Marina Del Rey: 877.298.9915

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. PLEASE REVIEW IT CAREFULLY.

THIS NOTICE IS FROM GRANT STEVENS, M.D., INC., A PROFESSIONAL MEDICAL CORPORATION, DBA Marina Plastic Surgery, AND MARINA OUTPATIENT SURGERY CENTER, A MEDICAL CORPORATION, AND MARINA DERMATOLOGY, A MEDICAL CORPORATION, AND APPLIES ALSO TO THEIR AFFILIATED “INSTITUTE” (COLLECTIVELY REFERRED TO HEREIN AS “PROVIDER”).

PROVIDER (“PROVIDER”) provides plastic surgery, dermatology, outpatient surgery and related services. PROVIDER desires to maintain the privacy of health information and desires to provide patients with a notice of its legal duties and privacy practices. PROVIDER will not use or disclose private health information except as described in this notice. “Private Health Information” is information about you which was created or received by PROVIDER and that relates to a past, present or future physical or mental health or condition, or the provision of, or payment for, health care and which could be used to identify the patient.

EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS. The following categories describe the ways that PROVIDER may use and disclose private health information without written authorization.

Treatment: PROVIDER will use health information in the provision and coordination of healthcare. We may disclose all or any portion of private health information, such as medical reports, to attending physicians and other health care providers who have a need for such information in the care and continued treatment of the patient. PROVIDER also may disclose health information to other people, such as family members, clergy and others who may be involved in the patient’s care.

Payment: PROVIDER may release private health information about the patient for the purposes of determining coverage, billing, claims management, private health data processing, and reimbursement. The information may be released to a health plan or health insurer, or a workers compensation or other insurance company responsible for payment of our services, an employer involved in a workers’ compensation program, and a third party payer or other entity (or their authorized representatives) involved in the payment of the patient’s medical bill, and may include copies or excerpts of the private health record which are necessary for payment of the account. For example, a bill sent to a third party payer may include information that identifies the patient, the diagnosis, and the modalities used, and may include a copy of the medical report.

Health Care Operations: PROVIDER may use and disclose private health information during routine healthcare operations including, without limitation, utilization review, evaluation of our staff, assessing the quality of care and outcomes in the patient’s case and similar cases, internal auditing, accreditation, certification, licensing or credentialing activities, private health research and educational purposes.

Scheduling and Appointment Reminders: PROVIDER may use and disclose private health information obtained when scheduling medical or other healthcare services and when it contacts the patient as a reminder of an appointment for services. PROVIDER may also use and disclose private health information to tell the patient or others of information about treatment alternatives or other health-related benefits and services of possible interest to the patient.

Business Associates: PROVIDER may use and disclose certain private health information about the patient to business associates. A business associate is an individual or entity under contract with the PROVIDER to perform or assist PROVIDER in a function or activity which necessitates access to, or the use or disclosure of, private health information. Examples of business associates, include, but are not limited to, a copy service used by PROVIDER to copy private health records, consultants, accountants, lawyers, practice management organizations, private health transcriptionists, case managers, marketing and customer service personnel and third-party billing companies. PROVIDER will attempt to require the business associate to protect the confidentiality of private health information.

Regulatory Agencies: PROVIDER may disclose private health information to a health oversight agency for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations and inspections.

Law Enforcement/Litigation: PROVIDER may disclose private health information for law enforcement purposes as required by law or in response to a valid subpoena or court order.

Public Health: PROVIDER may disclose private health information to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, PROVIDER may be required to report the existence of a communicable disease to the Department of Health to protect the health and wellbeing of the general public.

Workers Compensation: PROVIDER may release private health information to employers, health care providers, examiners, judges, insurance companies, and others with a need to know, in connection with workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

Military/Veterans: PROVIDER may disclose private health information as required by military command authorities, if the patient is a member of the armed forces.

Required by Law: PROVIDER will disclose private health information about you when required to do so by law including, without limitation, for judicial or administrative proceedings, to report information related to victims of abuse, neglect or violence, to assist law enforcement officials in their law enforcement duties.

Coroners, Medical Examiners, Funeral Directors: PROVIDER may release private health information to a coroner or private health examiner. This may be necessary, for example, to identify a deceased person or to determine a cause of death. PROVIDER may also release private health information to funeral directors as necessary to carry out their duties.

Other Uses: Any other uses and disclosures will be made only with written authorization.

PATIENT HEALTH INFORMATION RIGHTS: Although all records concerning treatment are the property of PROVIDER you have the following rights concerning private health information. (“CFR” below stands for the Code of Federal Regulations). To exercise any of these rights, please contact the Privacy Officer identified below, in writing.

Right to Confidential Communications: You have the right to receive confidential communications of your private health information by alternative means or at alternative locations as provided by 45 CFR § 164.522. For example, you may request that PROVIDER only contact you at work or by mail.

Right to Inspect and Copy: You have the right to inspect and copy your private health information as provided by 45 CFR §164.524.

Right to Amend: You have the right to amend your private health information as provided by 45 CFR §164.526.

Right to an Accounting: You have the right to receive an accounting of disclosures of your private health information as provided by 45 CFR §164.528.

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your private health information as provided by 45 CFR §164.522. PROVIDER may not agree to honor the request.

Right to Receive Copy of this Notice: You have the right to receive a paper copy of this Notice, upon request.

Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your private health information except to the extent that action has already been taken in reliance on your authorization.

FOR MORE INFORMATION OR TO REPORT A PROBLEM: If you have questions and would like additional information, you may contact: Jessica Palomares at the number and address below. If you believe your privacy rights have been violated, you may file a complaint with PROVIDER and/or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with the PROVIDER, please contact: Jessica Palomares, Privacy Officer, at 4644 Lincoln Blvd., Suite 552, Marina Del Rey, California 90292. All complaints must be submitted to the Privacy Officer in writing at the above address. There will be no retaliation for filing a complaint.

CHANGES TO THIS NOTICE: PROVIDER will abide by the terms of the Notice of Health Information Practices currently in effect. PROVIDER reserves the right to change the terms of its notice and to make the new notice provisions effective for all protected health information that it maintains. PROVIDER will post any revised Notice (prior to implementation of same).

NOTICE EFFECTIVE DATE: The effective date of the notice is April 13, 2003.

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