Notice of Privacy Practices

Face Forward Aesthetics LLC
Date effective: February 8, 2020

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

• Get an electronic or paper copy of your medical record. You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. You have the right to receive access to your health information or a summary of your health information within 30 days of your request. We may charge a reasonable, cost-based fee.
• Ask us to correct your medical record. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may not accommodate your request, but we will tell you why in writing within 60 days.
• Request confidential communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will accommodate all reasonable requests.
• Ask us to limit what we use or share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may not agree if it would affect your care. 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 agree to that, unless a law requires us to share that information.
• Get a list of those with whom we have shared information. You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
• Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
• File a complaint if you feel your rights are violated. You can complain if you feel we have violated your rights by contacting us using the information at the end of this notice. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Your Choices

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. Any authorization to share your health information must be in writing and can be revoked by you. In these cases, you will be given an opportunity to agree or object to: Sharing information with your family, close friends, or others involved in your care; Using or disclosing your information to notify, or assist in the notification of, your family or representative; and Sharing information in a disaster relief situation including your information in a hospital directory.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In the following cases we never share your information unless you give us written permission: marketing purposes; sale of your information; sharing of psychotherapy notes except in certain instances where disclosure is required by law (45 CFR §164.508(a)(2)).

In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways:

• Treat you. We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
• Run our organization. We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
• Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities, including credit card, debit card, or other financial institution. Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways without your prior authorization usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes:

Help with public health and safety issues. We can share health information about you as required for certain situations such as:

• To a public health authority authorized to collect information for the purposes of preventing disease, injury, or disability;
• To the FDA to collect or report adverse events, to track FDA-regulated products, to enable product recalls, repairs, or replacement, and to conduct post-marketing surveillance; Reporting adverse reactions to medications;
• Reporting suspected abuse, neglect, or domestic violence;
• Preventing or reducing a serious or imminent threat to anyone’s health or safety;

Do research: we can use or share your information for health research pursuant to an IRB waiver of the Authorization requirement; for reviews preparatory to research (accessing PHI in order to prepare a protocol or determine whether potential subjects exist), if the IRB obtains the proper assurances from the researcher; research on decedent information if the IRB obtains the proper assurances from the researcher;

Comply with the law.We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law or to comply with laws related to worker’s compensation; Respond to organ and tissue donation requests. We can share health information about you for cadaveric organ, eye or tissue donation purposes;

Work with a medical examiner or funeral director and representative of a decedent. We can share health information with a coroner, medical examiner, or funeral director when an individual dies as authorized or required by law. If you are deceased, we can share health information with your family or representative that is relevant to that person’s involvement in your care or payment and as long as sharing the information is not inconsistent with any prior preference you have expressed;

Address workers’ compensation, law enforcement, and other government requests. We can use or share health information about you:

• For workers’ compensation claims;
• With a law enforcement official for the location or identity of a suspect, fugitive, victim, or material witness or for other law enforcement purposes as required by legal process or applicable law, including grand jury subpoena, judicial warrant or order, or an authorized administrative request;
• With health oversight agencies for activities authorized by law;
• For special government functions such as military, national security, and presidential protective services.

Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

HIPAA protections apply for 50 years after death. If an individual has been deceased for more than 50 years, a HIPAA Authorization is not required. In situations where a HIPAA Authorization is required and the individual is deceased, the Authorization must be obtained from the deceased individual’s legally-authorized representative. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. We will inform you when this notice is updated. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

This Notice describes how Face Forward Aesthetics LLC may use and disclose your protected health information. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Contact Information

If you have any questions about this Notice, or have a complaint, please contact the Compliance and Regulatory Officer at 844-307-5929 or amhoney@ffaesthetics.com.

Acknowledgement of receipt of notice of privacy practices: I hereby acknowledge I have received a copy of this office Notice of Privacy Practices.