The Plastic Surgery Group, P.C.




This office is permitted by federal privacy laws to make uses and disclosures of your protected health information (“PHI”) for purposes of treatment, payment, and health care operations. PHI is the information we create and obtain regarding your health, healthcare or payment for your healthcare and that identifies you or can be used to identify you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents relating to those services.

Examples of uses and disclosures of your PHI for treatment purposes are:

  • Our staff obtains treatment information about you and records it in the medical record.
  • During the course of your treatment the physician determines you need to consult with another specialist.
  • Your PHI will be forwarded to that specialist.

Example of uses and disclosures of your PHI for payment purposes:

  • We submit requests for payment to your health insurance company. The insurance company or business associate helping us obtain payment requests information from us regarding your medical care. We will provide information to them about you and your care.

Example of uses and disclosures of your PHI for health care operations:

  • Our physicians and quality assurance staff may use PHI to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.


The health and billing records we maintain are the physical property of the doctor’s office. You have the following rights with respect to your PHI.

  1. Request a restriction on certain uses and disclosures of your PHI by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted.
  2. Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information (“Notice”) by making a request at our office.
  3. Right to inspect and copy your health record and billing record – you may exercise this right by delivering the request in writing to our office using the form we provide to you upon request. You also have the right to appeal a denial of access to your PHI except in certain circumstances.
  4. Right to request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request. (The physician or other health care provider is not required to make such amendments); you may file a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your PHI;
  5. Right to receive an accounting of disclosures of your PHI as required to be maintained by law by delivering a written request to our office using the form we provide to you upon request. An accounting will not include certain items, for example, internal uses of information for treatment, payment or operations, disclosure made to you or made at your request, or disclosures made to family members or friends in the course of providing care.
  6. Right to confidential communication by requesting that communication of your PHI be made by alternative means or at an alternative location by delivering the request in writing to our office using the form we give you upon request.
  7. We may contact you to raise funds for The Plastic Surgery Group, P.C., but you will have the right to opt out of receiving any such communications.
  8. We must agree to any request to restrict disclosure of PHI 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 PHI pertains solely to a health care item or service for which you, or a person other than the health plan on your behalf, has paid us in full.

If you want to exercise any of the above rights, please contact The Plastic Surgery Group, P.C., Privacy Officer, 901 Riverfront Parkway, Suite 100 Chattanooga, TN 37402, (423)756-7134, in person or in writing, during normal business hours. The Privacy Officer will provide you with assistance on the steps to take to exercise your rights.


The office is required to:

  • Maintain the privacy of your PHI;
  • Provide you with a copy of this Notice;
  • Abide by the terms of this Notice;
  • Notify you if we cannot accommodate a requested restriction on the use and/or disclosure of your PHI;
  • Accommodate your reasonable requests regarding methods to communicate PHI with you.
  • Accommodate your request for an accounting of disclosures of your PHI as provided by law.
  • Notify you following a breach of unsecured PHI.

We reserve the right to amend, change, or eliminate provisions in this Notice and our privacy and access practices and to enact new provisions regarding the PHI we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our Notice or by visiting our office and picking up a copy.


If you have questions, would like additional information, or want to report a problem regarding the handling of your PHI, you may contact The Plastic Surgery Group, P.C., Privacy Officer, 901 Riverfront Parkway, Suite 100 Chattanooga, TN 37402, (423)756-7134.

Additionally, if you believe your privacy right has been violated, you may file a written complaint at our office by delivering the written complaint to the Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services (“HHS”).

  • We cannot, and will not, require you to waive the right to file a complaint with HHS as a condition of receiving treatment from the office.
  • We cannot, and will not, retaliate against you for filing a complaint with the HHS.


Patient Contact: We may contact you to provide you with appointment reminders, with information about treatment alternatives or with information about other health-related benefits and services that may be of interest to you. We may contact you as part of a fund raising effort.

Opportunity to Agree or Object: We may use and/or disclose your PHI under the following circumstances, subject to your right to agree or object.

  • To maintain a directory of individuals at our facility, including your name, location, general condition, and religious affiliation.
  • For directory purposes, to members of the clergy or to other persons who ask for you by name.
  • In emergency circumstances for directory purposes, where we cannot practicably obtain your agreement or objection due to your incapacity or emergency treatment circumstances.
  • To notify, or assist in the notification of (including identifying and locating), a family member, personal representative, or other person responsible for your care, about your location, general condition, or death.
  • To a family member, other relative, close personal friend, or any other person you identify, PHI directly relevant to that person’s involvement in your care or in payment for such care.
  • To assist in disaster relief efforts.


We may use and/or disclose your PHI in a number of circumstances in which you do not have to give authorization and do not have a right to agree or object. Those circumstances include, but are not limited to:

Required by Law – We may use/and or disclose your PHI as required by law.

Public Health Activities – We may use and/or disclose your PHI for public health activities, such as disclosures to public health or legal authorities charged with preventing or controlling disease, injury, or disability, to report child abuse or neglect, to a person who has been exposed to a communicable disease, or to a person subject to the jurisdiction of the Food and Drug Administration (FDA) with respect to an FDA-regulated product or activity for which that person has responsibility.

Victims of Abuse, Neglect, or Domestic Violence – We may disclose PHI to governmental authorities if we reasonably believe that you are a victim of abuse, neglect or domestic violence.

Oversight Agencies – We may disclose PHI to a health oversight agency for health oversight activities authorized by law, including audits; civil, administrative or criminal investigations and proceedings; inspections; licensure or disciplinary actions; and for similar reasons related to the administration of healthcare.

Judicial and Administrative Proceedings – We may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal or in response to a subpoena, discovery request, or other lawful process.

Law Enforcement – We may disclose your PHI for law enforcement purposes to a law enforcement official. For example, we may disclose PHI as required by law for the reporting of certain types of wounds or other physical injuries.

Coroners, Medical Examiners and Funeral Directors – We may disclose your PHI to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Organ Procurement Organizations – We may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.

Research – Under certain circumstances, we may disclose PHI for medical research.

Threat to Health and Safety –We may disclose PHI to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions – We may disclose your PHI for specialized government functions as authorized by law such as for medical suitability determinations in governmental hiring, to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Correctional Institutions – If you are an inmate of a correctional institution, we may disclose to the institution or its agents the PHI necessary for your health and the health and safety of other individuals.

Workers Compensation – If you are seeking compensation through Workers Compensation, we may disclose your PHI to the extent necessary to comply with laws relating to Workers Compensation.


Under the following circumstances, we may not disclose your PHI without your authorization:

Psychotherapy Notes – We must obtain your authorization for any use or disclosure of psychotherapy notes, except to carry out treatment, payment or health care operations or a use or disclosure that is required by law.

Marketing — We must obtain your authorization for any use or disclosure of PHI for marketing, except if the communication is in the form of a face-to-face communication or a promotional gift of nominal value.

Sale of PHI — We must obtain your authorization for any sale of your PHI.


Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization, which you may revoke except to the extent such use and/or disclosure has already occurred.


As long as The Plastic Surgery Group, P.C. maintains a website, this Notice will be available on the website.

Effective Date: August 10, 2016