtained at SCULPTED MD are the property of SCULPTED MD,
you have the following rights concerning your protected health information:
- Right to Confidential Communications: You have the right to receive confidential communications of your
protected health information by alternative means or at alternative locations. For example, you may request that we contact you at work or by mail. - Right to Inspect and Copy: You generally have the right to inspect and copy your protected health information,
except as restricted by your physician or by law. Further, if we maintain your health records on an electronic
health records system, you have the right to request an electronic copy of your health records. - Right to Amend: You have the right to request an amendment or correction to your protected health
information. If we agree that an amendment or correction is appropriate, we will ensure that the amendment or
correction is attached to your medical record. - Right to an Accounting: You have the right to obtain a statement of the disclosures that have been made of
your protected health information other than by your authorization, other than to you and other than for the
purpose of treatment, payment or routine operational purposes. - Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your
protected health information. If we agree, we will abide by the restrictions. Additionally, if you (or anyone on
your behalf besides a health plan) pay for the care or services at issue in full out of your own pocket, we are
required to comply with your request not to disclose your protected health information to a health plan, unless
required by law to do so. - Right to Receive a Copy of this Notice: You have the right to receive a paper copy of this Notice, upon request,
if this Notice has been provided to you electronically. - Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your
protected health information, except to the extent that action has already been taken in reliance on your
authorization. - Right to Notice of Breach of Security: You have the right to be notified in the event of a breach of unsecured
protected health information occurs. - Right to Opt Out: You may be contacted for certain fund-raising purposes and you have the right to opt out of
receiving such communications.
FOR MORE INFORMATION REGARDING HOW TO EXERCISE THESE RIGHTS:
If you have questions or would like more information regarding any of the rights listed above, please contact the Compliance Officer at 720-446-5519
IF YOU BELIEVE THAT YOUR RIGHTS HAVE BEEN VIOLATED:
You may file a complaint with SCULPTED MD or with the
U.S. Secretary of Health and Human Services. To file a complaint with SCULPTED MD, please contact the Compliance
Officer at 720-446-5519 All complaints must be submitted in writing. There will be no retaliation for filing a complaint.
NOTICE EFFECTIVE DATE:
This Notice is effective for all protected health information created on or after January 1, 2015.
Notice of Health Information Privacy Practices
Effective Date: September 23, 2013
Updated Sept 2013