Schedule a Consultation.

There’s a $75 non-refundable deposit collected at the time of booking your consultation. Fee is fully credited back with any scheduled surgery.

THOMAS H. BARTELL, M.D., S.C

Notice of Medical Policies and Practices to Protect the Privacy of Your Health Information

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.

As part of the federal health insurance Portability and Accountability Act of 1996, known as HIPAA, the health care provider has created this Notice of Privacy Practices (Notice). This Notice describes the health care provider’s practices and the rights of you, the individual, as they relate to the privacy of your Protected Health Information (PHI). Your PHI is information about you, or that could be used to identify you, as it relates to your past and presents physical and health care services. The HIPAA regulations require that the health care provider protect the privacy of your PHI that the health care provider has received or created.

This health care provider will abide by the terms presented within this Notice. For any uses of disclosures that are not listed below, the health care provider will obtain a written authorization from you for that use or disclosure, which you will have the right to revoke at any time, as explained in more detail below. The health care provider reserves the right to change the health care provider's privacy practice and this Notice. Revisions to the Notice will be posted at the health care provider facility and upon your request, provided to you in a paper format.

HOW THE HEALTH CARE PROVIDER MY USE AND DISCLOSE YOUR PERSONAL HEALTH INFORMATION (PHI)

The following is an accounting of the ways that the health care provider is permitted, by law, to use and disclose your PHI.

Uses and disclosures of PHI for treatment: we will use the PHI that we receive from you to coordinate or manage your health care.

Used and disclosures of PHI for payment: The health care provider will disclose your PHI to obtain payment for reimbursement from insurers for your health care services.

Uses and Disclosures of PHI for Health Care Operations: The health care provider will yours your PHI to conduct quality assessments, improvement activities and evaluate the health care provider workforce.

The following is an accounting of additional ways in which the health care provider is permitted or required to use or disclose PHI about you without your written authorization.

Uses and disclosures as required by law: The health care provider is required to use or disclose PHI about you as required and as limited by law.

Uses and disclosure for Public Health Activities: The health care provider may use or disclose PHI about you to a public health authority that is authorized by law to collect for the purpose of prevention or controlling disease, injury or disability.

Uses and disclosure about victims of abuse, neglect or domestic violence: The health care provider may use or disclose Phi about you to a government authority if it’s reasonably believed you are a victim of abuse, neglect or domestic violence.

Uses and disclosures for health oversight activities: The health care provider may use or disclose PHI about you to a health oversight agency or oversight activities that are authorized by law to conduct.

Disclosures for judicial and administrative proceedings: The health care provider may disclose phi about you in the course of any judicial or administrative proceedings, provided that the proper documentation is presented to the health care provider.

Disclosures for law enforcement purposes: The health care provider may disclose PHI about the deceased, or prior to, and in reasonable anticipation of an individual’s death, the coroners, medical examiners, and funeral directors.

Uses and disclosures for cadaveric organ, eye or tissue donation purposes: The health care provider may use and disclose PHI for the purpose of procurement, banking or transplantation of cadaveric organs, eye or tissues for donation purposes.

Uses and disclosures for research purposes: The Health care provider may use and disclose PHI about you foro research purposes with a valid waiver of authorization from the research board. Otherwise, the health care provider will request a signed authorization by the individual for all other research purposes.

Uses and disclosures of avert a serious threat to health or safety: The ehealth care provider may use or disclose PHI about you, if it believes in good faith, and is consistent with any applicable law and standards of ethical conduct, to avert a serious threat to health or safety.

Disclosure for worker’s compensation: The health care provider may disclose phi about you as authorized by and to the extent necessary to comply with worker’s compensation laws or programs established by law.

I understand that the information submitted as part of this consultation request is given freely and is solely intended for Dr. Thomas Bartell, board-certified plastic surgeon, to guide your medical assessment during this upcoming consultation. An in person examination by Dr. Thomas Bartell will be required prior to scheduling surgery. Your information is kept confidential and is never shared.