Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information as required by the Privacy Regulations of the Health Information Portability and Accountability Act of 1996 (HIPAA). Please review it carefully.
Questions about this Notice may be addressed to our Privacy Contact: Beth Agami, Compliance Officer.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information (PHI) is information about you, including demographic information that may identify you and that relates to your past, present or future physical condition and the products or services we provide to you.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices.
A. OUR COMMITMENT TO YOUR PRIVACY
A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. is committed to maintaining the privacy of your identifiable health information. In conducting your business, we create records of your purchases and the services we provide you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
To summarize, this notice provides you with the following important information:
- How we may use and disclose your identifiable health information
- Your privacy rights in your identifiable health information
- Our obligations concerning the use and disclosure of your identifiable health information
B. WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS:
A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. will use or disclose your protected health information for the purpose of providing appropriate products for your particular needs. Your protected health information may also be used and disclosed to obtain reimbursement for you for these products and to operate our business.
The following categories describe the different ways in which we may use and disclose your identifiable health information.
A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. may use your identifiable health information to take your order, i.e., by asking personal questions to help you select the appropriate product for your particular needs. We may also disclose your identifiable health information to others who may assist in your care, such as your spouse, children, parents, or appointed caretaker. Adequate identification will be required.
A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. use and disclose your identifiable health information in order to file your Medicare and/or any insurance claims and respond to secondary insurance inquiries so they may reimburse you. Adequate identification will be required from insurance companies.
3. HEALTH CARE OPERATIONS
A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. may use and disclose your identifiable health information to operate our business. We maintain physical, electronic, and procedural safeguards to comply with federal regulations to guard this information. These activities may include, but are not limited to, response to any lawful appropriate government agency request, quality assessment activities, accreditation, marketing, and conducting or arranging for other business activities. We may use or disclose your protected health information, as necessary, to provide you with information about products or other health-related benefits and services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you.
4. TO THE EXTENT OF THE LAW
A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. will use and disclose your identifiable health information when requested to do so according to federal, state, or local laws. These may include but are not limited to public health authorities, health oversight agencies, law enforcement authorities, military and national security authorities, worker’s compensation, and authorities investigating our compliance with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
5. COMMUNICATION BARRIERS
We may use and disclose your protected health information if your Certified Fitter/Office Staff attempts to obtain consent from you but is unable to do so due to substantial communication barriers and it is determined, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
C. YOUR RIGHTS
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to INSPECT AND COPY your protected health information: This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. uses for conducting business with you. Your request must be made in writing to A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. Privacy Contact.
You have the right to REQUEST A RESTRICTION of your protected health information: This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. You may request a PHI Restriction Form by calling our Privacy Contact person.
You have the right to REQUEST TO RECEIVE CONFIDENTIAL COMMUNICATIONS from us by alternative means or at an alternative location: We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.
You may have the right to AMEND YOUR PROTECTED HEALTH INFORMATION: This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. You must provide us with a reason that supports your request for amendment. Our organization will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the identifiable health information kept by or for the organization; (c) not part of the identifiable health information which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information. Your request must be made to A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. Privacy Contact.
You have the right to RECEIVE AN ACCOUNTING OF CERTAIN DISCLOSURES we have made, if any, of your protected health information: This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter time frame. Your request must be in writing to A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. Privacy Contact.
You may complain to us or to 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 Contact of your complaint. We will not retaliate against you for filing a complaint.
E. MEDICARE DMEPOS SUPPLIER STANDARDS
DMEPOS suppliers have the option to disclose the following statement to satisfy the requirement outlined in Supplier Standard 16 in lieu of providing a copy of the standards to the beneficiary.
“The products and/or services provided to you by A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. Inc. are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g. honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.”
You may contact our Privacy Contact, Beth Agami at (954) 978-8287 or firstname.lastname@example.org for further information about the complaint process. This notice was published and becomes effective on April 14, 2003.
Secretary of Health and Human Services
U.S. Dept. of Health and Human Services
200 Independence Avenue SW,
Washington, DC 20201