THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This Privacy Notice is being
provided to you as a requirement of a federal law, the Health Insurance
Portability and Accountability Act (HIPAA).
This Privacy Notice describes how we may use and disclose your protected
health information to carry out treatment, payment or health care operations
and for other purposes that are permitted or required by law. It also describes your rights to access and
control your protected health information in some cases. Your "protected health information"
means any written and oral health information about you, including demographic
data that can be used to identify you.
This is health information that is created or received by your health
care provider, and that relates to your past, present or future physical or
mental health or condition.
The Center may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless the Center has obtained your authorization or the HIPAA privacy regulations or state law otherwise permits the use or disclosure. Disclosures of your protected health information for the purposes described in this Privacy Notice may be made in writing, orally, or by facsimile.
A. Treatment. We will use and disclose your protected
health information to provide, coordinate, or manage your health care and any
related services. This includes the
coordination or management of your health care with a third party for treatment
purposes. For example, we may disclose
your protected health information to a pharmacy to fill a prescription or to a
laboratory to order a blood test. We may
also disclose protected health information to physicians who may be treating
you or consulting with the Center with respect to your care. In some cases, we may also disclose your
protected health information to an outside treatment provider for purposes of
the treatment activities of the other provider.
B. Payment. Your protected health information will be
used, as needed, to obtain payment for the services that we provide. This may include certain communications to
your health insurance company to get approval for the procedure that we have
scheduled. For example, we may need to
disclose information to your health insurance company to get prior approval for
the surgery. We may also disclose
protected health information to your health insurance company to determine
whether you are eligible for benefits or whether a particular service is
covered under your health plan. In order
to get payment for the services we provide to you, we may also need to disclose
your protected health information to your health insurance company to
demonstrate the medical necessity of the services or, as required by your
insurance company, for utilization review.
We may also disclose patient information to another provider involved in
your care for the other provider’s payment activities. This may include disclosure of demographic
information to anesthesia care providers for payment of their services.
C. Operations. We may use or disclose your protected health
information, as necessary, for our own health care operations to facilitate the
function of the Center and to provide quality care to all patients. Health care operations include such
activities as: quality assessment and improvement activities, employee review
activities, training programs including those in which students, trainees, or
practitioners in health care learn under supervision, accreditation,
certification, licensing or credentialing activities, review and auditing,
including compliance reviews, medical reviews, legal services and maintaining compliance
programs, and business management and general administrative activities.
In
certain situations, we may also disclose patient information to another
provider or health plan for their health care operations.
D. Other Uses and
Disclosures. As part of treatment, payment and health
care operations, we may also use or disclose your protected health information
for the following purposes: to remind you of your surgery date, to inform you
of potential treatment alternatives or options, to inform you of health-related
benefits or services that may be of interest to you, or to contact you to raise
funds for the Center or an institutional foundation related to the Center. If you do not wish to be contacted regarding
fundraising, please contact our Privacy Officer using the contact information
below.
II.
Uses and Disclosures
Beyond Treatment, Payment, and Health Care Operations Permitted Without
Authorization or Opportunity to Object
Federal privacy rules allow us to use or disclose
your protected health information without your permission or authorization for
a number of reasons including the following:
A. When Legally Required. We will disclose your protected health
information when we are required to do so by any federal, state or local law.
B. When There Are
Risks to Public Health. We may
disclose your protected health information for the following public activities
and purposes:
C. To Report Suspected
Abuse, Neglect Or Domestic Violence. We may
notify government authorities if we believe that a patient is the victim of
abuse, neglect or domestic violence. We
will make this disclosure only when specifically required or authorized by law
or when the patient agrees to the disclosure.
D. To Conduct Health
Oversight Activities. We may disclose your protected health
information to a health oversight agency for activities including audits;
civil, administrative, or criminal investigations, proceedings, or actions;
inspections; licensure or disciplinary actions; or other activities necessary
for appropriate oversight as authorized by law.
We will not disclose your health information under this authority if you
are the subject of an investigation and your health information is not directly
related to your receipt of health care or public benefits.
E. In Connection With
Judicial And Administrative Proceedings. We may
disclose your protected health information in the course of any judicial or
administrative proceeding in response to an order of a court or administrative
tribunal as expressly authorized by such order.
In certain circumstances, we may disclose your protected health
information in response to a subpoena to the extent authorized by state law if
we receive satisfactory assurances that you have been notified of the request
or that an effort was made to secure a protective order.
F. For Law Enforcement Purposes. We may disclose your protected health
information to a law enforcement official for law enforcement purposes as
follows:
G. To Coroners, Funeral
Directors, and for Organ Donation. We may disclose
protected health information to a coroner or medical examiner for
identification purposes, to determine cause of death or for the coroner or
medical examiner to perform other duties authorized by law. We may also disclose protected health
information to a funeral director, as authorized by law, in order to permit the
funeral director to carry out their duties.
We may disclose such information in reasonable anticipation of
death. Protected health information may
be used and disclosed for cadaveric organ, eye or tissue donation purposes.
H. For Research Purposes. We may use or disclose your protected health
information for research when the use or disclosure for research has been
approved by an institutional review board that has reviewed the research
proposal and research protocols to address the privacy of your protected health
information.
I. In the Event of a
Serious Threat to Health or Safety. We may,
consistent with applicable law and ethical standards of conduct, use or
disclose your protected health information if we believe, in good faith, that
such use or disclosure is necessary to prevent or lessen a serious and imminent
threat to your health or safety or to the health and safety of the public.
J. For Specified
Government Functions. In certain circumstances,
federal regulations authorize the Center to use or disclose your protected
health information to facilitate specified government functions relating to
military and veterans activities, national security and intelligence
activities, protective services for the President and others, medical
suitability determinations, correctional institutions, and law enforcement
custodial situations.
K. For Worker's
Compensation. The Center may release your
health information to comply with worker's compensation laws or similar
programs.
III.
Uses and Disclosures
Permitted without Authorization but with Opportunity to Object
We may disclose your protected health information to your
family member or a close personal friend if it is directly relevant to the
person’s involvement in your surgery or payment related to your surgery. We can also disclose your information in
connection with trying to locate or notify family members or others involved in
your care concerning your location, condition or death.
You may object to these
disclosures. If you do not object to
these disclosures or we can infer from the circumstances that you do not object
or we determine, in the exercise of our professional judgment, that it is in
your best interests for us to make disclosure of information that is directly
relevant to the person’s involvement with your care, we may disclose your
protected health information as described.
IV. Uses and Disclosures, which you Authorize
Other than as stated above, we will not disclose
your health information other than with your written authorization. You may revoke your authorization in writing
at any time except to the extent that we have taken action in reliance upon the
authorization.
You have the following
rights regarding your health information:
A. The right to inspect and copy your
protected health information. You may inspect and obtain a copy of your protected health information
that is contained in a designated record set for as long as we maintain the
protected health information. A
“designated record set” contains medical and billing records and any other
records that your surgeon and the Center uses for making decisions about you.
Under federal law, however, you may not inspect or copy the
following records: psychotherapy notes;
information compiled in reasonable anticipation of, or for use in, a civil,
criminal, or administrative action or proceeding; and protected health
information that is subject to a law that prohibits access to protected health
information. Depending on the
circumstances, you may have the right to have a decision to deny access
reviewed.
We may deny your request to inspect or copy your protected
health information if, in our professional judgment, we determine that the
access requested is likely to endanger your life or safety or that of another
person, or that it is likely to cause substantial harm to another person
referenced within the information. You
have the right to request a review of this decision. ++
To inspect and copy your medical information, you must submit
a written request to the Privacy Officer using the contact information listed
on the last page of this Privacy Notice.
If you request a copy of your information, we may charge you a
reasonable cost-based fee for the costs of copying, mailing or other costs
incurred by us in complying with your request.
Please contact our Privacy Officer using the contact
information below if you have questions about access to your medical record.
B. The right to request a restriction on
uses and disclosures of your protected health information. You may ask us not to use or disclose certain
parts of your protected health information for the purposes of treatment,
payment or health care operations. You
may also request that we not disclose your health information to family members
or friends who may be involved in your care or for notification purposes as
described in this Privacy Notice. Your
request must state the specific restriction requested and to whom you want the
restriction to apply.
The Center is not required to agree to a restriction that you
may request. We will notify you if we
deny your request to a restriction. If
the Center does agree to the requested restriction, we may not use or disclose
your protected health information in violation of that restriction unless it is
needed to provide emergency treatment.
Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting
the Privacy Officer using the contact information below.
C. The right to request to receive
confidential communications from us by alternative means or at an alternative
location. You have the right to request that we
communicate with you in certain ways. We
will accommodate reasonable requests. We
may condition this accommodation by asking you for information as to how
payment will be handled or specification of an alternative address or other method
of contact. We will not require you to
provide an explanation for your request.
Requests must be made in writing to our Privacy Officer using the
contact information below.
D. The right to request amendments to
your protected health information. You may request an
amendment of protected health information about you in a designated record set
for as long as we maintain this information.
In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you
have the right to file a statement of disagreement with us and we may prepare a
rebuttal to your statement and will provide you with a copy of any such
rebuttal. Requests for amendment must be
in writing and must be directed to our Privacy Officer using the contact
information below. In this written
request, you must also provide a reason to support the requested amendments.
E. The right to receive an accounting. You have the right to request an accounting
of certain disclosures of your protected health information made by the
Center. This right applies to
disclosures for purposes other than treatment, payment or health care
operations as described in this Privacy Notice.
We are also not required to account for disclosures that you requested,
disclosures that you agreed to by signing an authorization form, disclosures
for a Center directory, to friends or family members involved in your care, or
certain other disclosures we are permitted to make without your
authorization. The request for an
accounting must be made in writing to our Privacy Officer. The request should specify the time period
sought for the accounting. We are not
required to provide an accounting for disclosures that take place prior to
April 14, 2003. Accounting requests may
not be made for periods of time in excess of six years. We will provide the first accounting you
request during any 12-month period without charge. Subsequent accounting requests may be subject
to a reasonable cost-based fee.
F. The right to obtain a paper copy of
this notice. Upon request, we will
provide a separate paper copy of this notice even if you have already received
a copy of the notice or have agreed to accept this notice electronically.
VI. Our Duties
The Center is required by law to maintain the privacy of your
health information and to provide you with this Privacy Notice of our duties
and privacy practices. We are required
to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of
this Notice and to make the new Notice provisions effective for all future
protected health information that we maintain.
If the Center changes its Notice, we will provide a copy of the revised
Notice by sending a copy of the revised Notice via regular mail or through in-person
contact.
VII. Complaints
You have the right to express complaints to the Center and to
the Secretary of Health and Human Services if you believe that your privacy
rights have been violated. You may
complain to the Center by contacting the Center’s Privacy Officer verbally or
in writing, using the contact information below. We encourage you to express any concerns you
may have regarding the privacy of your information. You will not be retaliated against in any way
for filing a complaint.
The Center’s contact person for all issues regarding
patient privacy and your rights under the federal privacy standards is the
Privacy Officer. Information regarding
matters covered by this Notice can be requested by contacting the Privacy
Officer. If you feel that your privacy
rights have been violated by this Center you may submit a complaint to our
Privacy Officer by sending it to:
ATTN: Center Administrator
(Privacy Officer)
The Privacy Officer can be contacted by
telephone at (330)702.1489
This Notice is
effective April 14, 2003.
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE
I acknowledge that I have received
the attached Privacy Notice.
______________________________ _______________
Patient or Personal Representative Date
Signature
If Personal Representative’s
signature appears above, please describe Personal Representative’s relationship
to the patient: