Patient Information

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

State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect April 14, 2003 and will remain in effect until it is amended or replaced by us.

It is our right to change our privacy practices provided law permits the changes. Before we make a significant change, this Notice will be amended to reflect the changes and we will make the new Notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made. You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer. Information on contacting us can be found at the end of this Notice.

Typical Uses and Disclosures of Health Information

We will keep your health information confidential, using it only for the following purposes:

Treatment: We may use your health information to provide you with our professional services. We have established “minimum necessary or need to know” standards that limit various staff members’ access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement. For example: We may disclose medical information about you to doctors, nurses or other healthcare professionals involved in your care. For example, your doctor will need to know if you are allergic to any medicines. The doctor may share this information with pharmacists and others caring for you. ?We may also disclose information to other professionals providing your health care. For example, we may need to tell a specialist about your medical conditions if we refer you to a specialist so you may receive the proper care.

Disclosure: We may disclose and/share your healthcare information with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so.

Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances. If you have health insurance, we request payment from your health insurance plan for the services we provide. For example, we may need to give your health plan information about your visit, your diagnosis, procedures, and supplies used so that we can be compensated for the treatment provider. However, we will not disclose your health information to a third party payer without your authorization except required by law. We may also tell your health plan about your recommended treatment to get their prior approval, if that is required under your insurance plan. For example, if you need surgery, we will call your health plan to make sure the surgery is covered and will be paid for by the health plan.

Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death. If at all possible, we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your care. We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise.

Healthcare Operations: We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities. For example, we may use your health information to review the quality of services you receive or to provide training to our staff.

Required by Law: We may use or disclose your health information when we are required by law to do so. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security, intelligence and other State and/or Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.

Public Health Responsibilities: We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.

Marketing Health-Related Services: We will not use your health information for marketing purposes unless we have your written authorization to do so.

National Security: The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voice mail messages, postcards or letters.

Your Privacy Rights As Our Patient

Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the Request Form. You may also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to review your records. If you prefer a summary or an explanation of your health information, we will provide it for a fee. Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure.

Amendment: You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.

Non-routine Disclosures: You have the right to receive a list of non-routine disclosures we have made of your health care information. (When we make a routine disclosure of your information to a professional for treatment and/or payment purposes, a record of these disclosures is not kept; therefore it would not be available.) You have the right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment or healthcare operations. You can request non-routine disclosures going back 6 years starting on April 14, 2003. Information prior to that date would not have to be released. (Example: If you request information on May 15, 2004, the disclosure period would start on April 14, 2003 up to May 15, 2004. Disclosures prior to April 14, 2003 do not have to be made available.)

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We do not have to agree to these additional restrictions, but if we do, we will abide by our agreement. (Except in emergencies.) Please contact our Privacy Officer if you want to further restrict access to your health care information. This request must be submitted in writing.

Confidential Communication: You have the right to request to receive confidential communications by alternative means or at alternative locations. We will accommodate reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the request. Requests must be made in writing to our Privacy Officer.

Language Assistance

The Plastic Surgical Center of Mississippi, LLC (PSCM) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.  PSCM does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

ATTENTION:  If you speak a foreign language, language assistance services, free of charge, are available to you.  Call 1-601-939-9999 TTY: 1-866-939-4999).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.  Llame al 1-601-939-9999  (TTY: 1-866-939-4999).

CHÚ Ý:  Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.  Gọi số 1-601-939-9999   (TTY:   1-866-939-4999).

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電1-601-939-9999   (TTY:   1-866-939-4999)。

ATTENTION : Si vous parlez français, des services d’aide linguistique-vous sont proposés gratuitement.  Appelez le 1-601-939-9999  (ATS : 1-866-939-4999).

ملحوظة:  إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان.  اتصل برقم 1-601-939-9999 (رقم هاتف الصم والبكم: 1-1-866-939-4999.

ANOMPA PA PISAH:  [Chahta] makilla ish anompoli hokma, kvna hosh Nahollo Anompa ya pipilla hosh chi tosholahinla.   Atoko, hattak yvmma im anompoli chi bvnnakmvt, holhtina pa payah: 1-601-939-9999    (TTY:  1-866-939-4999).

PAUNAWA:  Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.  Tumawag sa 1-601-939-9999 (TTY: 1-866-939-4999).

ACHTUNG:  Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.  Rufnummer: 1-601-939-9999 (TTY: 1-866-939-4999).

주의:  한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 있습니다.  1-601-939-9999 (TTY: 1-866-939-4999)번으로 전화해 주십시오.

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-601-939-9999 (TTY: 1-866-939-4999).

注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-601-939-9999TTY:1-866-939-4999)まで、お電話にてご連絡ください。

ВНИМАНИЕ:  Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.  Звоните 1-601-939-9999 (телетайп: 1-866-939-4999).

ਧਿਆਨ ਦਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਵਿੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 1-601-939-9999 (TTY: 1-866-939-4999) ‘ਤੇ ਕਾਲ ਕਰੋ।

ATTENZIONE:  In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti.  Chiamare il numero 1-601-939-9999 (TTY: 1-866-939-4999).

ध्यान दें:  यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-601-939-9999 (TTY: 1-866-939-4999) पर कॉल करें।

Grievance

If you believe that PSCM has failed to provide these services or discriminated in another way on thebasis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Attn: Taylor Burnett, Plastic Surgical Center of MS, LLC,
2250 Flowood Dr., Suite 101, Flowood, MS  39232,
Telephone 601-939-5544 or 1-866-939-5544, Fax 601-939-8874,
Email; tburnett@psc-ms.com,

You can file a grievance in person or by mail, fax, or email.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
available at: http://www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources/

Questions and Complaints

You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us in writing. Request a Complaint Form from our Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

The Board of Directors, Medical Staff and Management of The Plastic Surgical Center of Mississippi support our patients’ rights by providing a grievance process to respond to your concerns regarding patient’s rights, quality of care, privacy, or patient safety.

We encourage you to be an active participant in your health care experience. The Center’s employees are available to answer questions and address concerns promptly during your visit. If you do not receive a satisfactory response to your concern or problem from our staff, please ask to speak with a member of our Administrative Team. To voice or file a formal complaint or grievance, please contact us verbally or in writing:

The Plastic Surgical Center of MS
T. Taylor Burnett 
Administrator
2550 Flowood Dr.
Suite 101
Flowood, MS 39232
Phone: 601-939-5544

Should you wish to discuss your concerns with an agency outside the center, you also have the right to contact:

MS State Department of Health
Bureau Director 
Health Facilities Licensure and Certification
P.O. Box 1700
Jackson, MS 39215-1700
Hot Line: 1-800-227-7308
Local Phone: 601-362-2194

All Medicare beneficiaries may also file a complaint or grievance with the Medicare Beneficiary Ombudsman http://www.medicare.gov/Ombudsmanlresources.asp

Medicare Beneficiary Ombudsman
www.medicare.gov

www.cms.hhs.gov/center/ombudsman
Phone: 1-800-633-4227

For more detailed information, please consult the patient rights and responsibilities document provided to you upon admission.