Notice of 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.

We are required by law to maintain the privacy of your protected health information (PHI). This notice applies to all records of the health care and services you received at Victorious Images. This notice will tell you about the ways in which we may use and disclose your PHI. This notice also describes your rights and certain obligations we have regarding the use and disclosure of your PHI.
This notice describes the privacy practices of Victorious Images, as well as the privacy practices of:
a) Any health care professional authorized to enter information into your medical record
b) All departments, sections and units of our business
c) Any member of a volunteer group that interacts with you while you are here
d) All employees, staff, students and other Victorious Images personnel
We are required by law to:
a) Make sure that your PHI is kept private
b) Give you this notice of our legal duties and privacy practices with respect to your PHI
c) Follow the terms of this notice as long as it is currently in effect. If we revise this notice, we will follow the terms of the revised notice as long as it is currently in effect
d) Train our personnel concerning privacy and confidentiality
e) Mitigate (lessen the harm of) any breach of privacy/confidentiality
Each time you visit us, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for care or treatment.
This information, often referred to as your health or medical record, serves as a:
a) Basis for planning your care, treatment, and any follow up care you may need
b) Means of communication among the many health professionals who contribute to your care
c) Legal document describing the care you received
d) Means by which you or a third-party payer (for example, insurance carriers, Medicare, Medicaid) can verify that services billed were actually provided
e) Tool in educating health professionals
f) Source of information for medical research
g) Source of information for public health officials charged with improving the health of the nation
h) Source of information for facility planning and marketing
i) Tool which can be used to assess and continually improve the care rendered and the results achieved
Understanding what is in your record and how your health information is used helps you to:
a) Ensure its accuracy
b) Better understand who, what, when, where and why others may access your health information
c) Make more informed decisions when authorizing disclosure to others

The following categories (listed in bold-face print, below) describe different ways that we use and disclose your protected health information (PHI).

For each category of uses or disclosures we will explain what we mean and give you 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 information fall within the categories below.

For Treatment: We are permitted to use and disclose your PHI to practitioners, technicians, residents or other personnel who are involved in taking care of you or providing you with services. For example, a practitioner treating you for a m may need to know if you have diabetes because diabetes may slow the healing process. Different departments also may share your PHI in order to coordinate the different services that you need. We also may disclose your PHI to health care providers outside our organization who may be involved in your medical care, such as physicians who will provide follow-up care, physical therapy organizations, medical equipment suppliers, and skilled nursing facilities. information about the services and equipment you received so your health plan will pay us or reimburse you for the care. We also may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations: We are permitted to use and disclose your PHI for our business operations. These uses and disclosures are necessary to run Victorious Images and to make sure that all of our patients receive quality care. For example, we may use PHI to review our treatment and services and to evaluate the performance of our staff in caring for you. We also may disclose information to staff (including residents and interns) and other personnel to conduct training programs. We also may combine certain PHI about several of our patients as part of a study to determine what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We also may remove all information that identifies you from a set of PHI so that others may use that information to study health care and health care delivery without learning who the specific patients are.
To Business Associates for Treatment, Payment and Health Care Operations: We are permitted to disclose your PHI to our business associates in order to carry out treatment, payment or health care operations. For example, we may disclose your PHI to a company we hire to bill insurance companies on our behalf to help us obtain payment for the health care services we provide. We may also disclose your PHI to a company we hire to collect performance data about our services.
Individuals Involved in Your Care or Payment for Your Care: We may release your PHI to a family member, other relative or close personal friend who is involved in your medical care if the PHI released is directly relevant to the person’s involvement with your care. We also may release information to someone who helps pay for your care.
Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or care.
Treatment Alternatives: We may use and disclose medical information to give you information about treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Special Situations
As Required By Law: We will disclose your PHI when required to do so by federal, state, or local law.
Public Health Activities: We may disclose your PHI for public health activities. public health activities generally include:
a) Preventing or controlling disease, injury or disability
b) Reporting child abuse or neglect
c) Reporting reactions to or problems with products
d) Notifying patients of recalls of products they may be using
e) Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
f) Notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law
Health Oversight Activities: We may disclose PHI to a health oversight agency for activities authorized by law such as audits, investigations, inspections, accreditations and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement: We may release PHI if asked to do so by a law enforcement official:
a) In response to a court order, subpoena, warrant, summons or similar process
b) To identify or locate a suspect, fugitive, material witness or missing person, but only if limited information (e.q., name and address, date and place of birth, Social Security number, type of injury, date and time of treatment) is disclosed
c) About the victim of a crime if, under certain limited circumstances, we are unable to obtain the victim’s agreement
d) About criminal conduct we believed occurred on our premises
e) In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime

Coroners, Medical Examiners and Funeral Directors: We may release PHI about our patients to a coroner or medical examiner to identify a deceased person or to determine the cause of death. We may also release PHI about our patients to funeral directors as necessary to help them carry out their duties.
Research: Under certain circumstances, we may use and disclose your PHI for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one treatment to those who received another for the same condition. Most research projects, however, are subject to a special approval process. This process requires an evaluation of the proposed research project and its use of PHI, and balances these research needs with our patients’ need for privacy. Before we use or disclose PHI for research, the project will have been approved through this special approval process. However, this special approval process is not required when we allow researchers who are preparing a research project to look at information about patients with specific medical needs, so long as the PHI they review does not leave our premises.
To Avert a Serious Threat to Health or Safety: We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to law enforcement in order to help prevent the threat.
Armed Forces and Foreign Military Personnel: If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
National Security and Intelligence Activities: We may release your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose your PHI to authorized federal officials so they may provide protection to the President of the United States, other authorized persons or foreign heads of state, or to conduct special investigations.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official under specific circumstances such as (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Workers’ Compensation: We may release your PHI for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Uses or disclosures of your PHI for other purposes or activities not listed above will be made only with your written authorization (permission). If you provide us authorization to use or disclose your PHI, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by your written permission. However, we are unable to take back any disclosures we have already made with your permission.
You may obtain an authorization form by contacting: Marty Masters at (423) 231-5978
You have the following rights regarding the PHI we maintain about you.
Right to Request Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. Our Privacy Officer will notify you in writing whether we agree or do not agree with your request. In your request, you must tell us:
(1) what information you want to limit;
(2) whether you want to limit our use and/or disclosure of the information;
(3) to whom you want the limits to apply (for example, disclosures to your spouse); and
(4) your contact address. A restriction request form is available at the reception area or by requesting one from:
Marty Masters at (423) 231-5978.
Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by telephone at work or that we only contact you by mail at home. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.
Right to Inspect and Receive a Copy: You have the right to inspect and receive a copy of PHI that may be used to make decisions about your care. Usually, this includes medical and billing records.
If you request a copy of your PHI, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect or receive a copy in certain very limited circumstances. If you are denied access to PHI, we will notify you in writing, and you may request that the denial be reviewed. Another health care professional chosen by us will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend: If you believe that PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us. You must include a reason that supports your request. In order to ensure that we collect the information we need, we provide a form at the reception area or by requesting one from: Marty Masters at (423) 231-5978.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the PHI kept by or for us; (3) is not part of the information that you would be permitted to inspect and copy; or (4) is accurate and complete. We will notify you in writing whether we agree or do not agree with your amendment request.
Additionally, if we grant the request, we will make the correction and distribute the correction to those who need it and those you identify that you want to receive the corrected information. If we deny your request for an amendment, we will notify you how you may file a complaint with us or the Department of Health and Human Services.
Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures” that has been made by us in the past six (6) years. The accounting (or list) of disclosures will include: (1) the date of the disclosure; (2) the name of the entity or person who received the PHI and, if known, the address; (3) a brief description of the PHI disclosed; and (4) a brief statement of the purpose of the disclosure.
Your request must state a time period not longer than six (6) years and may not include dates before _____________________. The first list you request within a twelve (12) month period will be free of charge. For additional lists, we will charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Contact information for these rights. Any requests related to these rights should be directed to: Marty Masters at (423) 231-5978.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, contact our Privacy Office at (423) 231-5978.
Access to Electronic Copy of This Notice: You may obtain an electronic copy of this notice at our web site, www.journeywithcancer.com
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for PHI we already have about you as well as any information we receive in the future. We will post a copy of the current notice on our premises, and on our web site. The notice will contain on the first page, in the lower right-hand corner, the effective date. In addition, each time you visit us for treatment or services, you may request a copy of the current notice in effect.

If you have questions or would like additional information, you may contact Marty Masters at (423) 231-5978.

If you believe your privacy rights have been violated, you can file a complaint with:
Marty Masters at (423) 231-5978, or in writing to:
Office for Civil Rights
S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201

There will be no retaliation for filing a complaint.

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Patient’s Bill of Rights

A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity and with protection of his or her need for privacy.
A patient has the right to a prompt and reasonable response to questions and requests.
A patient has the right to know who is providing medical services and who is responsible for his or her care.
A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
A patient has the right to know what rules and regulations apply to his or her conduct.
A patient has the right to be given by his/her health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
A patient has the right to refuse treatment, except as otherwise provided by law.
A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care.
A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment; whether the health care provider or health care facility accepts the Medicare assignment rate.
A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have charges explained.
A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap, or source of payment.
A patient has the right to express grievances regarding any violation of his or her rights through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency.
Patient Responsibilities: A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
A patient is responsible for reporting unexpected changes in his or her condition to the health care provider.
A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
A patient is responsible for following the treatment plan recommended by the health care provider.
A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider of the health care facility.
A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider’s instructions.
A patient is responsible for assuring that the financial obligations of his or her health care is fulfilled as promptly as possible.
A patient is responsible for following health care and facility rules and regulations affecting patient care and conduct.

Patient’s Bill of Rights Specific to Post Mastectomy

As a patient who has been diagnosed with breast cancer, undergone treatment and/or surgery, and is about to be properly fitted for post-mastectomy products you have rights that are specific to you and your present medical situation.
Be seen as quickly as reasonably possible: Patients who have been advised by their physician to be fitted for a post mastectomy bra and/or prosthesis, lymphedema bra, or lymphedema sleeve and/or glove should be seen as soon as feasibly possible by a Certified Mastectomy Fitter who specializes in such needed products.

Fitted by a Certified Mastectomy Fitter: Patients should expect to be fit for prosthesis and post mastectomy bra by fitters who are certified in the fitting of such products

Receive the best Fitting Possible: This is best provided by those, such as are employed by Just About You, who meet the standards defined by the American Board for Certification for Medicare Certification.

Patients have the right to directly participate in the decision making about their fitting process. They should be treated as an equal partner of the fitting team starting at the time of their first appointment for evaluation.

Patients should expect to be offered resources to help with image recovery, targeted at improving and rebuilding self-image and self-esteem which may change as a result of breast cancer treatment. The goal is to restore the patient’s health status, including their emotional well-being.

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We will consistently strive to provide quality services to our Patient and to the community in accordance with the highest professional and ethical standards possible.

We will abide by Federal, State, and local laws, statutes, rules, regulations, and ordinances, and with federal, state and private payer health care program requirements.

We will conduct business professionally and properly, and we will do our best to prevent any fraud or abuse of federal, state or private payer health care programs.

We will not discriminate on the basis of age, sex, race, creed, color, national origin or disability.

We will fulfill our obligation to screen, test, manage and evaluate personnel.

We will fulfill our obligation to orient employees to their roles and to provide staff development education to maintain the current knowledge and skills needed to competently serve our Patient/patients.

We adhere to standards of integrity in advertising, marketing, billing practices, and managing the services we offer.

We will assist in admitting, planning, and discharging Patient/patients in a manner that will meet the total Patient care needs, in cooperation with community resources and agencies.

We will not knowingly misrepresent the relationship of the Company to other health care providers, institutions, or payers.

We will take appropriate precautions necessary to ensure the safety of our employees and Patient/patients.

We will protect our employees and Patient/patients with appropriate insurance coverage.

We will take appropriate measures to provide our Patient/patients and fellow employees with respect, emotional support and personal dignity.

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