LEE H. COLONY, M.D., F.A.C.S.
When you started:
In connection with the plastic surgical services which I am receiving from Dr. Lee Colony, I consent that photographs, videos, or other images may be taken of me or parts of my body, under the following conditions:
The patient requesting care is responsible for payment. Co-payments and deductibles are due at the time of service.
I hereby authorize release of information necessary to file a claim with my insurance company and assign benefits otherwise payable to me to
the doctor or the corporation as indicated on the claim. A copy of my signature is as valid as the original. I certify that all of the demographic,
medical, and insurance information is complete and correct.
To our patients – This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how
you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability
and Accountability Act of 1996 (HIPPA).
Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your
We realize that these laws are complicated, but we must provide you with the following important information:
The following circumstances may require us to use or disclose your health information:
1. Communications. You can request that our practice communicates with you about your health and related issues in a particular manner or at
a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.
2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally,
you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the
payment for you care, such as family member and friends. We are not required to agree to your request, however, if we do agree, we are
bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient
medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Administrator–Dr. Lee H. Colony, 2900 Hannah Boulevard, Suite 110, East Lansing, Michigan 48823 or by telephone 517-333-4960 for further information.
A meeting will be schedule with the Administrator to inspect your records after we receive your request.
4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for
our practice. To request an amendment, your request must be made in writing and submitted to Administrator – Dr. Lee H. Colony, 2900
Hannah Boulevard, Suite 110, East Lansing, Michigan 48823. You must provide us with a reason that supports your request for amendment.
5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this
notice at any time. To obtain a copy of this notice, contact Administrator – Dr. Lee H. Colony, 2900 Hannah Boulevard, Suite 110, East Lansing,
Michigan 48823 or by telephone 517-333-4960.
6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the
Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Administrator – Dr. Lee H. Colony,
2900 Hannah Boulevard, Suite 110, East Lansing, Michigan 48823 or by telephone 517-333-4960. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
7. 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.
If you have any questions regarding this notice or our health information privacy policies, please contact Administrator – Dr. Lee H. Colony,
2900 Hannah Boulevard, Suite 110, East Lansing, Michigan 48823 or by telephone 517-333-4960.
I hereby acknowledge that I have been presented with a copy of Dr. Lee H. Colony – Michigan Plastic Surgery – Notice of Privacy Practice
Notice of Privacy Practices
Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical/dental information for the purpose of improving patient care. Providers may include primary care clinicians, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
As with any healthcare procedure, there are potential risks associated with the use of telemedicine. The risks include, but may not be limited to:
1. I understand the laws that protect privacy and the confidentiality of healthcare information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and my receive copies of this information for a reasonable fee.
4. I understand a variety of alternative methods of healthcare may be available to me, and that I may choose one or more of these at any time. My clinician has explained the alternatives to my satisfaction.
5. I understand telemedicine may involve electronic communication of my personal healthcare information to other healthcare practitioners who may be located in other areas, including out of state.
6. I understand it is my duty to inform my clinician of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand I may expect the anticipated benefits from the use of telemedicine in my care, but no results can be guaranteed or assured.
I have read and understand the information provided above regarding telemedicine, have discussed it with my clinician as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my healthcare.
I hereby authorize LEE H. COLONY, MD, PC to use telemedicine in the course of my diagnosis and treatment.
Phone: 517-333-4960 || Fax: 517-333-5970
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