HIPAA Notice of Privacy Practice for Personal Health Information:

This notice describes how medical information about you may be used and disclosed and how you can get access to the information.

Please review it carefully. if you have any questions about this notice please contact us at our office, 954-585-3800.

Who Will Follow This Notice?

|This notice describes out facility's practice and that of:
--Any physician or health care professional authorized to enter information into your medical chart.
--All departments and units of our facility.
--All employees, staff and other office personnel.
--All these individuals, sites and locations follow the terms of this notice. In addition, these individuals, sites and locations may share medical information with each other or with third party specialists for treatment, payment or office operations purposes described in this notice.

Our Pledge Regarding Medical Information:

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at our facility. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all the records of our generated by our facility.

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

The law requires us to:
--Maintain the privacy of your Personal Health Information;
--Provide you this notice of our legal duties and privacy with respect to your Personal Health Information and
--Follow the terms of this notice.

The main reason for which we may use and disclose your Personal Health Information are to evaluate and process any request for coverage and claims for benefits you may make or in connection with other health-related benefits or services that may be of interest to you. The following describes these and other uses and disclosures, together with some examples.

For Treatments. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to the facility's office personnel who are involved in taking care of you at the facility or elsewhere. We also may disclose medical information about you to people outside our facility who may be involved in your care after you leave the facility, such as family members or others we use to provide services that are part of your care, provided you have consented to such disclosers. These entities include third party physicians, hospitals, nursing homes, pharmacies or clinical labs with whom the office consults or makes referrals.

For Payments. We may use or disclose medical information about you so that the treatment and services that you receive at our office may be billed to and payment may be collected from you, an insurance or third party. For example, we may need to give your health plan information about procedures received at the facility so your health plan will pay us or reimburse you for the services. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your pain will cover treatment.

For Your Care Operations. We may use and disclose medical information about you for our internal operations. These uses and disclosures are necessary to run our facility and make sure that all of our patients receive quality care. For example, we may use medical information about you to review our treatment and services and to evaluate our performance and staff in caring for you. We may also combine medical information about many patients to decide what additional services the facility should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to our physicians, staff and other office personnel for review and learning purposes.

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 provided you have consented to such disclosures. We may also give information to some one who helps pay for your care. In addition, we may disclose medical information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

To Avert a Serious Threat to Health and Safety. We may disclose Personal Health information to avert a serious threat to someone's health or safety. We may also disclose Personal Health Information to federal, state, or local agencies engaged in a disaster relief or disaster assistance agencies to allow such entities to carry out their responsibilities in specific disaster situations.

For Health-Related Benefits or Services. We may use Personal Health Information provide you with information about benefits available to you under your current coverage or policy and, in limited situations, about health-related products or services that may be of interest to you.

For Law Enforcement or Specific Government Functions. We may disclose Personal Health Information in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose Personal Health Information about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

When Requested as Part of a Regulatory or Legal Proceeding. If you or your estate are involved in a lawsuit or a dispute, we may disclose personal Health Information about you in response to a court or administrative order. We may also disclose personal Health Information about you in response to a subpoena, discovery request, or law 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 Personal health Information requested. We may disclose Personal Health Information to any government agency or regulator with whom you have filled a complaint or as part of a regulatory agency examination.

Right to Request Confidential Communications. You have the right to request that we communicate with you about Personal Health Information in a certain way or at a certain location if you tell us that communication in another manner will endanger you. For example, you can ask that we only contact you at work or by mail. To request confidential communication, you must make your request in writing to the applicable administrator listed above and specify how or where you wish to be contacted. We will accommodate all reasonable requests.

Right to File a Complaint. If you believe your privacy right have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact us at Take Shape Plastic Surgery PA, 4161 NW 5th Street, Plantation FL 33317, 954-585-3800. All complaints must be submitted in writing. You will not be penalized for filing a complaint. If you have any questions as to how to file a complaint please contact us at this above mentioned address or phone number.

ADDITIONAL INFORMATION

Changes to this Notice. We reserve the right to change the terms of this notice at any time. We reserve the right to make the revised or changed notice effective for Personal Health Information we already have about you as well as any Personal Health Information we receive in the future. The effective date of this notice and any revised or changed notice may be found on the last page, on the bottom right hand corner of the notice. You will receive a copy of any revised notice from us by e-mail, but only if delivery is offered by us and you agree to such delivery.

Other Uses of Medical Information. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care of the care that we provided you.