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.

I.        What this Is

This Notice describes the privacy practices of South Shore Skin Surgeons, PC (the "Practice").

II.      Our Privacy Obligations

We are required by law to maintain the privacy of medical and health information about you (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to PHI.  When we use or disclose PHI, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure). 

III.     Permissible Uses and Disclosures Without Your Written Consent or Authorization

In certain situations, which we will describe in Sections IV and V below, we must obtain your written consent or authorization in order to use and/or disclose your PHI.  However, we do not need any type of consent or authorization from you for the following uses and disclosures:

A.      Use For Treatment, Payment and Health Care Operations.  We may use (but not disclose to a third party) your PHI in order to treat you, obtain payment for services provided to you and conduct our “health care operations” as detailed below:

• Treatment.  We use PHI to provide treatment and other services to you--for example, to diagnose and treat your injury or illness.  In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. 

• Payment.  We may use PHI to obtain payment for services that we provide to you--for example, to identify our claims for payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”).

• Health Care Operations.  We may use PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care and customer service that we deliver to you.  For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers, and we may provide PHI to our office manager in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.

B.       Disclosure to Relatives, Close Friends and Other Caregivers.  We may disclose PHI, other than Highly Confidential Information (described below in Section IV.B), to a family member, other relative, a close personal friend, or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, and do not object to such disclosure after being given the opportunity to do so.  We may also disclose your PHI to such person with your verbal agreement or written consent.

                     If you are incapacitated or in an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests.  If we disclose information to a family member, other relative or a close personal friend in such circumstances, we would disclose only information that is directly relevant to the person’s involvement with your health care or payment related to your health care.  We may also disclose PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.

C.       Public Health Activities.  We may disclose PHI for the following public health activities:

(1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability;

(2) to report child abuse and neglect, elder abuse, disabled persons abuse, or rape or sexual assault to public health authorities or other government authorities authorized by law to receive such reports;

(3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration;

(4) if we know or have reason to believe that you are infected with a venereal disease, to alert: (a) your fiancée, if you are engaged, or your spouse, if you are married, or (b) your parent or guardian if you are a minor, unless as a minor you have sought treatment with us for such venereal disease;

(5) to report information to your insurer and/or the Massachusetts Industrial Accident Board as required under laws addressing work-related illnesses and injuries or workplace medical surveillance;

(6) to report information related to the birth and subsequent health of an infant to state government agencies as required by law;

(7) to file a death certificate and report fetal deaths; and

(8) to report abortions performed after 24 weeks of pregnancy to state government agencies as required by law.

D.      Health Oversight Activities.  We may disclose PHI to a health oversight agency that oversees the health care system or government benefit programs (such as Medicare or Medicaid). 

E.       Judicial and Administrative Proceedings.  We may disclose PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

F.       Law Enforcement Officials.  We may disclose PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena accompanied by a court order.

G.      Decedents.  We may disclose PHI to a coroner or medical examiner as authorized by law.

H.      Organ and Tissue Procurement.  If you are an organ donor, we may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

I.        Research.  We may use or disclose PHI without your consent or authorization for research purposes if an Institutional Review Board/Privacy Board approves a waiver of authorization for such use or disclosure. 

J.        Health or Safety.  We may use or disclose PHI to prevent or lessen a serious and imminent danger to you or to others if the disclosure is to a person who is reasonably able to lessen or prevent the threat, including the target of the threat.

K.      Specialized Government Functions.  We may use and disclose PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances required by law.

L.       Ordered Examinations.  We may disclose PHI when required to report findings from an examination ordered by a court or detention facility.

          M.      As required by law.  We may use and disclose PHI when required to do so by any other law not already referred to in the preceding categories. 

IV.     Disclosures Requiring Your Written Consent

A.      Disclosures For Treatment, Payment and Health Care Operations.  With your written consent, we may disclose PHI in order to treat you, obtain payment for services provided to you and conduct our health care operations as detailed below:

• Treatment.  We may disclose PHI to provide treatment and other services to you--for example, we may disclose PHI to other providers involved in your treatment.

• Payment.  We may disclose PHI to obtain payment for services that we provide to you--for example, disclosures to file claims and obtain payment from Your Payor, or to verify that Your Payor will pay for health care.

• Health Care Operations.  We may disclose PHI for our health care operations.  For example, we may disclose PHI in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.

We may also disclose PHI to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.

B.       Disclosures of Your Highly Confidential Information. Federal and state law require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including: (1) your HIV/AIDS status; (2) genetic testing information; (3) confidential communications with a psychotherapist, psychologist, social worker, sexual assault counselor, domestic violence counselor, or other allied mental health professional or human services professional; (4) substance abuse (alcohol or drug) treatment or rehabilitation information; (5) venereal disease information; (6) abortion consent form(s); (7) mammography records; (8) family planning services; (9) treatment or diagnosis of emancipated minors; (10) mental health community program records; and (11) research involving controlled substances.  In order for us to disclose your Highly Confidential Information for a purpose related to treatment, payment, or health care operations, we must obtain your separate, specific written consent unless we are otherwise permitted by law to make such disclosure. 

          In addition, if you are an emancipated minor, certain information relating to your treatment or diagnosis may be considered “Highly Confidential Information” and as a result will not be disclosed to your parent or guardian without your consent.  Your consent is not required, however, if a physician reasonably believes your condition to be so serious that your life or limb is endangered.  Under such circumstances, we may notify your parents or legal guardian of the condition, and will inform you of any such notification.

          Please note that if you are a parent or legal guardian of an emancipated minor, certain portions of the emancipated minor’s medical record (or, in certain instances, the entire medical record) may not be accessible to you.

V.      Uses and Disclosures Requiring Your Written Authorization

A.      Use or Disclosure with Your Authorization.  For any purpose other than those described in Section III (for which no consent or authorization is required) and Section IV (for which your consent is required), we only may use or disclose your PHI when you give us your written authorization on our authorization form (“Authorization”) (an authorization form is similar to a consent form, but is more detailed and specific than a general consent form).  For instance, you will need to provide us your signed Authorization before we can send PHI to your life insurance company, to your child’s camp or school, or to the attorney representing the other party in litigation in which you are involved (unless the attorney has obtained a court order for such PHI). 

B.       Uses and Disclosures of Your Highly Confidential Information.  Please refer to Section IV.B above for information about our use and disclosure of your Highly Confidential Information.  In order for us to disclose your Highly Confidential Information for a purpose other than treatment, payment, or health care operations (for which your separate, specific consent is required), we must obtain your separate, specific Authorization, unless we are otherwise permitted by law to make such disclosure.

C.       Marketing Communications. We must also obtain your written authorization prior to using PHI to send you any marketing materials (“Marketing Authorization”).  We can, however, provide you with marketing materials in a face-to-face encounter, without obtaining your Marketing Authorization.  We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining your Marketing Authorization.  In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without your Marketing Authorization, and we may use PHI to identify health-related services and products that may be beneficial to your health and then contact you about the services and products. You do have the right to "opt out" with respect to receiving fundraising communications from us.

VI.     Your Individual Rights

A.      For Further Information; Complaints.  If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to PHI, you may contact our Office Manager.  You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services.  Upon request, the Office Manager will provide you with the correct address for the Director.  We will not retaliate against you if you file a complaint with us or the Director. 

B.       Right to Request Additional Restrictions.  You may request restrictions on our use and disclosure of PHI: (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition.  All requests for such restrictions must be made in writing.  While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction.  If you wish to request additional restrictions, please obtain a request form from our Office Manager and submit the completed form to the Office Manager.  We will send you a written response.

C.       Right to Receive Confidential Communications.  You may request, and we will accommodate any reasonable written request, to receive PHI by alternative means of communication or at alternative locations. 

D.      Right to Inspect and Copy Your Health Information.  You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records.  All requests for access must be made in writing.  Under limited circumstances, we may deny you access to your records.  If you desire access to your records, please obtain a record request form from the Office Manager and submit the completed form to the Office Manager.  If you request copies, we will charge you [$0.25 (25 cents)] for each page.  We will also charge you for our postage costs, if you request that we mail the copies to you. 

E.       Right to Revoke Your Authorization.  You may revoke your Authorization, your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Office Manager identified below.  [A form of Written Revocation is available upon request from the Office Manager.]

F.       Right to Amend Your Records.  You have the right to request that we amend PHI maintained in your medical record file or billing records.  If you desire to amend your records, please obtain an amendment request form from the Office Manager and submit the completed form to the Office Manager.  All requests for amendments must be in writing.  We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply. 

G.      Right to Receive An Accounting of Disclosures.  Upon written request, you may obtain an accounting of certain disclosures of PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.  If you request an accounting more than once during a twelve (12) month period, we will charge you [$0.25 per page] of the accounting statement. 

H.      Right to Receive Paper Copy of this Notice.  Upon written request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically. 

I.        Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity.  We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format.  If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form.  We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

I.        Right be Notified for a PHI Breach. If a breach of your PHI has occurred, you have a right to be notified by this office.

VII.   Effective Date and Duration of This Notice

A.      Effective Date.  This Notice is effective on September 23, 2013.

B.       Right to Change Terms of this Notice.  We may change the terms of this Notice at any time.  If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice.  If we change this Notice, we will post the revised notice in waiting areas of the Practice. You may also obtain any revised notice by contacting the Office Manager.

VIII.  Office Manager

You may contact the Office Manager at:

South Shore Skin Surgeons, P.C.

400 Washington St., Suite # 200

Braintree, MA  02184

                     (781) 380-8150

                     (781) 380-8160

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 781-380-8150.

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility

Your Rights and Protections Against Surprise Medical Bills

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re protected from balance billing for:

Emergency services                                                                                                     

If you have an emergency medical condition and get emergency services from an out-of -network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center                                                                                                                          When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

•           You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.

•            Generally, your health plan must:

o            Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).

o            Cover emergency services by out-of-network providers.

o            Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

o            Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact: The federal phone number for information and complaints: 1-800-985-3059].

Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.