As part of your medical treatment, Aesthetic Facial Plastic Surgery, P.S. originates and maintains paper and/or electronic records which contain PHI such as: demographic information; personal and family histories; symptoms; examination and test results; diagnoses; past, present and future plans for care and treatment; and information received from other health care providers, your employer and any health care plan. Aesthetic Facial Plastic Surgery, P.S. maintains Privacy Practices and Policies regarding the disclosure of PHI.
By entering your information through our website you should understand that:
1. Protected Healthcare Information may be disclosed or used for treatment, billing and payment, or healthcare operations;
2. The patient has the right and the opportunity to review Aesthetic Facial Plastic Surgery, P.S.’s Privacy Practices and Policies;
3. Aesthetic Facial Plastic Surgery, P.S. reserves the right to change it’s Privacy Practices and Policies at any time;
4. The Patient has the right to request, in writing, restricted disclosure of their PHI, however, Aesthetic Facial Plastic Surgery, P.S. is not bound by the restrictions unless an agreement regarding the requested restrictions has been reached;
5. The Patient understands that they will be responsible for copying and mailing charges associated with sending their medical records.
6. The patient may revoke their consent, in writing, at any time regarding all future disclosures.
By entering your information through our website you consent to our use and disclosure of protected health information about you for treatment, payment, or healthcare operations. You have a right to revoke this consent in writing, signed by you and delivered to our office. Revocation will apply to any future disclosures but not to any disclosure already made in reliance on your prior consent or as required by law. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Aesthetic Facial Plastic Surgery, P.S. reserves the right to change its Privacy Practices and Policies at any time. A revised copy of the Privacy Practices and Policies may be requested by contacting the office.