Notice of Privacy Practices & Patient Rights/Cosmetic Surgery & Dermatology of Issaquah, Inc.
This notice describes patient rights & responsibilities, how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
Cosmetic Surgery & Dermatology of Issaquah, Inc., respects your privacy. We understand that your personal health information is very sensitive. The law protects the privacy of the health information we create and obtain in providing care and services to you. Your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers and billing and payment information relating to these services.
We will not use or disclose your health information to others without your authorization, except as described in this Notice, or as required by law.
When you receive medical services from our practice, you have the right to:
- Receive, read, and ask questions about this Notice.
- To receive safe, private, high quality and respectful care.
- Be notified of your rights, and exercise your rights in regard to your care.
- Be informed of aspects of your condition necessary to make decisions regarding your care.
- Receive care from personnel that are properly trained to perform assigned tasks and to coordinate services.
- Actively participate in decisions involving your care, including ethical issues, and be informed of any change in plan or care in advance.
- Refuse treatment or services to the extent permitted by law, and be informed of the potential consequences of such an action.
- Be provided impartial access to care.
- Seek a second opinion or choose another caregiver.
- To be treated with dignity, respect and care without regard to age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.
- To be told of your health status and to include your family or representative in planning your care, and to discuss and resolve care issues.
- To have you or your representative make informed decisions about your care.
- To have advance directives if you are an adult.
- To know who is responsible for your care, and who is performing a procedure or treatment.
- To accept or refuse the care and treatment offered.
- To have personal privacy.
- To receive proper pain management.
- To be free from all abuse, neglect, exploitation or harassment.
- To expect reasonable safety and access to protective services when necessary for your personal safety.
- To be informed of unexpected outcomes of care, treatment or services.
- Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. We are not required to grant the request unless the request is to restrict disclosure of your protected health information to a health plan for payment or health care operations and the protected health information is about a service or treatment for which you paid directly.
- Request and receive from us a paper copy of the most current Notice of Privacy Practices (“Notice”).
- Request that you be allowed to see and get a copy of your protected health information. You may make this request in writing. We have a form available for this type of request.
- Have us review a denial of access to your health information—except in certain circumstances.
- Ask us to change your health information. You may give us this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record, and included with any release of your records.
- When you request, we will give you a list of certain disclosures of your health information. The list will not include disclosures for treatment, payment, or health care operations. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months.
- Ask that your health information be given to you by another means or at another location. Please sign, date, and give us your request in writing.
- Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.
For help with these rights during normal business hours, please contact:
295 NE Gilman Blvd #101
Issaquah, Wa 98027 425-391-2500
We are required to:
- Keep your protected health information private.
- Give you this Notice
- Follow the terms of this Notice
We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling and asking for it or by visiting our office to pick one up.
To ask for help or complain/grievance.
If you have questions, want more information, or want to report a problem about the handling of your protected health information or grievance, you may contact:
If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to the Practice Manager at Cosmetic Surgery & Dermatology of Issaquah, Inc. You may also file a complaint with the Department of Health and Human Services for Civil Rights (OCR). Complaint Intake Information is as follows:
HSQA Complaint Intake
P O Box 47857
Olympia, WA 98504-7857
Phone: 360-236-4700 Toll Free: 800-633-6828 Fax: 360-236-2626
Office of the Medicare Beneficiary Ombudsman:
Medicare Help and Support 1-800-MEDICARE
We respect your right to file a complaint with us or with the OCR. If you complain or have a grievance you may complain without fear of reprisal. We will respond to your complaint within 10 business days of receiving said complaint/grievance.
How we may use and disclose your protected health information.
Under the law, we may use or disclose your protected health information under certain circumstances without your permission. The following categories describe the different ways we may use and disclose your protected health information. For each category, we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose health information will fall within one of the categories.
Examples of uses and disclosures of protected health information for treatment, payment, and health care operations:
- Information obtained by a nurse, physician or other member of our health care team will be recorded in your medical record and used by members of our health care team to help decide what care may be right for you.
- We may also provide information to health care providers outside our practice who are providing you care or for a referral. This will help them stay informed about your care.
- We request payment from your health insurance plan. Health plans need information from us about your medical care. Information provided to health plans may include your diagnoses, procedures performed, or recommended care.
- We bill you or the person you tell us is responsible for paying for your care if it is not covered by your health insurance plan.
For health care operations:
- We may use your medical records to assess quality and improve services.
- We may use and disclose medical records to review the qualifications and performance of our health care providers and to train our staff.
- We may use and disclose your information to conduct or arrange for services, including:
• Medical quality review by your health plan
• Accounting, legal, risk management, and insurance services
• Audit functions, including fraud and abuse detection and compliance programs
Statements about certain uses and disclosures.
- We may contact you to remind you about appointments.
- We may use and disclose your health information to give you information about treatment alternatives or health-related benefits and services.
Some of the other ways that we may use or disclose your protected health information without your authorization are as follows:
- Required by law: We must make any disclosure required by state, federal or local law.
- Business Associates: We contract with individuals and entities to perform jobs for us or to provide certain types of services that may require them to create, maintain, use, and/or disclose your health information. We may disclose your health information to a business associate, but only after they agree in writing to safeguard your health information. Examples include billing services, accountants, and others who perform health care operations for us.
- Notification of family and others: Unless you object, we may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital.
- Public health and safety purposes: As permitted or required by law, we may disclose protected health information:
• To prevent or reduce a serious, immediate threat to the health or safety of a person or
• To public health or legal authorities.
• To protect public health and safety.
• To prevent or control disease, injury, or disability.
• To report vital statistics such as births or deaths.
• To report suspected abuse or neglect to public authorities.
- Research: This facility does not currently participate in research or clinical trials.
- Food and Drug Administration (FDA): For problems with food, supplements, and products, we may disclose protected health information to the FDA or entities subject to the jurisdiction of the FDA.
- Workplace injury or illness: Washington State law requires the disclosure of protected health information to the Department of Labor & Industries, the employer, and the payer (including a self-insured payer) for workers’ compensation and for crime victims’ claims. We also may disclose protected health information for work-related conditions that could affect employee health; for example, an employer may ask us to assess health risks on a job site.
- Correctional institutions: If you are in jail or prison, we may disclose your protected health information as necessary for your health and the health and safety of others.
- Law enforcement: We may disclose protected health information to law enforcement officials as required by law, such as reports of certain types of injuries or victims of a crime, or when we receive a warrant, subpoena, court order, or other legal process.
- Government health and safety oversight activities: We may disclose protected health information to an oversight agency that may be conducting an investigation. For example, we may share health information with the Department of Health.
- Disaster relief: We may share protected health information with disaster relief agencies to assist in notification of your condition to family or others.
- Military, Veteran, and Department of State: We may disclose protected health information to the military authorities of U.S. and foreign military personnel; for example, the law may require us to provide information necessary to a military mission.
- National Security: We are permitted to release protected health information to federal officials for national security purposes authorized by law.
- De-identifying information: We may use your protected health information by removing any information that could be used to identify you.
Patient Responsibilities: When you receive services from our practice you have the responsibility to:
- Provide a complete and accurate medical history to the best of your knowledge, and to provide information about current medications or treatments.
- To provide accurate and complete details about your illness, hospitalization and medications.
- To tell your doctor or Physician Assistant about a change in your condition or if problems arise.
- To tell your doctor or nurse if you do not understand your treatment or what you are expected to do.
- To follow instructions and rules of the practice to ensure your safety and the safety of others.
- To maintain appropriate and civil conduct in interactions with physicians and staff.
- To give accurate information about insurance or other business matters.
- To pay your bill promptly and tell the practice if you need to make special payment arrangements.
- Participate in decisions involving your care.
- We have a Web site that provides information about us. For your benefit, this Notice is on the
Web site at the following address: www.drmichalak.com.
Cosmetic Surgery & Dermatology of Issaquah, Inc., is solely owned and operated by Victor R. Michalak, M.D.