NOTICE OF PRIVACY PRACTICES

Last Revised: December 1, 2016

NOTICE OF PRIVACY PRACTICES

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Procedures (the “Policy” or “Notice”) describes the practices of Ohio Clinic for Aesthetic and Plastic Surgery, Inc. (“OCAPS,” “we" or "us") with respect to your protected medical information.

OUR PLEDGE REGARDING YOUR PROTECTED HEALTH INFORMATION

OCAPS understands that medical information about you and your health is personal. We are committed to protecting medical information about you. We maintain our records and conduct our treatment environment with a goal of providing the highest level of protection for your medical information, while still providing you with the highest level of medical care. This Policy applies to all of the records of your medical care which are received or created by OCAPS.

Your other medical treatment providers (e.g. doctors, hospitals, home health agencies, etc.) may have different policies regarding the use and disclosure of your medical information. This Policy describes the ways in which OCAPS may use and disclose medical information about you. Your medical information, also referred to as "protected health information" is that information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health information and related health care services. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

This Policy also describes your rights and certain of the obligations that OCAPS has regarding the use and disclosure of your protected health information. We are required to:

  1. Make sure that medical and other information that identifies you (protected health information) is kept private.
  2. Give you this notice of our legal duties and privacy practices with respect to protected health information about you.
  3. Follow the terms of the Policy that is currently in effect.

USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

If a doctor-patient relationship is formed between us, you are giving consent for OCAPS, OCAPS employees, and Dr. Michael H. Wojtanowski to use your protected health information for certain activities, including treatment, payment and other health care operations.

We may use and disclose protected health information about you so that OCAPS and its medical professionals can treat you. For example, we may use your past medical information in order to diagnose your present condition or we may provide information regarding your medical condition to another doctor to whom we refer you for additional care. We may also use and disclose protected health information about you so that we may be paid for the medical treatment we provide you. We may also use and disclose protected health information about you for OCAPS's health care operations, in other words, those other tasks that we need to perform to make sure that you are provided the highest quality of medical care. For example, we may use your protected health information to evaluate how we can better meet your needs or we may provide protected health information about you to an auditor who reviews our books so that we can keep our license to provide medical services in Ohio.

The following additional uses of your protected health information may be made without any additional authorization from you. (Not every use or disclosure is listed, but be assured that all uses and disclosures made by OCAPS are only those which are permitted under the law).

Ohio Clinic for Aesthetic and Plastic Surgery

Westlake Corporate Park

2237 Crocker Road

Suite 140

Westlake, Ohio 44145

        We will accommodate all reasonable requests.

OTHER USES AND DISCLOSURES THAT MAY OCCUR OF PROTECTED HEALTH INFORMATION

In addition to disclosures of your protected health information for treatment, payment and health care operations, we disclose your protected health information in the following circumstances:

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU

If you pay for a service or health care item out of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” to this request unless the law requires us to share that information.

To request restrictions, you must make your request in writing to Ohio Clinic for Aesthetic and Plastic Surgery, Westlake Corporate Park, 2237 Crocker Road, Suite 140, Westlake, Ohio 44145.

In your written 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.

YOUR CHOICES REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

CHANGES TO THIS NOTICE

OCAPS reserves the right to change this Notice. We reserve the right to make the revised or changed Notice effective for protected health information we already have about you, as well as any information we create or receive in the future. We will post a copy of the current Notice on OCAPS website: www.ohioclinic.com, at The Ohio Clinic for Aesthetic and Plastic Surgery, and will make paper copies available upon request. The Notice will contain, in the top left-hand corner, the effective date.

COMPLAINTS

If you believe your privacy rights have been violated and/or that OCAPS, its employees or Dr. Michael H. Wojtanowski have not followed this Policy, you may file a complaint with Dr. Carlos Wolf, Office Manager or with the Secretary of the Department of Health and Human Services.

To file a complaint contact:

Ohio Clinic for Aesthetic and Plastic Surgery

Westlake Corporate Park

2237 Crocker Road

Suite 140

Westlake, Ohio 44145

Attention: Office Manager

All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF PROTECTED HEALTH INFORMATION

Other uses and disclosures of your protected health information not covered by this Notice or the laws that apply to Dr. Michael H. Wojtanowski will be made only with your written permission ("authorization"). If you provide us authorization to use or disclose protected health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose protected health information about you for the reasons covered by your 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 medical treatment or other services that we have provided to you.

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