Facebook Profile - Rejuvenis Facial Cosmetic Surgery & Medical Spainstagram - icon
Trust Your Face To An Expert, Trust Your Face To A Facial Plastic Surgeon

Resource Center

New Patient Forms

    Notice of Privacy Practices

    The Federal Government published a rule regarding the privacy of protected health information. The Health Insurance Portability and Accountability Act (HIPPA) established privacy standards that govern organizations like Rejuvenis Facial Cosmetic Surgery & Medical Spa. Rejuvenis Facial Cosmetic Surgery & Medical Spa uses health information for treatment, to obtain payment for treatment, for administrative purposes and to evaluate the quality of care that you receive.

    This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about something in this notice please ask the receptionist.

    Our Legal Duty

    We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 4/14/2003.

    We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

    Uses and Disclosures of Health Information

    We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

    Treatment: We may use your medical information to provide you with medical treatment or services. We may disclose your medical information to other physicians who are also caring for you.

    Payment: We may use or disclose your health information to obtain payment for services we provide to you.

    Healthcare Operations: We may use or disclose your medical information for office operations. These uses and disclosures are necessary to run the office and make sure that all our patients receive quality care. This means we may use your medical information to review treatment and care you receive from our staff.

    Appointment Reminders, Results and Statements: We may use or disclose your healthcare information to provide you with appointment reminders, test and pathology results and statements as long as they are marked personal and confidential. We may send postcards and leave messages at your home and on your answering machine.

    Required by Law: We may use or disclose your health information when we are required to do so by law.

    Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

    National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal official health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to a correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

    Patient Rights

    Right to Inspect and Copy: You have the right to inspect and obtain a copy of your medical information. Usually, this includes medical and billing records.

    Right to Amend: If you feel the medical information we have about you is incorrect, or incomplete, you have the right to ask us to amend the information. Amending the information means adding to the information with which you disagree. It does not include deleting, removing or otherwise changing the content of the record. You have the right to request and amendment for as long as the information is kept by or for the office. You may request an amendment in writing to the Privacy Officer at the office address.

    Right to Disclosure of Accounting: You have the right to receive a list of disclosure we made of your medical information. This does not include certain disclosures such as those made for the purpose of treatment, payment, healthcare operations or those you have authorized. It also does not include anything before the effective date of this policy (4/14/2003).

    Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or certain location. (Example: We can only call or contact you at home and not at work.) There are certain people who may call us concerning your healthcare to which we may talk with.

    Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our Privacy Officer at the office address.

    Rejuvenis Facial Cosmetic Surgery & Medial Spa are required by law to notify you of our privacy practices. This document serves as our notice to you. To acknowledge that you have received this notice please sign this form and return it to the office.

    Patient Name *

    Date *

    Electronic Signature of Patient or Legal Guardian *

    Please complete this section if you are over the age of 18 or an emancipated minor and would like the staff of Rejuvenis Facial Cosmetic Surgery & Medical Spa to discuss any aspect of your medical treatment with the persons below (includes spouse, parents, children, significant other, etc.). Otherwise we will only be able to speak with you about your lab or pathology results or other health issues or questions.

    Authorized Name


    Authorized Name


    About author - Dr. Russo

    Dr. Russo

    Dr. Russo is the founder of Rejuvenis Med Spa. He developed a passion for lasers, fillers, and other non-cosmetic treatments during his over 30 years of practice in Champaign-Urbana. He started his career after completing an AAFPRS fellowship in Facial Plastic Surgery. After many years of managing a busy surgical practice and med spa, Dr. Russo focuses his interest and practice on non and minimally-invasive facial and skin rejuvenation. Visit Rejuvenis Beauty today for experienced care in health, beauty, and wellness!

    Rejuvenisbeauty - emailFacebook Profile - Rejuvenis Facial Cosmetic Surgery & Medical Spa