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THE CENTER FOR FACIAL PLASTIC & LASER SURGERY, PA, The Forum @ Ballantyne
Commons, 11220 Elm Lane, Suite 101, Charlotte, NC 28277

TO OUR PATIENTS: NOTICE OF PRIVACY PRACTICES

This notice describes how health information about you, as a patient of The Center for Facial
Plastic Surgery, may be used and disclosed, and how you can get access to your health
information.  This is required by the Privacy Regulations created as a result of the Health
Insurance Portability and Accountability Act of 1996, (HIPAA).

OUR COMMITMENT TO YOUR PRIVACY

The Center for Facial Plastic & Laser Surgery is dedicated to maintaining the privacy of your
health information. We are required by law to maintain the confidentiality of your health
information.

We realize that these laws are complicated, but we must provide you with the following
important information.

USES AND DISCLOSURE OF YOUR HEALTH INFORMATION IN CERTAIN SPECIAL
CIRCUMSTANCES

The following circumstances may require us to use or disclose your health information:

• To public health authorities and health oversight agencies that are authorized by law to
  collect information.

• Lawsuits and similar proceedings in response to a court or administrative order.

• If required to do so by a law enforcement official.

• When necessary to reduce or prevent a serious threat to your health and safety or the
  health and safety of another individual or the public. We will only make disclosures to a
  person or organization able to help prevent the threat.

• If you are a member of U.S. or foreign military forces (including veterans) and if required
  by the appropriate authorities.

• To federal officials for intelligence and national security activities authorized by law.

• To correctional institutions or law enforcement officials if you are an inmate or under the
  custody of a law enforcement official.

• For Workers Compensation or similar programs.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

• Communications: You can request that Center for The Facial Plastic Surgery
  communicate with you about your health and related issues in a particular manner or
  at a certain location. For instance, you may ask that we contact you at home, rather
  than at work.  We will accommodate reasonable requests.
• You can request a restriction in our use or disclosure of your health information for
  treatment, payment, or health care operations. Additionally, you have the right to request
  that we restrict our disclosure of your health information to only certain individuals involved
  in your care or the payment for your care, such as family members and friends. We are
  not required to agree to your request; however, if we do agree, we are bound by our
  agreement except when otherwise required by law, in emergencies, or when the
  information is necessary to treat you.
• You have the right to inspect and obtain a copy of the health information that may be
  used to make decisions about you, including patient medical records and billing records,
  but not including psychotherapy notes. You must submit your request in writing to: The
  Center for Facial Plastic & Laser Surgery, 11220 Elm Lane, Suite 101, Charlotte, NC
  28277, ATTN: Helen Mundy.
• You may ask us to amend your health information if you believe it is incorrect or
  incomplete, and as long as the information is kept by or for our practice. To request and
  amendment, your request must be made in writing and submitted to: The Center for
  Facial Plastic & Laser Surgery, 11220 Elm Lane, Suite 101, Charlotte, NC
  28277, ATTN: Helen Mundy.

You must provide us with a reason that supports your request for the amendment.

• Right to a copy of this notice. You are entitled to receive a copy of the Notice of Privacy
  Practices. You may ask us to give you a copy of this Notice at any time. To obtain a
  copy of this notice, contact our front desk receptionist.
• Right to file a complaint. If you believe that your privacy rights have been violated, you
  may file a complaint with our practice or with the Department of Health and Human
  Services. To file a complaint with our practice, contact: The Center for Facial Plastic &
  Laser Surgery, 11220 Elm Lane, Suite 101, Charlotte, NC 28277, ATTN: Helen Mundy. 

All complaints must be submitted in writing. You will not be penalized or otherwise retaliated
against for filing a complaint.

• Right to provide an authorization for other uses and disclosures. Our practice will obtain
  your written authorization for uses and disclosures that are not identified by this notice or
  permitted by applicable law.

If you have any questions regarding this notice or our health information privacy policies, please
contact: The Center for Facial Plastic & Laser Surgery, 11220 Elm Lane, Suite 101, Charlotte,
NC 28277, ATTN: Helen Mundy.


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