Authorization to Release Medical Information
(HIPAA Authorization Under 45 C.F.R. § 164.508)
A. Statement of Intent. It is my understanding that Congress passed a law entitled the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), that there are federal regulations that interpret and implement that law, and that HIPAA limits disclosure of my “Individually Identifiable Health Information” to certain of my family, friends, and 3rd party organizations, regardless of my state of health. I am signing this authorization so Aesthetic & Reconstructive Plastic Surgery, PLLC., and Skin Raleigh, LCC. (“My Health Care Providers”) can disclose my health care information to the 3rd party organizations listed below and openly discuss that information with them.
B. Authorization. I hereby authorize My Health Care Providers to fully disclose Individually Identifiable Health Information to any or all of their 3rd party software providers, including but not limited to: Nextech, Eden Knows Implants NC LLC, SquareSpace Inc, Microsoft, MailChimp, and Intuit Inc (the “Organizations”).
Each 3rd party organization shall have the authority to act individually and without notice to any other designated organization.
C. Authority to Discuss and Answer Questions. My Health Care Providers are expressly authorized to answer questions posed by the Organizations and the Personal Representatives listed above and openly discuss with them my condition, treatment, test results, prognosis, and all other information pertinent to my health care, even if I am fully competent to ask questions and discuss my medical condition. This document constitutes a full authorization to disclose any Individually Identifiable Health Information to any or all of the 3rd party software providers (named or unnamed under Organizations) named in this Authorization.
D. Waiver and Release. I hereby release any Health Care Provider who acts in reliance on this Authorization from any liability that may accrue from releasing my Individually Identifiable Health Information and for any actions taken by the Organizations or my Personal Representatives.
E. Termination. This Authorization is effective as of the date shown and shall not be affected by my subsequent disability or incapacity. This authorization shall terminate on this first to occur of: (1) two years following my death or (2) upon my written revocation actually received by the Health Care Provider. Proof of receipt of my written revocation may be by certified mail, registered mail, facsimile, or any other receipt evidencing actual receipt by the Health Care Provider.
F. Re-Disclosure. I readily acknowledge that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the Personal Representatives and Organizations named in this Authorization and no longer protected by the HIPAA rules. I realize that such re-disclosure might be improper, cause me embarrassment, cause family strife, be misinterpreted by non-health care professionals, and otherwise cause me and my family various forms of injury. I fully indemnify my Health Care Providers for all consequences which may occur as a result of their good faith reliance and compliance with this Authorization. No Health Care Provider shall require the Organizations or my Personal Representatives to indemnify the Health Care Provider or agree to perform any act in order for the Health Care Provider to comply with this Authorization.
G. Enforcement. The Organizations or my Personal Representatives shall have the right to bring a legal action in any applicable forums against any Health Care Provider who refuses to recognize and accept this Authorization. Additionally, the Organizations or my Personal Representatives are authorized to sign any documents that my Personal Representatives deem necessary or appropriate to obtain my Individually Identifiable Health Information.
H. Conflicts With Other Authorizations. This Authorization is in addition to other medical release authorizations I may have granted in the past or future; it does not replace them. This Authorization may be relied upon by my Health Care Providers regardless of any real or perceived conflict with any Medical Power of Attorney signed by me, whether prior to or subsequent to the date of this Authorization. I recognize and intend that this may result in multiple persons having the authority to obtain my protected Individually Identifiable Health Information. This Authorization is not intended to replace a Medical Power of Attorney, nor to grant any person the authority to make health care decisions, but merely to obtain information and explanations.
I. Copies. A copy or facsimile of this original Authorization may be accepted and relied upon as though it was an original document.
1. Individually Identifiable Health Information. In regards to this Authorization, the term “Individually Identifiable Health Information” includes (but is not limited to) the following: first and last name, email address, relevant procedures, diagnosis, prognosis, treatment, billing information, the identity of health care providers and insurers, whether past, present or future, and any other medical information which is in any way related to my health care. In this Authorization, the term also includes the term “Protected Medical Information” as sometimes used in HIPAA.
2. Health Care Providers. The term “Health Care Providers” includes (but is not limited to) the following: Doctors (including, but not limited to, physicians, podiatrists, chiropractors, or osteopaths), psychiatrists, psychologists, dentists, therapists, nurses, hospitals, clinics, pharmacies, laboratories, ambulance services, assisted living facilities, residential care facilities, bed and board facilities, nursing homes, medical insurance companies, and any other medical providers or affiliates. In this Authorization, the term also includes the term “Covered Entity” as sometimes used in HIPAA.
Personal Identification Information
We may collect personal identification information from Users in a variety of ways, including, but not limited to, when Users visit our site, request a consultation, contact us via our contact form, and in connection with other activities, services, features or resources we make available on our Site. Users may be asked for, as appropriate, name, email address, mailing address, and phone number. We will collect personal identification information from Users only if they voluntarily submit such information to us. Users can always refuse to supply personally identification information, except that it may prevent them from engaging in certain Site related activities.
Non-Personal Identification Information
We may collect non-personal identification information about Users whenever they interact with our Site. Non-personal identification information may include the browser name, the type of computer and technical information about Users means of connection to our Site, such as the operating system and the Internet service providers utilized and other similar information.
Modifying or Deleting Identification Information
If you wish to modify or delete identification information from Davis & Pyle Plastic Surgery’s database, you may do so by sending a request via the contact form at contact-us, or by calling 919-785-1220.
How We Use Collected Information
Davis & Pyle Plastic Surgery collects and uses Users personal information for the following purposes:
To personalize user experience: We may use information in the aggregate to understand how our Users as a group use the services and resources provided on our Site.
To improve our Site: We continually strive to improve our website offerings based on the information and feedback we receive from you.
To send periodic emails: The email address Users provide may be used, with their permission, to send periodic emails regarding services, products and special offers. The email address may also be used to respond to their inquiries, and/or other requests or questions. Users may opt out of receiving email communication by requesting to opt out at the bottom of an email, by sending a separate email via the contact form at contact-us, or by calling 919-785-1220.
How We Protect Your Information
We adopt appropriate data collection, storage and processing practices and security measures to protect against unauthorized access, alteration, disclosure or destruction of your personal information, username, password, transaction information and data stored on our Site.
Sharing Your Personal Information
We do not sell, trade, or rent Users’ personal identification information to others. We may share generic aggregated demographic information not linked to any personal identification information regarding visitors and users with our business partners, trusted affiliates and advertisers for the purposes outlined above.
Third Party Websites
Users may find links or other content on our Site that connect to the sites and services of our partners, suppliers, advertisers, sponsors, licensors and other third parties. We do not control the content or links that appear on these sites and are not responsible for the practices employed by websites linked to or from our Site. In addition, these sites or services, including their content and links, may be constantly changing. These sites and services may have their own privacy policies and customer service policies. Browsing and interaction on any other website, including websites which have a link to our Site, is subject to that website’s own terms and policies.
Your Acceptance of These Terms
By using this Site, you signify your acceptance of this policy. If you do not agree to this policy, please do not use our Site. Your continued use of the Site following the posting of changes to this policy will be deemed your acceptance of those changes.
Health Care Disclosure Notification
Effective April 14th, 2003, the Federal Health Privacy Rule must be implemented and we must inform our patients of their rights under this law. While we have always made every effort to keep all your information confidential, we are now required to inform you of those persons or entities who may have access to your personal and health care information.
Employees of Davis & Pyle Plastic Surgery (limited by job classification)
Any or all of our 3rd party software providers, including but not limited to: Nextech Systems LLC, Eden Knows Implants NC LLC, SquareSpace Inc, Microsoft, MailChimp, and Intuit Inc.
Physicians associated with your treatment or surgical procedure
Outside physicians or pathologists who would examine tissue removed
Anesthesiologists associated with the Surgery Center
Any physician or hospital to whom you are referred by our staff physicians
Any independent contractor working with Davis & Pyle Plastic Surgery, i.e. consultants and aestheticians
Your health insurance provider
Designated family members or friends (post surgical)
Medical staff committees for the purpose of quality assessment and peer review
Licensing agencies in response to inquiries
Issuance of a subpoena and upon verification of authorization
ALL PATIENTS WILL BE REQUESTED TO SIGN A CONSENT FORM ACKNOWLEDGING OUR PRIVACY PRACTICES PRIOR TO TREATMENT. Patients have the right not to sign this consent form. However, this would necessitate the physician to refuse treatment. A patient has the right to revoke the consent after receiving treatment and to request restrictions and request confidential communication.
A patient has the right to request a copy of his or her health information upon written request. The copy will be completed within 15 days of receiving request at a cost to the patient of $ 0.25 per page.
A patient has the right to examine and review his or her health information upon written request. This request will be honored within five (5) working days. A patient has the right to request an amendment to his or her health information and, if accepted, this will become a part of the complete medical record. Information and procedure to be followed can be received by contacting us at 919-785-1220.
Patients who feel their privacy with regards to personal or health care information has been compromised may contact:
The Department of Health and Human Services
The Federal Office of Civil Rights