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Rebecca Small, M.D.
820 Bay Avenue, Suite 246
Capitola, CA 95010

831.475.1077

Monterey Bay Laser Aesthetics

Notice of Privacy Practices
Effective Date: April 14, 2005

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

If you have any questions about this notice, please contact our Office Privacy Official, Rebecca Small, M.D. This notice applies to all of the records of your care generated by your physician.
Our Responsibilities
We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice.
Uses and Disclosures
The following categories describe examples of the way we use and disclose health information:
For Treatment: We may use health information about you to provide you treatment or, services. We may disclose health information about you to doctors, nurses, technicians, or other personnel who are involved in your care.
For Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about your treatment so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether it will be covered.
For Health Care Operations: Members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients we serve. We may remove information that identifies you from this set of health information to protect your privacy. We may also use and disclose health information:

  • To business associates we have contracted with to perform the agreed upon service and to bill them
  • For population based activities relating to improving health or reducing healthcare costs
  • For conducting training programs or reviewing competence of healthcare professionals
  • To remind you of a medical appointment
  • To assess your satisfaction with our services
  • To tell you about possible treatment alternatives
  • To inform Funeral Directors consistent

When disclosing information, primary appointment reminders and billing/collections efforts, we may leave messages on your answering machine or voice mail.
Business Associates: There are some services provided in our organization through contracts with business associates. Examples include copy service we use when making copies of your health record or a billing service. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do and bill you, your insurance company or a third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Individuals Involved in Your Care or Payment for Your Care: We may release health information about you to a friend or family member who is involved in your medical care or who helps pay for your care. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Research: We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research and granted a waiver of the authorization requirement.
Future Communications: We may communicate to you via newsletters, mail outs or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities in which we participate.
Affiliated Covered Entity: As required by law, we may also use and disclose health information for the following types of entities, including but not limited to:

  • Food and Drug Administration
  • Protective Services for the President and Others
  • Correctional Institutions
  • Workers Compensation Agents
  • Organ and Tissue Donation Organizations
  • Military Command Authorities
  • Health Oversight Agencies
  • Funeral Directors, Coroners and Medical Directors
  • National Security and Intelligence Agencies
  • Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability

Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
State Specific Requirements: Many states have requirements for reporting including population-based activities relating to improving health or reducing healthcare costs. Some states have separate privacy laws that may apply additional legal requirements. If the state privacy laws are more stringent than federal privacy laws, the state law preempts the federal law.

Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the Right to:
Inspect and Copy: You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the hospital 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.
Amend: If you feel that health 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 office keeps the information. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.
An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of certain disclosures we make of your health information for purposes other than treatment, payment or healthcare operations where an authorization was not required.
Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health 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. For example, you could ask that we not use or disclose information about a surgery you had. 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.
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 contact you at work instead of your home. The facility will grant requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by the facility and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

Changes to this Notice
We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the office and include the effective date. In addition, each time you have an appointment, we will offer you a copy of the current notice in effect.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with the facility by following the process outlined in the facility's Patient Rights documentation. You may also file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Health Information
Other uses and disclosures of health 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 health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health 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 and documented.

Rebecca Small, MD
Monterey Bay Laser Aesthetics | 820 Bay Avenue, Suite 246 | Capitola, CA 95010 | 831.475.1077
Serving Capitola, Scotts Valley, Monterey, Carmel, Watsonville, Los Gatos, Aptos, Soquel, Felton, and the surrounding areas.