Acknowledgement Receipt Notice Privacy Form

, acknowledge that I received and reviewed the office Privacy Policy Notice for Penn Medicine, Dr. Nicole Schrader. 

Pledge Regarding Your Medical Informaiton

This page describes the type of information we gather about you, with whom that information may be shared and the safeguards we have in place to protect it. You have the right to confidentiality of your medical information and the right to approve or refuse the release of specific information except when the release is required by law. If the practices described in this brochure meet your expectations, please sign on the first page indicating your agreement. If you prefer that we not share information we may honor your written request in certain circumstances described below. If you have any questions about this notice, please contact our Privacy Officer at the address on page 5 of this agreement.

WHO WILL FOLLOW THIS NOTICE

This notice describes the Schrader Plastic Surgery Center’s practices regarding the use of your medical information and that of: Any health care professional authorized to enter information into your Clinic chart or medical record, and employees, staff and other personnel who may need access to your information. All entities, sites and locations Penn Medicine Schrader Plastic Surgery Center follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or health care purposes described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. Protecting medical information about you is important. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by the Penn Medicine Schrader Plastic Surgery Center, whether made by health care professionals or other personnel. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to: keep medical information that identifies you privately, give you this notice of our legal duties and privacy practices with respect to medical information about you, and to follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we may use and disclose medical information. Not every use or disclosure in a category will be listed.

For Treatment
We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, training doctors, or other health care professionals who are involved in taking care of you. Different health care professionals also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose information about you to people outside the Clinic who may be involved in your medical care after you leave the Clinic or that provide services that are part of your care.

For Payment
We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, and insurance company or a third party. For example, your insurance company may need to know about surgery you received so they will pay us or reimburse you for the surgery. We will also use and disclose medical information about you to obtain prior approval or to determine whether your insurance will cover the treatment.

For Health Care Purposes
We may use and disclose medical information about you for health care purposes. This is necessary to make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, nurses, technicians, and training doctors, for review and learning purposes. If we do disclose this information, we will remove or omit any information which identifies you specifically.

Appointment reminders
We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.

Treatment Alternatives
We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services
We may release medical information about you 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. We may also update your family or friends regarding your condition, Research medical information about you will NOT be used or disclosed for research purpose unless all specific identification information about you is removed from the information. (i.e. the information will only be used anonymously).

As Required By Law
We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety
We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Special Situations

Workers’ Compensation
We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks
We may disclose medical information about you for public health activities. These activities generally include the following: to prevent or control disease, injury or disability: to report births and deaths: to report child abuse or neglect: to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence.

Health Oversight Activities
We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. The activities are necessary for compliance with civil rights laws.

Lawsuits and Disputes
We may disclose medical information about you in response to a subpoena, discovery request, or other lawful order from a court.

Law Enforcement
We may release medical information if asked to do so by a law enforcement official as part of law enforcement activities; in investigations of criminal conduct or of victims of crime; in response to court orders; in emergency circumstances; or when required to do so by law.

Coroner, Medical Examiners and Funeral Directors
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Protective Services for the President, National Security and Intelligence Activities
We may release medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations, or for intelligence, counterintelligence, and other national security activities authorized by law.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

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

Right to Inspect and Copy
You have the right to inspect and copy medical information that may be used to make decisions about your care.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer at the address on the last page.

We may deny you request to inspect and copy in certain very limited circumstances. If you are denied access to medical information you may request that the denial be reviewed. Another licensed health care professional chosen by the Penn Medicine Schrader Plastic Surgery Center will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept. To request an amendment, your requests must be made in writing and submitted to our Privacy Officer. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
• Is not part of the medical information kept by the Penn Medicine Schrader Plastic Surgery Center.
• Is not part of the information which you would be permitted to inspect and copy.
• Is accurate and complete.

Rights to Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical information about you. To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer.

Rights to Request Restrictions
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to your Privacy Officer at the address below. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.

Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to our Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website. To obtain a paper copy of this notice, please request one in writing from our Privacy Officer at the address below.

CHANGES TO THIS NOTICE

We have the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice. The notice will contain on the first page, in the top right-hand corner, the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Penn Medicine Schrader Plastic Surgery Center or with the Secretary of the Department of Health and Human Services. To file a complaint with the Penn Medicine Schrader Plastic Surgery Center, contact our Privacy Officer at the address and phone number listed below. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, thereafter we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

PRIVACY OFFICER

Schrader Plastic Surgery Center