HIPAA Privacy Policy

Learn How Excelin Medical Spa in Appleton, WI, Handles Your Medical Information

NOTICE OF PRIVACY PRACTICES

Effective 05/07/2015

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.

Your Health Care Information – Protecting Your Privacy

It is your right as a patient to be informed of the privacy practices of your health care provider as well as your privacy rights with respect to your personal health information. This Notice of Privacy Practices (the “Notice”) is intended to provide you with this information.

Forefront Dermatology Responsibilities

It is your right as a patient to be informed of Forefront Dermatology’s legal duties with respect to protection of the privacy of your protected health information (“PHI”).

Forefront Dermatology is required to:

  • Maintain the privacy of your health information;
  • Provide you with a notice of the legal duties and privacy practices regarding PHI collected and maintained about you;
  • Notify you if you are affected by a breach of unsecured PHI; and
  • Abide by the terms of this notice.

Forefront Dermatology reserves the right to change our privacy practices and update this Notice accordingly. We reserve the right to make the revised or changed Notice effective for PHI we already have about you as well as any PHI we receive in the future.

Forefront Dermatology will not use or disclose your PHI without your authorization, except as described in this notice.

Your Rights Regarding Your PHI

NOTE:

All written requests must be made in writing to the Forefront Dermatology Privacy Officer at the address below.

You have the right to:

  • Request a restriction on certain uses and disclosures of your PHI. You have the right to request restrictions on certain uses and disclosures of your PHI. Requests for restrictions must be in writing, as specified above. You must advise Forefront Dermatology: (1) what information you want to limit; (2) whether you want to limit Forefront Dermatology’s internal use, disclosure to third parties, or both; and (3) to whom you want the limit(s) to apply. We are not required to agree to your request, except when you request that we restrict disclosure of your PHI to a health plan for a health care item or service for which you have paid out-of-pocket in full and the disclosure is for the purpose of carrying out payment or health care operations, and not otherwise required by law.
  • Receive Confidential Communications. You have the right to request that Forefront Dermatology communicate your PHI to you by alternative means or at alternative locations. We will use our best efforts to accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your health care record.
  • Inspect and obtain a copy of your health record. You have the right to inspect and obtain a copy of your health care record. This request for access to your health care record must be submitted in writing, as specified above. This right may not apply to certain types of psychotherapy notes. Forefront Dermatology may charge you a reasonable fee for a copy of your health care record.We will inform you if we cannot fulfill your request, and you can ask us to reconsider the denial by contacting our Privacy Officer at the address below. Depending upon why the denial was made, we may ask a licensed health care professional to review your request and the denial.
  • Amend your health record. If you believe that any PHI in your records is incorrect or incomplete, you may submit a written request (as specified above) to correct the information in your records. We may deny your request if you ask us to amend PHI that is: (i) accurate and complete; (ii) not created by Forefront Dermatology; (iii) not part of the PHI kept by or for Forefront Dermatology; or (iv) not PHI that you would be permitted to inspect and copy. If we deny your request, you can ask us, in writing, to review that denial.
  • Obtain an accounting of disclosures of your PHI. You have the right to an “accounting of disclosures,” which is a list of disclosures of your PHI that we have made to outside parties, except for: (i) those necessary to carry out treatment, payment and healthcare operations; (ii) disclosures made before April 14, 2003; (iii) disclosures made to you; (iv) disclosures you authorized; and (v) certain other disclosures. You may receive one accounting per year at no charge; we may charge you a reasonable fee for each subsequent request.
    Your request for an accounting of disclosures must be in writing, as specified above, and must state a time period that may not be longer than six years prior to the date the accounting was requested.
  • Obtain a paper copy of the notice upon request. You have the right to obtain a paper copy of the notice upon request. For example, if you received the notice electronically, you may request that Forefront Dermatology provide a paper copy of the notice.

How We May Use and Disclose Your PHI

  • For Treatment. Forefront Dermatology may use or disclose your PHI in the provision, coordination or management of your health care.
    • Example: Physicians involved in your care will need PHI relating to your history, symptoms, disease and prognosis in order to coordinate care for you.
    • Example: Forefront Dermatology may use your PHI to provide you with an appointment reminder.
    • Example: Forefront Dermatology may send you information about treatment alternatives or other health related services that may be of interest to you.
  • For Payment. Forefront Dermatology may use or disclose your PHI to obtain reimbursement for the provision of health care services. The bill may include information that identifies you, your diagnosis and your treatment.
    • Example: Forefront Dermatology may use or disclose your information to your insurer to obtain payment for the provision of health care services.
  • For Health Care Operations. Forefront Dermatology may use or disclose your PHI for our health care operations.
    • Example: Forefront Dermatology may use your PHI to assess the care and outcomes in your case or to, as a whole, improve the quality and effectiveness of the health care we provide.
  • To Business Associates. Forefront Dermatology may disclose your PHI to “business associates” who provide services to or on behalf of Forefront Dermatology.
  • Communication with Individuals Involved in Your Care. Unless you tell us otherwise, we may share your PHI with friends, family members or others you have identified or who are involved in your care. We may share your PHI with disaster relief organizations so that your family, friends or others you have identified can be notified of your location and condition in case of disaster or other emergency.
  • Research: Under certain circumstances, Forefront Dermatology may use or disclose your PHI for research purposes. Under certain circumstances, we may share your PHI for research purposes without your written permission. All research projects are, however, subject to a special approval process. Most research projects will require your specific permission if a researcher will have access to information that identifies you.
  • As Required by Law: Forefront Dermatology will disclose your PHI where required by law. For example, federal law may require your PHI to be released to an appropriate health oversight agency, public health authority or attorney.
  • Workers compensation: Forefront Dermatology may disclose PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs that provide benefits for work-related injuries or illness.
  • Public Health: We may disclose your PHI for public health activities. For example, Forefront Dermatology may disclose your protected PHI to State agencies for the purpose of statutory reporting.
  • Health Oversight Activities: We may share your PHI with a health oversight agency for audits, investigations, inspections and licensure necessary for the government to monitor the health care system and government programs.
  • Public Safety: We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person.
  • Victims of abuse, neglect or domestic violence: Forefront Dermatology may disclose PHI if Forefront Dermatology reasonably believes that an individual is a victim of child or elderly abuse.
  • Judicial and Administrative Proceedings: Forefront Dermatology may disclose your PHI in response to a court or administrative order, a subpoena, a warrant, a discovery request or other lawful due process.
  • Law enforcement: Forefront Dermatology may disclose your PHI for law enforcement purposes as authorized or required by law or other lawful due process. For example, we may be required by law to report certain types of wounds or other physical injuries.
  • Coroner or Medical Examiner: Forefront Dermatology may release PHI to a coroner or medical examiner. This may be necessary to identify a deceased person or to determine the cause of death. We may also release your PHI to a funeral director, as necessary, to carry out his/her duties.
  • For cadaveric organ, eye or tissue donation purposes: We may release your PHI to organizations that handle organ, eye or tissue donation and transplantation.
  • Specialized Government Functions: If you are a member of the armed forces, we may share your PHI with the military for military command purposes. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
  • Correctional Institution: Should you be an inmate of a correctional institution, Forefront Dermatology may disclose to limited staff of the institution or agents thereof PHI necessary for your health and the health and safety of other individuals.

Other Uses and Disclosures of Your PHI

We may use or disclose your PHI as described above without your authorization. Other uses and disclosures of PHI not described in this Notice will be made only with your authorization. We will obtain your written authorization for: (i) most uses and disclosures of psychotherapy notes; (ii) most uses and disclosures of PHI for marketing purposes, as defined by HIPAA; and (iii) disclosures that constitute a sale of PHI, as defined by HIPAA. If you give us authorization to use or disclose your PHI, then you may revoke that authorization, in writing, at any time. Your revocation will be effective upon receipt, but will not be effective to the extent that Forefront Dermatology or others have acted in reliance upon the authorization.

Patient Complaint Process

If you believe your privacy rights have been violated, you may file a complaint with Forefront Dermatology or with the Office for Civil Rights of the United States Department of Health and Human Services electronically via the OCR Complaint Portal, or on paper by mail, fax or via e-mail (OCRComplaint@hhs.gov). We will not take any action against you for filing a complaint.

To file a complaint with Forefront Dermatology please contact the Forefront Dermatology’s Privacy Officer who will provide you with the necessary assistance.

Questions or Concerns

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:

Cathy Lacenski
Forefront Dermatology
801 York St.
Manitowoc, WI 54220
(920) 663-9012
E-mail: Clacenski@forefrontderm.com