Notice of Privacy Policies and
Practices for Hamzavi Dermatology
& Rejuvenation

DEAR PATIENT:

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

At Hamzavi Dermatology and Rejuvenation we are committed to treating and using protected health information about you responsibly. This Notice describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effec­tive April 14, 2003 and applies to all protected health information as defined by federal regula­tions.

If you believe that your privacy rights have been violated, please contact the aforementioned prac­tice Privacy Official or you may file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the practice^'s Privacy Official or with the Office for Civil Rights. The address for the Office for Civil Rights is listed below:

UNDERSTANDING YOUR MEDICAL RECORD/HEALTH INFORMATION

Each time you visit Hamzavi Dermatology or Reju­venation a record of your visit is made. Typically, this record contains information about your visit including your examination, diagnosis, test results and treatment as well as other pertinent health­care data. This information often referred to as your health or medical record, serves as a:

• Basis for planning your care and treat­ment.
• Means of communication with other health professionals involved in your care.
• Legal document outlining and describing the care you received.
• A tool that you or another payer (your in­surance company) will use to verify that services billed were actually provided.
• An education tool for medical health pro­viders.
• A source for medical research.
• Basis for public health officials who might use this information to assess and/or im­prove state as well as national healthcare standards.
• A source of data for planning and/or mar­keting.
• A tool that we can reference to ensure the highest quality of care and patient satis­faction.

Understanding what is in your record and how your health information is used helps you to ensure its accuracy, determine what entities have access to your health information, and make an informed decision when authorizing the disclosure of this information to other individuals.

YOUR RIGHTS

You have certain rights under the federal privacy standards. These include:

• The right to request restrictions on the use and disclosure of your protected health information.
• The right to receive confidential communi­cations concerning your medical condition and treatment.
• The right to inspect and copy your pro­tected health information.
• The right to amend or submit corrections to your protected health information.
• The right to receive an accounting of how and to whom your protected health infor­mation has been disclosed.
• The right to receive a printed copy of this notice.

OUR RESPONSIBILITIES

Hamzavi Dermatology & Rejuvenation are re­quired to:

• Maintain the privacy of your health infor­mation.
• Provide you with this Notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
• Abide by the terms of this Notice.
• Notify you if we are unable to agree to a requested restriction.
• Accommodate reasonable requests you may have regarding communication of health information via alternative means and/or locations.

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be re­quired by changes in federal and state laws and regulations.  Whatever the reason for these revi­sions, we will provide you with a revised notice on your next office visit.  The revised policies and practices will be applied to all protected health information that we maintain.  We will not use or disclose your health information without your au­thorization, except as described in this notice.  We will also discontinue using or disclosed your health information after we have received a written revo­cation of the authorization according to proce­dures included in the authorization.

HOW WE MAY USE AND/OR DISCLOSE YOUR HEALTH INFORMATION

We will use your health information for treatment - Your health information may be used by staff members or disclosed to other healthcare profes­sionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.  For example: results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treat­ment or who may be consulted by staff members.

We will use your information for payment - Your health plan may request and receive information on dates of service, the services provided and the medical condition being treated in order to pay for the service rendered to you.

We will use your information for regular health operations - Your health information may be used as necessary to support the day-to-day activities and management of Hamzavi Dermatology & Rejuvena­tion.  For example: Information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Business Associates - In some instances, we have contracted separate entities to provide services for us.  These "associates^" require your health infor­mation in order to accomplish the tasks that we ask them to provide.  Some examples of these "business associates" might be a billing service, collection agency, answering services and com­puter software/hardware provider.

Communication with family - Due to the nature of our field, we will use our best judgment when dis­closing health information to a family member, other relatives, or any other person that is involved in your care or that you have authorized to receive this information.  Please inform the practice when you do not wish a family member or other individ­ual to have authorization to receive your informa­tion.

Research / Teaching / Training - We may use your information for the purpose of research, teaching and training.

Healthcare Oversight  - Federal law requires us to release your information to an appropriate health oversight agency, public health authority or attor­ney, or other federal/state appointee if there are circumstances that require us to do so.

Public Health Reporting - Your health information may be disclosed to public health agencies as re­quired by law.

INTRODUCTION

Appointment Reminders - The practice may use your information to remind you about upcoming appointments.  Typically, appointment reminders are sent by mail in a closed envelope or a brief, non-specific message may be left on your answer­ing machine. If you do rot approve of these meth­ods, or if you prefer alternative methods (i.e. e­mail) please inform the practice.

Other uses and Disclosures - A disclosure of your health information or its use for any purpose other than those listed above requires your specific writ­ten authorization.  If you change your mind after authorizing a use or disclosure of you information you may submit a written revocation of the authori­zation.  However, your decision to revoke the au­thorization will not affect or undo any use or disclo­sure of information that occurred before you noti­fied us of your decision.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have complaints, questions or would like additional information regarding this notice or the privacy practices of Hamzavi Dermatology and Re­juvenation please contact:

Privacy Officer

Gina Fleming

S.L. Husain Hamzavi, M.D. P.C.
1201 Stone Street, Suite 8
Port Huron, MI 48060
810-985-4411

Privacy Officer

Fasahat Hamzavi, M.D.

43151 Dalcoma, Suite 1
Clinton Township, MI 48038

586-286-8720

Privacy Officer

Iltefat Hamzavi

49650 Cherryhill Rd, Suite 230

Canton, MI 48187

734-495-1506

If you believe that your privacy rights have been violated, please contact the aforementioned prac­tice Privacy Official or you may file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the practice^'s Privacy Official or with the Office for Civil Rights. The address for the Office for Civil Rights is listed below:

OFFICE FOR CIVIL RIGHTS
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington. D.C., 20201