This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
It is important to read and understand the Notice of Privacy Practices before signing our consent and acknowledgement forms.
If you have any questions please contact our Privacy Officer at 860-521-3921.
Purpose:
This Notice of Privacy Practices (the “Notice”) is meant to inform you of the uses and disclosures of protected health information that we may make. It also describes your rights to access and control your protected health information and certain obligations we have regarding the use and disclosure of your protected health information.
Your “protected health information” is information about you created and received by us, including demographic information, that may reasonably identify you and that relates to your past, present or future physical or mental health or condition, or payment for the provision of your health care.
We are required by law to maintain the privacy of your protected health information. We are also required by law to provide you with this Notice of our legal duties and privacy practices with respect to your protected health information and to abide by the terms of the Notice that is currently in effect. However, we may change our notice at any time. The new revised Notice will apply to all of your protected health information maintained by us. You will not automatically receive a revised Notice. If you would like to receive a copy of any revised Notice you should access our web site at www.facerxmd.com, contact Face Rx Boutique, LLC (“Face Rx Boutique, LLC”) or ask at your next appointment.
How We May Use or Disclose Your Protected Health Information:
Face Rx Boutique, LLC will ask you to sign a consent form that allows Face Rx Boutique, LLC to use and disclose your protected health information for treatment, payment and health care operations. You will also be asked to acknowledge receipt of this Notice.
The following categories describe some of the different ways that we may use or disclose your protected health information. Even if not specifically listed below, Face Rx Boutique, LLC may use and disclose your protected health information as permitted or required by law or as authorized by you. We will make reasonable efforts to limit access to your protected health information to those persons or classes of persons, as appropriate, in our workforce who need access to carry out their duties. In addition, if required, we will make reasonable efforts to limit the protected health information to the minimum amount necessary to accomplish the intended purpose of any use or disclosure and to the extent such use or disclosure is limited by law.
“For Treatment”- We may use and disclose your protected health information to provide you with medical treatment and related services. Your protected health information may be used such as sending medical information about you to a specialist as part of a referral. This includes psychiatric or HIV if needed for the purposes of your diagnosis and treatment. If we are permitted to do so, we may also disclose your protected health information to individuals or facilities that will be involved with your care after you leave Face Rx Boutique, LLC and other treatment reasons. We may also use or disclose your protected health information in an emergency situation.
“Appointment Reminders” – We may use and disclose protected health information to contact you as a reminder that you have an appointment at Face Rx Boutique, LLC.
“Treatment Alternatives and Other Health-Related Benefits and Services” – We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives and to tell you about health related benefits, services, or medical education classes that may be of interest to you.
“Individuals Involved in Your Care or Payment of Your Care” – Unless you object, we may disclose your protected health information to a family member, a relative, a close friend or any other person you identify, if the information relates to the person’s involvement in your health care, to notify the person of your location or general condition or payment related to your health care. In addition, we may disclose your protected health information to a public or private entity authorized by law to assist in a disaster relief effort. If you are unable to agree or object to such a disclosure we may disclose such information if we determine that it is in your best interest based on our professional judgment or if we reasonably infer that you would not object.
“Public Health Activities” – We may disclose your protected health information to a public health authority that is authorized by law to collect or receive such information, such as for the purpose of preventing or controlling disease, injury, or disability; reporting births, deaths or other vital statistics; reporting child abuse or neglect; notifying individuals of recalls of products they may be using; notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.
“Health Oversight Activities” – We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, accreditation, licensure and disciplinary actions.
“Judicial and Administrative Proceedings” – If you are involved in a lawsuit or a dispute, we may disclose your protected health information in response to your authorization or a court or administrative order. We may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process if such disclosure is permitted by law.
“Law Enforcement” – We may disclose your protected health information for certain law enforcement purposes if permitted or required by law. For example, to report gunshot wounds; to report emergencies or suspicious deaths; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes.
“Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations” – We may release your protected health information to a coroner, medical examiner, funeral director, or, if you are an organ donor, to an organization involved in the donation of organs and tissues.
“Research Purposes” – Your protected health information may be used or disclosed for research purposes, but only if the use and disclosure of your information has been reviewed and approved by a special Privacy Board or Institutional Review Board, or if you provide authorization.
“To Avert a Serious Threat to Health or Safety” – We may use and disclose your protected health information when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. Any disclosure, however, would be to someone able to help prevent the threat.
“Military and National Security” – If required by law, if you are a member of the armed forces, we may use and disclose your protected health information as required by military command authorities or the Department of Veterans Affairs. If required by law, we may disclosure your protected health information to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities authorized by law. If required by law, we may disclose your protected health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
“Workers’ Compensation” – We may use or disclose your protected health information as permitted by laws relating to workers’ compensation or related programs.
You consent in writing;
The disclosure is allowed by a court order; or
The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.
Violation of these Federal laws and regulations by us is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the substance abuse program or against any person who works for the program or about any threat to commit such a crime.
Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.
HIV-related information – We may disclose HIV-related information as permitted or required by Connecticut law. For example, your HIV-related information, if any, may be disclosed without your authorization for treatment purposes, certain health oversight activities, pursuant to a court order, or in the event of certain exposures to HIV by personnel of Face Rx Boutique, LLC, another person, or a known partner.
Minors – We will comply with Connecticut law when using or disclosing protected health information of minors. For example, if you are an unemancipated minor consenting to a health care service related to HIVIAIDS, venereal disease, abortion, outpatient mental health treatment or alcohol/drug dependence, and you have not requested that another person be treated as a personal representative; you may have the authority to consent to the use and disclosure of your health information.
“Other Uses of Medical Information” – In any other situation not covered by this notice, we will ask you for your written authorization before using or disclosing medical information about you. For example, your written authorization is required prior to:
Appearing in any television or website advertisement or testimonial
Participation in a radio advertisement
Participation in any contest offered by Vanishing Veins and Facerxmd
Participation in any seminar given by Vanishing Veins and Facerxmd
When We May Not Use or Disclose Your Protected Health Information:
Except as described in this Notice, or as permitted by Connecticut or Federal law, we will not use or disclose your protected health information without your written authorization.
Your written authorization will specify particular uses or disclosures that you choose to allow. Under certain limited circumstances, Face rx boutique Facerxmd may condition treatment on the provision of an authorization, such as for research related to treatment. If you do authorize us to use or disclose your protected health information for reasons other than treatment, payment or health care operations, you may revoke your authorization in writing at any time by contacting Face Rx Boutique, LLC’ Privacy Officer. If you revoke your authorization, we will no longer use or disclose your protected health information for the purposes covered by the authorization, except where we have already relied on the authorization.
Psychotherapy Notes:
A signed authorization or court order is required for any use or disclosure of psychotherapy notes except to carry out certain treatment, payment, or health care operations and for use by Face Rx Boutique, LLC for treatment, for training programs, or for defense in a legal action.
Marketing:
A signed authorization is required for the use or disclosure of your protected health information for a purpose that encourages you to purchase or use a product or service except for certain limited circumstances such as when the marketing communication is face-to-face or when marketing includes the distribution of a promotional gift of nominal value provided by Face Rx Boutique, LLC.
Your Health Information Rights:
You have the following rights with respect to your protected health information. The following briefly describes how you may exercise these rights.
Right to Request Restrictions of Your Protected Health Information – You have the right to request certain restrictions or limitations on the protected health information we use or disclose about you. You may request a restriction or revise a restriction on the use or disclosure of your protected health information by providing a written request stating the specific restriction requested. You can obtain a Request for Restriction form from Face Rx Boutique, LLC. We are not required to agree to your requested restriction. If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you with emergency treatment. If restricted protected health information is disclosed to a health care provider for emergency treatment, we will request that such health care provider not further use or disclose the information. In addition, you and Face Rx Boutique, LLC may terminate the restriction if the other party is notified in writing of the termination. Unless you agree, the termination of the restriction is only effective with respect to protected health information created or received after we have informed you of the termination.
Right to Receive Confidential Communications – You have the right to request a reasonable accommodation regarding how you receive communications of protected health information. You have the right to request an alternative means of communication or an alternative location where you would like to receive communications. You may submit a request in writing to Face Rx Boutique, LLC requesting confidential communications. You can obtain a Request for Confidential Communications form from Face Rx Boutique, LLC.
Right to Access, Inspect and Copy Your Protected Health Information – You have the right to access, inspect and obtain a copy of your protected health information that is used to make decisions about your care for as long as the protected health information is maintained by Face Rx Boutique, LLC. To access, inspect and copy your protected health information that may be used to make decisions about you, you must submit your request in writing to Face Rx Boutique, LLC. If you request a copy of the information, we may charge a fee for the costs of preparing, copying, mailing or other supplies associated with your request at the cost of $0.65 cents per page. We may deny, in whole or in part, your request to access, inspect and copy your protected health information under certain limited circumstances. If we deny your request, we will provide you with a written explanation of the reason for the denial. You may have the right to have this denial reviewed by an independent health care professional designated by us to act as a reviewing official. This individual will not have participated in the original decision to deny your request. You may also have the right to request a review of our denial of access through a court of law. All requirements, court costs and attorney’s fees associated with a review of denial by a court are your responsibility. You should seek legal advice if you are interested in pursuing such rights.
Right to Amend Your Protected Health Information – You have the right to request an amendment to your protected health information for as long as the information is maintained by or for Face Rx Boutique, LLC. Your request must be made in writing to Face Rx Boutique, LLC and must state the reason for the requested amendment. You can obtain a Request for Amendment form from Face Rx Boutique, LLC. If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial. We may rebut your statement of disagreement. If you do not wish to submit a written statement disagreeing with the denial, you may request that your request for amendment and your denial be disclosed with any future disclosure of your relevant information.
Right to Receive an Accounting of Disclosures of Protected Health Information- You have the right to request an accounting of certain disclosures of your protected health information by Face Rx Boutique, LLC or by others on our behalf. To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning on or after April 14, 2003 that is within six (6) years from the date of your request. The first accounting provided within a twelve-month period will be free.
We may charge you a reasonable, cost-based fee for each future request for an accounting within a single twelve-month period. However, you will be given the opportunity to withdraw or modify your request for an accounting of disclosures in order to avoid or reduce the fee.
Right to Obtain a Paper Copy of Notice – You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting Face Rx Boutique, LLC. In addition, you may obtain a copy of this Notice at our web site, www.facerxmd.com.
Right to Complain – You may file a complaint with us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint at 860-521-3921. You will not be penalized for filing a complaint and we will make every reasonable effort to resolve your complaint with you.
Face Rx Boutique, LLC
Privacy Officer