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.

The physicians and staff of 4 Ever Young Aesthetics have always been committed to the absolute
protection of every patient’s health information. The Health Insurance Portability and Accountability Act, more about requires that we provide notice to each of our patients of how this information is used.

This Notice of Privacy Practices describes how we may use and disclose your protected health
information to carry out treatment, shop payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information (PHI). “PHI” is information about you, including demographic information, that may identify you and that relates to your past, present or future phsical or mental health or condition and related health care services. We collect information from you and store it in a medical record, which may be electronically stores on computer. We safeguard information about your “PHI”, storing our medical record charts in a secure area available only to designated staff and only for specific reasons. If your record is computerized, we use security measures to protect it.

Our office is required to abide by the terms of the Notice for Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. To request a revised notice you may call the office and request that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED:

We will use and/or disclose your medical information as part of rendering patient care. Your PHI may also be used and/or disclosed to pay your health care bills and to support the operation of 4 Ever Young Aesthetics.

TREATMENT: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes other physicians to whom you have been referred to, to ensure that the physician has the necessary information to diagnose or treat you. It may also include but is not limited to home health care services, lab and diagnostic centers, pharmacies, emergency rooms, hospitals, nursing homes and rehab centers.

PAYMENT: Your PHI will be used, as needed, to obtain payment for your health care services. This includes, but is not limited to: determination of eligibility and benefits, referral authorizations, treatment, tests, equipment and claims filing and follow up, medical necessity review, and utilization reviews.

HEALTHCARE OPERATIONS: We may use and/or disclose as needed your PHI in order to support the business activities of 4 Ever Young Aesthetics. These activities include but are not limited to training of students and staff, quality assessment activities, and medical research. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician or PCP. We may also call you by name in the waiting room when your physician is ready to see you.

We may also use and/or disclose your information in accordance with federal and state laws for the following reasons:

1. APPOINTMENT REMINDERS AND TREATMENT CONTRACT
We may contact you to provide appointment reminders or to request that you call our office
for information relevant to your medical treatment. We will use your records to provide treatment to you in the event there is a language or communication barrier.

2. DISCLOSURE TO DEPARTMENT OF HEALTH AND HUMAN SERVICES
We may disclose medical information when required by the United States Department of Health
and Human Services as part of an investigation or determination of our compliance with relevant laws.

3. FAMILY AND FRIENDS
Only with your express written authorization will we disclose your medical information
to family members, other relatives or close personal friends that are directly involved with your
medical care.

4. NOTIFICATION
Unless you object, we may use or disclose your medical information to notify a family member,
a personal representative, or another person responsible for your care of your location, general condition or death.

5. DISASTER RELIEF
We may disclose your medical information to a public or private entity, such as the American
Red Cross, for the purpose of coordinating with that entity to assist in disaster relief efforts.

6. HEALTH OVERSIGHT ACTIVITES
We may use or disclose your medical information for public helath activities, including the reporting of disease, injury, vital events and the conduct of public health surveillance, investigation and/or intervention. We may disclose your medical informtion to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure, or disciplinary actions, administrative and/or legal proceedings.

7. ABUSE OR NEGLECT
We may disclose your mecical information when it concerns abuse, neglect or violence to you in accordance with federal and state laws. These include but are not limited to: death, child abuse, domestic violence, gunshots, communicable disease, infectious disease control, Food and Drug Administration (FDA) compliance/reporting adverse events, product defects/recall, biological product defects, tracking FDA related products, etc.

8. LEGAL PROCEEDINGS
We may disclose your medical information in the course of certain jucicial or administrative
proceedings.

9. LAW ENFORCEMENT
We may disclose your medical information for law enforcement purposes or other specialized
government functions including but not limited to: Military, National Security, Aversion of
Criminal Activities, Correctional Institutions, Parole.

10. CORONORS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
We may disclose your medical information to a coroner, medical examiner or funeral director.

11. ORGAN DONATION
We may disclose your health information to federal or state officials for organ or tissue donation.

12. PUBLIC SAFETY
We may use or disclose your medical information to prevent or lessen a serious threat to the
health and/or safety of another person or to the public. These include but are not limited to:
communicable disease, infectious disease control, Food and Drug Administration (FDA)
compliance/reporting adverse events, product defects/recall, biological product defects, tracking FDA related products, etc.

13. WORKER’S COMPENSATION
We may disclose your medical information as authorized by laws relating to workers compensation or similar programs.

14. BUSINESS ASSOCIATES
We may disclose your health information to a business associate with whom we contract to provide services on our behalf. To protect your helath information, our business associates that may have access to your “PHI” are required to sign a written agreement protecting any use or disclosure of your “PHI”, in order to protect your privacy. For example, our medical record copying services, medical waste disposal services and transcriptionist services.

AUTHORIZATIONS

We will not use or disclose your medical information for any other purpose without your written authorization. Once given, you may revoke your authorization in writing at any time. To request a Revocation of Authorization form, you may contact:

Office Administration
4 Ever Young Aesthetics
1400 Main Street
Little Rock, AR 72202
501-371-0055
Fax: 501-371-0088

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights with respect to your medical information:

*You may ask us to restrict certain uses and disclosures of your medical information. We are
not required to agree to your request, but if we do, we will honor it.

* You have the right to receive communications from us in a confidential manner.

*You may inspect and copy your medical information. This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records.

*You may ask us to amend your medical information. We may deny your request for certain
specific reasons. If we deny your request, we will provide you with a written explanation for
the denial and information regarding further rights you may have at that point.

*You have the right to receive an accounting of the disclosures of your medical information
made by our practice during the last six years (or following April 14, 2003), except for
disclosures for treatment, payment or healthcare operations, disclosures which you
authorized and certain other specific disclosure types.

*You may request a paper copy of this Notice of Priacy Practices for Protected Health
Information.

*You have the right to complain to us and/or to the United States Department of Helath and
Human Services if you believe that we have violated your privacy rights. If you choose to file
a complaint, you will not be retaliated against in any way.

To complain to us or if you would like further information regarding your rights or regarding the uses and disclosures of your medical information, please contact:

Office Administration
4 Ever Young Aesthetics
1400 Main Street
Little Rock, AR 72202
501-371-0055
Fax: 501-371-0088

REVISION OF NOTICE OF PRIVACY PRACTICES

We reserve the right to change the terms of this Notice, making any revision applicable to all the protected health information we maintain. If we revise the terms of this Notice, we will post a revised notice at our office and wil make paper copies of the revised Notice of Priacy Practices available upon request.

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