NOTICE OF HIPAA PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Protected Health Information (PHI)
PHI is any information identifying you or could be used to identify you relating to your past, present, or future health care. Terms of this Notice apply to all health information generated or received by SOMA Aesthetic (“FMG,” “we,” “us,” “our”) whether recorded in your medical record, billing invoices, paper or electronic forms, video, or in other ways.
Confidentiality Commitment & Responsibility
FMG must meet the following requirements:
- To maintain the privacy and security of PHI according to applicable state and federal law.
- To provide this Notice of HIPAA Privacy Practices, FMG’s legal duties, and your rights concerning PHI.
- To follow the privacy practices described in this Notice while it is in effect.
- To notify promptly in the event a breach of unsecured PHI occurs.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
SOMA Aesthetic reserves the right to change the terms of this Notice and privacy practices at any time as permitted by law. Changes to privacy practices and new terms to this Notice are effective for all PHI maintained by SOMA Aesthetic including PHI created or received before changes were made. Prior to making significant changes in privacy practices, SOMA Aesthetic will change this Notice, post it in the common areas of our facilities, on our website at www.somaaestheticbirmingham.com, and make it available upon request.
SOMA Aesthetic will not use or disclose PHI other than as described in this Notice unless authorized by you using SOMA Aesthetic’s Authorization form. You may elect to change your decision at any time in writing.
Copies of this Notice are available to you and can be obtained by contacting Administration at info@somaaestheticbirmingham.com or by phone: 947-274-9272 or by mail: SOMA Aesthetic, 180 S Old Woodward Ave, Birmingham MI 48009.
Uses & Disclosures
This section explains the typical use or disclosure of PHI by SOMA Aesthetic. Some uses and disclosures may require your written authorization or the written authorization of your legal representative using SOMA Aesthetic’s Authorization Form. SOMA Aesthetic may also use or disclose some PHI without prior consent.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Permitted Uses and Disclosures
Treatment. To provide treatment-related health care services. Example: SOMA Aesthetic discloses PHI to a physician who needs the information to treat you.
Payment. To bill and receive payment from you, health plans, or other entities. Example: SOMA Aesthetic discloses PHI to your health insurance plan to get prior approval or so it will pay for your services.
Operation. To run SOMA Aesthetic’s practice, improve your care, and contact you when necessary. Example: SOMA Aesthetic uses PHI to manage your treatment and services.
Uses and Disclosures Not Requiring Your Authorization
Required by Law. To comply with state or federal laws including statutes, regulations, and court orders.
Public Health Activities. To report information regarding births, deaths, and various diseases to government officials responsible for such collection.
Coroners, Medical Examiners, and Funeral Directors. To report necessary information relating to a deceased person, to determine cause of death, or to assist a funeral director as necessary.
Victims of Abuse, Neglect, or Domestic Violence. To report information relating to suspected victims of abuse, neglect, or domestic violence to the appropriate government authority.
Health Oversight Committee. To assist health oversight agencies acting as authorized by law. Example: licensure, inspections, investigations, audits, or facility accreditation.
Lawsuits & Disputes. To comply or respond to a court or administrative order or if SOMA Aesthetic is party to litigation or potential litigation. SOMA Aesthetic may also use or disclose PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute. In this event, SOMA Aesthetic will take steps to notify you or to obtain an order protecting the information requested.
Law Enforcement or Other Agencies. To comply with state or federal law enforcement officials as (1) required by law, (2) to identify or locate a suspect, fugitive, material witness, or missing person, (3) in response to a law enforcement official’s request regarding a victim or suspected victim of a crime, (4) to alert law enforcement of a person’s death if criminal activity is suspected as a cause of the death, (5) if it is suspected that PHI is evidence of a crime, and (6) in cases of emergency.
Organ & Tissue Donation. To assist organizations that handle organ procurement if you are a donor. Research. To use or disclose PHI for health research purposes.
Serious Threat to Health or Safety. To avoid a serious threat to the health or safety of a person or the public to prevent or lessen such harm.
Federal Officials & Functions. To assist authorized federal officials and functions for military, intelligence, presidential protective services, and other national security activities as authorized by law.
Disaster Relief. To coordinate your care or notify family and friends of your location or condition in a disaster.
Workforce Safety and Insurance. To assist those programs providing benefits for work-related injuries or illness.
Uses and Disclosures with The Opportunity to Opt-in or Opt-out
Fundraising. To manage fundraising efforts by SOMA Aesthetic. You have the option to opt-out of fundraising contacts.
Appointment Reminders, Treatment Alternatives, and Health Related Benefits & Services. To remind you of an appointment or to contact you regarding treatment alternatives or health-related benefits and services.
Marketing or Remuneration. You must give written authorization using SOMA Aesthetic’s Authorization Form for SOMA Aesthetic to use PHI for its own promotional use or to make disclosures that constitute the sale of PHI.
Special Use. SOMA Aesthetic does not create or manage a public client directory or create or maintain psychotherapy notes.
Family, Friend, or Other. To communicate with a family member, friend, or other person/entity involved in your treatment, care, or payment. (Consent can be retroactively obtained in the case of an emergency.)
Uses and Disclosures Requiring Authorization
Limiting Uses and Disclosures
SOMA Aesthetic must take reasonable efforts to ensure only the minimum PHI is disclosed to accomplish the intended purpose. When consent cannot be obtained, SOMA Aesthetic will exercise professional judgment that the disclosure of PHI is in your interest.
Your Rights
This section explains your rights or the rights of an individual with the legal authority to act on your behalf.
Right to Inspect or Copy. To request an electronic or paper copy of your medical record and other PHI. Requests must use SOMA Aesthetic’s Patient Request Form. SOMA Aesthetic will provide a copy or summary of PHI within 30 days of your request. A reasonable cost-based fee may be charged. In some cases, your request may be denied or limited in scope.
If SOMA Aesthetic is unable to produce a copy or summary of PHI within 30 days, the time to produce may be extended by no more than 30 days and you will be provided notice detailing the reasons for the delay.
Right to Authorize. To request PHI be sent to an individual or entity designated by you. This request must be made using SOMA Aesthetic’s Authorization Form.
Right to Amend. To correct health information about you that you think is incorrect or incomplete. SOMA Aesthetic reserves the right to deny your request, and you may add a statement of disagreement to your record.
Right to Request Restrictions. To limit what SOMA Aesthetic uses or discloses such as certain health information for treatment, payment, or SOMA Aesthetic operations. SOMA Aesthetic may deny your request if it would affect your care or if required by law. You may also limit what SOMA Aesthetic uses or discloses if you pay for a service or health care item out-of-pocket in full.
Right to Revoke Permission. To revoke authorization to use or disclose PHI except to the extent that any person or entity has already acted in reliance upon that authorization.
Right to Confidential Information. To request SOMA Aesthetic contact you in a specific manner regarding health care matters. Example: To contact only by mail or at work. Requests must be made using SOMA Aesthetic’s Patient Request Form.
Right to an Accounting of Disclosures. To request a list of the times SOMA Aesthetic shared PHI for six years prior to the date you make the request. Requests must be made using SOMA Aesthetic’s Patient Request Form and will include all the disclosures except regarding treatment, payment, and health care operations and certain other disclosures (such as any you asked SOMA Aesthetic to make). SOMA Aesthetic will provide one accounting a year for free and may charge a reasonable cost-based fee to comply with additional requests.
Right to a Copy of This Notice. To request a paper copy of this Notice at any time, even if you have agreed to receive notice electronically. Copies are available at any SOMA Aesthetic location.
Right to Exercise Your Rights. To exercise the above rights only in the form and manner prescribed by SOMA Aesthetic and this Notice. Applicable forms may be obtained at any SOMA Aesthetic location or facility or by mail or electronic communication (use contact information provided below).
For More Information
Questions and additional information are available upon request. Please contact Administration at info@somaaestheticbirmingham.com or by phone: 947-274-9272 or by mail: SOMA Aesthetic, 180 S Old Woodward Ave, Birmingham MI 48009.
To File a Complaint
If you feel SOMA Aesthetic has violated your rights, contact us using the above information. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. SOMA Aesthetic will not retaliate against you for filing a complaint.
Effective Date
This Notice of HIPAA Privacy Practices is effective 12/27/2024.
Notice of Organized Health Care Arrangement for SOMA Aesthetic
SOMA Aesthetic, its independent contractors of the medical staff, and other health care providers affiliated with SOMA Aesthetic have agreed as permitted by law to share your health information among themselves for the purposes of treatment, payment, or health care operations. This allows us to better address your health care needs in a clinically integrated setting. This notice is being provided to you as a supplement to this Notice of Privacy Practices.