Cosmetica Plastic Surgery & Anti-Aging
The Department of Health and Human Services, Office of Civil Rights, under the Public Law 104-191, (The Health Insurance Portability and Accountability Act of 1996) (HIPAA), mandates that we issue this new revised Privacy Notice to our patients. This notice to our patients meets all current requirements as it relates to Standards for Privacy of Individually Identifiable Health Information IIHI); affecting our patients. You are urged to read this notice.
As part of the Privacy Standard, implemented on April 14, 2001, you are required to provide this office with a new, signed and dated, Consent Agreement. Every patient must receive our new Privacy Notice and execute a new Consent Agreement before this office may use your information for treatment, payment, or other health care operations (TPO).
Our Privacy Notice informs you of our use and disclosure of your Protected Health Information (PHI), defined as: “any information, whether oral or recorded in any medium, that is either created or received by a health care provider, health plan, public health authority, employer, life insurance company, school or university or clearinghouse and that relates to the past, present or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past present or future payment for the provision of health care to an individual.”
Our office will use or disclose your PHI for purposes of treatment, payment and other healthcare purposes as required to provide you the best quality healthcare services that we offer to the extent permitted by your Consent Agreement or in such specific situations, by your signed and dated Authorization. It is our policy to control access to your PHI; and even in cases where access is permitted, we exercise a “minimum necessary information” restriction to that access. We define the minimum necessary information as the minimum necessary to accomplish the intent of the request.
An Authorization differs from a Consent Agreement in that it is very specific with regard to the information allowed to be disclosed or used, the individual or entity to which the information may be disclosed to, the intent for which it may be disclosed, and the date that it was initiated which may include the duration of the authorization. This is a form, separate from the Consent Agreement, and usually used only for one specific request for information. In the event of a non-healthcare related request for personal health information this office will request you to complete an Authorization Form.
You, as our patient, may revoke any Consent Agreement or Authorization at any time and all use and disclosure and administration of related healthcare services will be revised accordingly, with the exception of matters already in process as a result of prior use of your PHI. To revoke either the Consent Agreement or the Authorization you will have to provide this office with a written request with your signature and date and your specific instructions regarding an existing Authorization or Consent Agreement. Any revocation will not apply to information already used or disclosed.
If you had a “personal representative” initiate as Authorization you may revoke that authorization at any time.
You, the patient have access to your health care information and may request to examine your information, may request copies of your information, and under the law you may request amendments to your information. The physician or principal will exercise professional judgment with regard to requests for amendments and is not bound by law to make any changes to the information. If the physician or professional agrees with the request to amend the information, we are bound by law to abide by the changes.
In limited circumstances, The Privacy Standard permits, but does not require, covered entities to continue certain existing disclosures of health information without individual authorization for specific public responsibilities.
These permitted disclosures include: emergency circumstances; identification of the body of a deceased person, or to assist in determining the cause of death; public health needs; research, generally limited to when a waiver of authorization is independently approved by a privacy board or Institutional Review Board; oversight of the health care system; judicial and administrative proceedings; limited law enforcement activities; and activities related to national defense and security. There are specific state laws that required the disclosure of health care information related to Hepatitis C, and AIDS. Where the state laws are more stringent than HIPAA Privacy Standard, the state laws will prevail.
All of these disclosures could occur previously under former laws and regulations however; The Privacy Standard establishes new safeguards and limits. If there is no other law requiring that your information be disclosed, we will use our professional judgments to decide whether to disclose any information, reflecting our own policies and ethical principles.
On some occasions we may furnish your PHI to a third party. This could be an insurance company for the purpose of payment or another health care provider for further treatment or additional services. Although we will institute a “chain of trust” contract and monitor our business associates€™ contracts with us, we cannot absolutely guarantee that they will not use or disclose your PHI in such a way as to violate the Privacy Standard.
Although the law requires a signed and dated Privacy Notice, this office does not demand that you sign this agreement as a condition of receiving care. It is the law that your rights are communicated in this manner.
It is our practice to retain information about non-healthcare related requests for your health care information for a period of six years.
In complying with the Privacy Standard, we have appointed a Privacy Officer, trained our Privacy Officer and the staff in the law, and implemented policies to protect your PHI. We have instituted privacy and security processes to guard and protect your IIHI. This office is taking and continues to monitor and improve steps for the protection of your information and to remain in compliance with the law.
FINANCIAL POLICY January 2019
The Hormone Replacement consultation charge is $175.00.
For a second surgical opinion within 3 months of surgery performed elsewhere, the charge is $250; $500 if a letter is required.
Payment for injectable products (i.e. Botox, Juvederm, etc.), minor surgical procedures and skin care products are due on the day of service. Personal checks are not accepted on the day of service.
If you elect to finance through www.carecredit.com, there will be a 6 % transaction fee.
Approved methods of payment in place of cash are considered payment in full for goods and services rendered. There is no further recourse for these charges. Your signature is in good faith for all procedure and product charges.
I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment and that there are no refunds. In the event of non-payment I further agree to bear the cost of collection, and/or Court costs and reasonable legal fees, should this be required. I agree to reimburse Cosmetica Plastic Surgery & Anti – Aging a chargeback processing fee of $250.00 if I attempt to reverse credit, debit or approved financing charges.
Charges for surgical procedure(s) represents a package charge, which includes the facility fee (42%), the provider fee (20%), anesthesia fee (16%), and operating room supplies (22 %) and includes all follow up visits with Adley DaSilva, P.A..
There are no refunds for services or products. The facility does not in any way guarantee a particular result, nor are the fees quoted contingent upon any particular and/or desired outcome.
Expenses related to complications of cosmetic surgery are not usually covered by medical insurance and are the patient’s responsibility.
We are not affiliated with any insurance companies or health plans and we do not accept assignment from Medicare, Medicaid or any other insurance payer.
At no charge, we will provide you with ONE form you can submit to your insurance company for possible reimbursement after a surgical procedure and after each hormone pellet insertion. Because we do not participate with Medicare, you should not submit claims to Medicare, as Medicare will not honor submissions from non-participating physicians. There is a $35.00 charge per form, paid in advance, for the completion of any additional forms.
A non-refundable deposit of $1000.00 is required in order to schedule a surgical procedure. Surgery must be paid in full 7 days before the date of your procedure. The surgical fee does NOT include laboratory, pathology, or radiology charges, nor does it include emergency room visits, hospitalization, prescription medications, garments, bandages, office visits or procedures with other physicians. Your initial surgical fee does not cover revisions or future surgery
We understand that a situation may arise that could force you to postpone your surgery. Please understand that such changes affect not only your provider and office staff but other patients as well. If we are notified within 7 days of your surgery we will reschedule your procedure at no charge. If you need to cancel a surgical procedure with less than 7 days notice, your $1,000.00 deposit will not be returned nor can the deposit be used for a future procedure. If you choose to reschedule, you will be required to pay another non-refundable deposit of $1000.00 to secure your space on the surgical schedule.
HIPAA PRIVACY NOTICE
THE FOLLOWING NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THE INFORMATION CAREFULLY.
Your confidential healthcare information may be released to other healthcare professionals within the organization for the purpose of providing you with quality healthcare.
Your confidential healthcare information may be released to your insurance provider for the purpose of the organization receiving payment for providing you with needed healthcare services.
Your confidential healthcare information may be released to public or law enforcement officials in the event of an investigation in which you are a victim of abuse, a crime or domestic violence.
Your confidential healthcare information may be released to other healthcare providers in the event you need emergency care.
Your confidential healthcare information may be released to a public health organization or federal organization in the event of a communicable disease or to report a defective device or untoward event to a biological product (food or medication).
Your confidential healthcare information may not be released for any other purpose than that which is identified in this notice.
Your confidential healthcare information may be released only after receiving written authorization from you. This provision includes but is not limited to any psychotherapy notes, for marketing purposes and any disclosures that may constitute a sale of your protected healthcare information. Any other uses or disclosures not described in this notice can only be made with your express authorization. You may revoke your permission to release confidential healthcare information at any time.
You may restrict the disclosure of your protected health information for any services provided whereby your or somebody else pays “out of pocket”, in full, for the services.
You may be contacted by the organization to remind you of any appointments.
You have the right to opt out of notifications regarding healthcare treatment options, marketing and fundraising, or other health services that might be of interest to you.
You may be contacted by the organization for the purposes of raising funds to support the organization’s operations. It is your express right to opt out of any fund raising communications.
You have the right to restrict the use of your confidential healthcare information. However, the organization may chose to refuse your restriction if it is in conflict of providing you with quality healthcare or in the event of an emergency situation.
You have the right to receive confidential communication about your health status.
You have the right to review and photocopy any/all portions of your healthcare information.
You have the right to make changes to your healthcare information.
You have the right to know who has accessed your confidential healthcare information and for what purpose.
You have the right to possess a copy of this Privacy Notice upon request. This copy can be in the form of an electronic transmission or on paper.
The organization is required by law to protect the privacy of its patients. It will keep confidential any and all patient healthcare information and will provide patients with a list of duties or practices that protect confidential healthcare information.
The organization will promptly contact you should there be any breach of your protected health information.
The organization will abide by the terms of this notice. The organization reserves the right to make changes to this notice and continue to maintain the confidentiality of all healthcare information.
You have the right to complain to the organization if you believe your rights to privacy have been violated. If you feel your privacy rights have been violated, please mail your complaint to the organization:
ATTN: Cosmetica Plastic Surgery & Anti-Aging 1941 SE Port St. Lucie Blvd. Port St. Lucie FL, 34952
All complaints will be investigated. No personal issue will be raised for filing a complaint with the organization.
For further information about this Privacy Notice, please contact:772-337-1717
This notice is effective as of 9/23/2013. This date must not be earlier than the date on which the notice is printed or published.
A PATIENT’S BILL OF RIGHTS
Cosmetica Plastic Surgery & Anti-Aging presents a Patient’s Bill of Rights with the expectation that observance of these rights will contribute to more effective patient care and greater satisfaction for the patient, his physician, and the group organization. It is recognized that a personal relationship between the facility and the patient is essential for the provision of proper medical care. The traditional physician-patient relationship takes on a new dimension when care is rendered within an organizational structure. Legal precedent has established that the facility itself also has a responsibility to the patient. It is in recognition of these factors that rights are affirmed.
The patient has the right:
- To respectful treatment with concern for individual, cultural or educational difference.
- To complete, up-to-date information about the condition, treatment and outlook for recovery.
- To know who is responsible for the care provided.
- To personal privacy and confidentiality in communication and medical records.
- To an explanation of the various types of care to be received.
- To refuse treatment, except in some cases where life saving treatment is mandated.
- To know of any affiliations your hospital and physician(s) have with other institutions and physicians.
- To change their provider if other qualified providers are available.
The patient has the responsibility:
- To provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications including over the counter products and any dietary supplements and any allergies or sensitivities and other health related matters.
- To report any unexpected change in condition to the responsible physician.
- To say whether a contemplated course of treatment and the patient’s obligation in its administration are understood.
- To follow the treatment plan recommended by the physician. The patient is expected to follow up on his/her doctor’s instructions, take medication when prescribed, and ask questions concerning his/her own health care that he/she feels is necessary.
- To keep appointments or notify the appropriate person if it is not possible to do so.
- To accept the consequences of choosing to ignore physician instructions or to refuse treatment.
- To see that the financial obligations assumed in receiving health care are met as promptly as possible.
- To inform the provider about any living will, medical power of attorney, or other directive that could affect his/ her care.
- Be Respectful of all health care providers and staff, as well as other patients.
Patient Complaints and Compliments:
If you are dissatisfied or overly satisfied with any service you have received, please ask to speak to an Administrator so we may improve the quality of care.
No catalog of rights can guarantee for the patient the kind of treatment he has a right to expect. Within this facility, all activities must be conducted with an overriding concern for the patient, and, above all, the recognition of his dignity as a human being. Success in achieving this recognition assures success in the defense of the rights of the patient.