Choose Your Dermatologist

ACT OF 1 AS REQUIRED BY THE HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY996 (HIPAA)

A. OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your individually identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your protected health information (PHI). By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time. We realize that these laws are complicated, but we must provide you with the following important information:

How we may use and disclose your PHI

Your privacy rights regarding your PHI

Our obligations concerning the use and disclosure of your PHI

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will always post a copy of our current Notice in our offices in a visible location, and you may request a copy of our most current Notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Magnolia Dermatology of Frisco, PLLC

13192 Dallas Parkway Ste 620

Frisco, Texas 75034

info@magnoliadermfrisco.com

C. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS:

Treatment. Our practice may use your PHI to treat you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment.

Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us.

Health Care Operations. Our practice, and its affiliated entities and management company, may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice.

Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment. We will notify you about your appointment utilizing an automated phone system, a personal call, text or by mail. This notification may involve leaving a message on an answering machine or other automated or electronic equipment for such purposes, which could (potentially) be received or intercepted by others.

Sign in Sheet. We may use and disclose medical information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.

Treatment Options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.

Health-Related Benefits and Services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.

Release of Information to Family/Friends. Our practice will routinely disclose to your responsible party(ies) the PHI directly relevant to his/her involvement with your health care, PHI related to payment of your health care, and PHI used for notification purposes. Our practice may release your PHI to another responsible party(ies) you identify, that is involved in your care.

Marketing. We may contact you to give you information about products or services related to your treatment, or care. We will not otherwise use or disclose your medical information for marketing purposes, without your prior written authorization.

Sale of Health Information. We will not sell your health information without your prior written authorization.

Disclosures Required by Law. Our practice will use and disclose your PHI when we are required to do so by federal, state, or local law.

Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law.

Responding to Lawsuits. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

D. USE AND DISCLOSURE OF PHI IN SPECIAL CIRCUMSTANCES

The following categories describe unique scenarios in which we may use or disclose your protected health information:

Public Health Risk Reporting. Our practice may disclose your PHI to public health authorities that are authorized by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Law Enforcement. Your health information may be disclosed to law enforcement agencies, military, and national security without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.

Workers’ Compensation. Our practice may release your PHI for workers’ compensation and similar programs that provide benefits for work-related injuries or illnesses.

E. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding the PHI that we maintain about you. These include:

The right to request restrictions on the use and disclosure of your protected health information, including to request that a health plan not be informed of treatment for which patient paid entirely out of pocket.

The right to prohibit the sale of your protected health information, its use for marketing purposes, or participation in research.

The right to request to receive confidential communications concerning your medical condition and treatment in a specific manner.

The right to inspect and obtain copies of your protected health information.

The right to request an amendment or corrections to your protected health information.

The right to receive an accounting of how and to whom your protected health information has been disclosed outside of our practice if not for treatment, payment, or health care operations.

The right to file a complaint if you believe your privacy rights have been violated. Please file your complaint in writing. You will not be penalized for filing a complaint.

The right to receive a printed copy of this notice.

All requests must be in writing and directed to Magnolia Dermatology of Frisco, PLLC, 13192 Dallas Parkway, Ste 620, Frisco, Texas 75034. Our practice may charge a fee for the costs associated with any request.

F. RIGHT TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES

Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing.After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care. If you believe your privacy rights have been violated, you may complain to the secretary of the U.S. Department of Health and Human Services by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201 or to the Compliance/Privacy Officer listed below. There will not be retaliation against you for filing a complaint. Again, if you have any questions regarding this notice or our health information privacy policies, please contact:

Magnolia Dermatology of Frisco, PLLC

13192 Dallas Parkway Ste 620

Frisco, Texas 75034

info@magnoliadermfrisco.com

Updated as of December 20, 2021

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

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:

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.

Applicable State balance billing information may be found at the bottom of this notice.

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.

Applicable State balance billing information may be found at the bottom of this notice.

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:

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

Cover emergency services by out-of-network providers.

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.

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 Centers for Medicare & Medicare Services (CMS) Website: https://www.cms.gov/nosurprises/consumers Phone: 1-800-985-3059 Visit Centers for Medicare & Medicaid Services No Surprises Act for more information about your rights under federal law

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 1-800-985-3059.

Texas Surprise Billing

Patients get surprise medical bills if they get care outside their health plan’s network without realizing it. For example, a patient may pick a surgeon in her plan’s network, however; the patient may not be asked about the anesthesiologist. Texas state law may protect patients with state-regulated health insurance from surprise medical bills in emergencies and when they didn’t have a choice of doctors. A patient has a right to be provided: a written disclosure that confirms whether the facility is in-network based on the insurance information the patient provides; to be told that facility-based physicians may bill separately and may not participate in the patient’s insurance plan; to request a list of physicians that have been granted medical staff privileges at that facility and to request from that facility-based physician information whether the physician is in-network with the patient’s insurance plan. For additional information, please visit the Texas Department of Insurance website or call 800-578-4677.