HIPAA Notice of Privacy Practices

Who Follows This Notice

This Notice of Privacy Practices (hereafter, this “Notice”) addresses the use of your medical information by Aspen Aesthetics, PLLC DBA Fifty 410 and your licensed healthcare provider (the “Practice,” “we” or “us”) and its business associates.

We may use your medical information, also known as protected health information (“PHI”), for treatment, payment, operations, or research purposes as described in this Notice. All employees of the Practice follow these privacy practices. The practitioners on our staff will also follow this Notice when they provide professional services to you on behalf of the Practice.

About This Notice

This Notice will tell you about the ways we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• make sure that medical information that identifies you is kept private;
• give you this Notice of our legal duties and privacy practices with respect to your medical information;
• follow the terms of the Notice that is currently in effect; and
• notify individuals, either known or reasonably believed to be affected, following a breach of unsecured protected health information.

This Notice applies to care furnished by Aspen Aesthetics, PLLC DBA Fifty 410 and its practitioners acting for the Practice. Other independent Providers and dispensing pharmacies may issue separate notices for their own records. The website Privacy Policy describes the platform's general information practices.

How We May Use and Disclose Medical Information

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and give 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 will fall within one or more of the categories.

For Treatment

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to physicians, physician assistants, advanced practice registered nurses, nurses, medical students or other Practice personnel who are involved in your care. Different departments and personnel of the Practice also may share medical information about you to coordinate the different services you may need, such as prescriptions, lab work and imaging services. We also may disclose medical information about you to people outside the Practice who may be involved in your medical care.

For Payment

We may use and disclose medical information about you so that we may bill for treatment and services you receive at the Practice and collect payment from you or another party. We may also disclose information about you to other healthcare facilities for purposes of payment as permitted by law.

For Healthcare Operations

We may use and disclose your medical information for operations of the Practice. These uses and disclosures are necessary to run the Practice and make sure that all of our patients receive quality care. For example, we may use medical information to evaluate the performance of our staff in caring for you or the outcome of your treatment. We may also combine medical information about many patients to decide what additional services the Practice should offer, what services are not needed and whether certain new treatments are effective. We may also combine medical information we have with medical information from other practices to compare our performance and to make improvements in the care and services we offer. We may also disclose information to doctors, nurse practitioners, nurses, technicians, medical students, clinicians and other Practice personnel for educational purposes. We may also disclose information about you to other healthcare facilities as permitted by law.

Appointment Reminders

We may use and disclose medical information to contact you to remind you that you have an appointment for treatment or medical care.

Treatment Alternatives

We may use and disclose medical information to tell you about possible treatment options 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.

Individuals Involved in Your Care or Payment for Your Care

We may release medical 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. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family may be notified about your condition, status and location. You may tell us whether to share with people involved in your care. We will provide an opportunity to agree or object when required; if you cannot express a preference, we may share as permitted by law and in your best interests.

As Required by Law

We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety

We may use and disclose medical information about you when necessary to prevent a serious and imminent threat to your health and safety or the health and safety of the public or another person.

Research

We may use or disclose medical information for research with your authorization or where the law permits research without authorization and the required privacy safeguards and approvals are in place.

Special Situations

State Law

In certain states, special privacy protections apply to certain information, including genetic, sexually transmitted disease, or mental health information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, and if applicable state laws govern, such information will be further protected pursuant to applicable state law. For further information, please contact us using the contact information listed in the Contact the Privacy Officer section below.

Substance Use Disorder Records

If we hold substance use disorder patient records protected by 42 CFR Part 2, additional federal restrictions apply. We will not use or disclose those records in civil, criminal, administrative, or legislative proceedings or investigations against you without your written consent or a court order and a subpoena as required by law. Other uses and disclosures must also comply with Part 2. The general disclosure categories in this Notice do not override these protections.

Organ and Tissue Donation

If you are an organ or tissue donor, we may release medical information about you to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank.

Military and Veterans

If you are a member of the armed forces of the United States or another country, we may release medical information about you as required by military command authorities.

Workers' Compensation

We may release medical information about you for workers' compensation or similar programs.

Public Health Risks

We may disclose medical information about you to authorized public health or government officials for public health activities. These activities generally include the following:

• to a person subject to the jurisdiction of the Food and Drug Administration (FDA) for purposes related to the quality, safety or effectiveness of an FDA-regulated product or service;
• to prevent or control disease, injury or disability;
• to report disease or injury;
• to report births and deaths;
• to report child abuse or neglect;
• to report reactions to medications and food or problems with products;
• to notify people of recalls or replacements of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• to notify 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 medical information about you to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request or other legal demand 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 medical information about you if asked to do so by a law enforcement official:

• in response to a court order, subpoena, warrant, summons or similar process;
• to identify or locate a suspect, fugitive, material witness or missing person;
• about the victim of a crime if, under certain circumstances, we are unable to obtain the person’s agreement;
• about a death we believe may be the result of criminal conduct;
• about criminal conduct at the Practice or by healthcare providers affiliated with the Practice;
• 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; and
• to authorized federal officials so they may provide protection for the President and other authorized persons or conduct special investigations.

Coroners, Medical Examiners and Funeral Directors

We may release medical information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information to funeral directors as may be required to carry out their duties.

National Security and Intelligence Activities

We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

To a School

We may disclose information to a school, about an individual who is a student or prospective student of the school, if:

• The protected health information that is disclosed is limited to proof of immunization;
• The school is required by State or other law to have such proof of immunization prior to admitting the individual; and
• The covered entity obtains and documents the agreement to the disclosure from either:
  • A parent, guardian, or other person acting in loco parentis of the individual, if the individual is an unemancipated minor; or
  • The individual, if the individual is an adult or emancipated minor.

Uses Requiring Written Authorization

Uses and disclosures not described in this Notice, marketing uses and disclosures, and most uses and disclosures of psychotherapy notes require your written authorization. We do not sell your health information. A sale of PHI would require a separate written authorization under HIPAA. You may revoke an authorization in writing, except to the extent we have already acted in reliance on it or another applicable legal exception applies. Contact the Privacy Officer to make or revoke an authorization.

Your Rights Regarding Medical Information

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy

You may request access to and an electronic or paper copy of medical and billing records used to make decisions about you. Submit a written request to the Privacy Officer. We will respond within the applicable legal timeframe, generally within 30 days; if a permitted extension is needed, we will explain the reason and expected completion date in writing. Any fee will be reasonable, cost-based, and limited to amounts permitted by law. The right of access excludes psychotherapy notes and information compiled in reasonable anticipation of, or for use in, a legal proceeding. We may deny access in limited circumstances allowed by law. When a denial is reviewable, you may request review by a licensed healthcare professional who did not participate in the original decision, and we will comply with the review outcome.

Right to Amend

If you believe that the 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 maintained by, or on behalf of, the Practice. To request an amendment to your PHI that you believe is inaccurate or incomplete, your request must be made in writing and submitted to the Privacy Officer for the location at which you were treated, as listed in the Contact the Privacy Officer section below. Your written request must include the reason that you believe your request is necessary to address an inaccurate or incomplete record of information about you. We may deny your request if you ask us to amend information that:

• was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• is not part of the medical information kept by or for the Practice;
• is not part of the information that you would be permitted to inspect and copy; or
• is accurate and complete.

We will provide you with written notice of action we take in response to your request for an amendment.

Right to an Accounting of Disclosures

You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical information about you. We are not required to account for any disclosures you specifically requested or for disclosures related to treatment, payment or healthcare operations or made pursuant to an authorization signed by you. To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer. This contact information is listed in the Contact the Privacy Officer section below. Your request must state a time period, which may not be longer than six years. We will provide the accounting as required by applicable law. The first accounting in a 12-month period is free. If you request more than one accounting in any 12-month period, we may charge you for our reasonable retrieval, list preparation and mailing costs for the second and subsequent requests. Before we fulfill your request, we will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions

You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the medical information 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. Additionally, you may request restrictions on medical information disclosed to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the information pertains solely to a health care item or service for which you, or person other than the health plan on your behalf, has paid us in full. To request a restriction, you must contact the Privacy Officer. This contact information is listed in the Contact the Privacy Officer section below.

We are not required to agree to your request. If we agree to your request, we will comply with your request unless the information is needed to provide emergency treatment to you. You may terminate the restriction at any time. If we terminate the restriction, we will notify you of the termination. We are not able to terminate or refuse your request for restrictions to disclosures to health plans if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the information pertains solely to a health care item or service for which you, or person other than the health plan on your behalf, has paid us in full.

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 may ask that we only contact you at work or by mail. To request confidential communications, you must submit a written request to the Privacy Officer. This contact information is listed in the Contact the Privacy Officer section below. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice

You have the right to receive a paper copy of this Notice upon written request to the Practice or at your first treatment encounter with the Practice. You may get an additional copy of this Notice at any time by contacting us. This contact information is listed in the Contact the Privacy Officer section below. You may request a paper copy even if you agreed to receive this Notice electronically.

Someone Acting on Your Behalf

A person legally authorized to act as your personal representative may exercise your rights to the extent of that authority. We will verify the person's authority before acting on a request.

Changes to This Notice

This version of the Notice takes effect on the effective date shown above and remains in effect until revised or replaced. We may change this Notice and make the revised terms apply to medical information we already maintain as well as information received in the future. We will post the current Notice and its effective date on this website, make copies available when you register for care, and provide a copy on request.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services, Office of Civil Rights. To file a complaint with the Practice, please email or write to the Privacy Officer, whose contact information is listed in the Contact the Privacy Officer section below. You will not be penalized for filing a complaint.

You may file a complaint directly with the U.S. Department of Health and Human Services, Office for Civil Rights, without first contacting the Practice. Visit HHS's complaint page, call 1-800-368-1019, or write to 200 Independence Avenue SW, Washington, DC 20201. We will not retaliate against you for filing a complaint.

Other Uses of Medical Information

Other uses and disclosures of medical information not described in this Notice or the laws that apply to us will be made only with your written authorization on a Practice authorization form. If you provide us with authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. However, we may continue to use or disclose that information to the extent we have relied on your authorization. You also understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.

Acknowledgment of Receipt

During the patient-care process, the Practice requests an acknowledgment that you received or had access to this Notice. That acknowledgment records receipt only: it does not waive your HIPAA rights or authorize additional uses or disclosures of your medical information.

The acknowledgment records the patient's name, the date, and the signature of the patient or an authorized representative. If a signature cannot be obtained, the Practice documents its efforts and the reason, including refusal or inability to sign. The acknowledgment becomes part of the medical record. Viewing this page does not constitute a signature or an acknowledgment of receipt.

Contact the Privacy Officer

To request records, a restriction, an amendment, an accounting, confidential communications, a paper copy of this Notice, or to raise a privacy concern, contact the Practice's Privacy Officer using the contact information below. Identify your request as a Practice privacy request.

Email: [email protected]

Mail:
Privacy Officer, Aspen Aesthetics, PLLC DBA Fifty 410
c/o Fifty 410
1630 W Prosper Trail, Suite 620
Prosper, TX 75078

Use the secure patient portal for sensitive medical information. Standard email is not guaranteed to be private; you can use the email above to request a secure way to submit your privacy request.