OF PRIVACY PRACTICES
Surgery Center, LLC.
Effective Date: January
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
If you have any questions about this notice, please contact
our Administrator at 614-932-9548.
Written requests should be addressed to:
Surgery Center, LLC.
5005 Parkcenter Ave
Dublin, Ohio 43017
WHO WILL FOLLOW THIS NOTICE:
Surgery Center, LLC.
OUR PLEDGE REGARDING HEALTH
We understand that health information about you and your
health care is personal. We are
committed to protecting health information about you. We create a record of the care and services
you receive from us. We need this record
to provide you with quality care and to comply with certain legal
requirements. This notice will tell you
about the ways in which we may use and disclose health information about
you. This notice also describes your
rights to get access to the health information we keep about you and describes
certain obligations we have regarding the use and disclosure of your health
We are required by law to:
· make sure that health information that
identifies you is kept private;
· give you this notice of our legal duties and
privacy practices with respect to
health information about you;
· follow the terms of the Notice of Privacy
Practices that is currently in effect.
YOUR RIGHTS REGARDING HEALTH INFORMATION
You have the
following rights with respect to your Protected Health Information:
to Inspect and Copy: You
have the right to inspect and copy all or any part of your medical or
health record, as provided by federal regulations. You may request and receive an
electronic copy of your protected health information, or “PHI” if Dublin
Surgery Center, LLC. maintains your PHI in an electronic health
inspect and copy your PHI, you must submit your request in writing to our Administrator
at the address listed on the first page of this notice. If you request a copy of your PHI we may
charge a reasonable, cost-based fee in accordance with state law for the costs
associated with fulfilling your request.
may deny your request to inspect and copy your PHI in certain limited
to Amend: You have the right to request that we
amend your PHI or a medical or health record about you if you feel that
health information we have about you is incorrect or incomplete. You have the right to request an
amendment for as long as we keep the information. To request an amendment, your request
must be made in writing, submitted to our Administrator at the address
listed on the first page of this notice, and must be contained on one page
of paper legibly handwritten or typed in at least 10 point font size. In addition, you must provide a reason
that supports your request for an amendment.
may deny your request for an amendment if it is not in writing or does not
include a reason to support the request.
In addition, we may deny your request if you ask us to amend information
was not created by us, unless you
provide a reasonable basis for us to believe that the person or entity that
created the information is no longer available to make the requested amendment;
is not part of the health
information kept by or for our practice;
is not part of the information which
you would be permitted to inspect and copy; or
is accurate and complete.
amendment we make to your PHI or other medical or health records about you will
be disclosed to those with whom we disclose information.
to an Accounting of Disclosures: You
have the right to request a list accounting for any disclosures of your
PHI we have made, except for disclosures made for the purpose of
treatment, payment, health care operations and certain other purposes if
such disclosures were made through a paper record or other health record
that is not electronic, as set forth in federal regulations. If you request an accounting of
disclosures of your PHI, the accounting may include disclosures made for
the purpose of treatment, payment and health care operations to the extent
that disclosures are made through an electronic health record.
request an accounting of disclosures, you must submit your request in writing
to our Administrator at the address listed on the first page of this
notice. Your request must state a time
period which may not be longer than six years and may not include dates before
April 14, 2003. The first list you
request within a 12 month period will be free.
For additional lists, we may charge you for the costs of providing the
list. We will notify you of the cost
involved and you may choose to withdraw or modify your request at that time
before any costs are incurred. We will,
to the extent possible, mail you a list of disclosures in paper form within 60
days of your request, or notify you if we are unable to supply the list within
that time period and by what date we can supply the list; such date will not be
later than a total of 90 days from the date you made the request.
to Request Restrictions: You have the right to request a
restriction or limitation on the use and disclosure of your PHI. You also have the right to request a
restriction or limitation on the disclosure of your PHI to someone who is
involved in your care or the payment for your care, such as a family
member or friend. For example, you
could ask that we restrict a specified nurse from use of your PHI or that
we not disclose information to your spouse about a surgery you had.
We are not required to agree to your request for
restrictions, except if you pay for a service entirely out-of-pocket. If you pay for a service entirely
out-of-pocket, you may request that information regarding the service be
withheld and not provided to a third party payor for purposes of payment or
health care operations. We are obligated
by law to abide by such restriction.
request a restriction on the use and disclosure of your PHI, you must make your
request in writing to our Administrator at the address listed on the first page
of this notice. In your request, you
must tell us what information you want to limit and to whom you want the
limitations to apply; for example, use of any PHI by a specified nurse, or
disclosure of specified surgery to your spouse.
We will notify you of our decision regarding the requested restriction. If we do agree to your requested restriction,
we will comply with your request unless the information is needed to provide
you emergency treatment.
to Receive Confidential
have the right to request that we communicate with you about your health
information in a certain way or have such communications addressed to a
certain location. For example, you
can ask that we only contact you at work or by mail to a post office box.
communications, you must make your request in writing to our Administrator at
the address listed on the first page of this notice. We will not ask you the
reason for your request. We will
accommodate all reasonable requests.
Your request must specify how or where you wish to be contacted.
to a Paper Copy of This Notice: You
have the right to obtain a paper copy of this notice at any time upon
request. At the time of first
service rendered, we are required to provide you with a paper copy of this
notice. To obtain a copy of this
notice at any other time, please request it from our Administrator at the
address listed on the first page of this notice.
- Right to Revoke Authorization: If you execute any authorization(s) for
the use and disclosure of your PHI, you have the right to revoke such
authorization(s), except to the extent that action has already been taken
in reliance on such authorization.
HOW WE MAY USE AND DISCLOSE HEALTH
INFORMATION ABOUT YOU WITHOUT YOUR AUTHORIZATION:
The following categories describe different ways that we use
and disclose your PHI without your authorization. For each category of such uses or disclosures
we will explain what we mean and try to give some examples. Not every use or disclosure in a category
will be listed.
Treatment: We may use your PHI to provide you with
health care treatment of services.
We may disclose your PHI to provide you with health care treatment
or services. We may disclose your
PHI to doctors, nurses, technicians, health students, or other personnel
who are involved in taking care of you.
They may work at our surgery center, at the hospital if you are
hospitalized under our supervision, or at a doctor’s office, lab,
pharmacy, or other health care provider to whom we may refer you for
consultation, to take x-rays, to perform lab tests, to have prescriptions
filled, or for other treatment purposes.
For example, a doctor treating you for a broken leg may need to
know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell
the dietitian at the hospital if you have diabetes so that we can arrange
for appropriate meals. We may also
disclose your PHI to an entity assisting in a disaster relief effort so
that your family can be notified about your condition, status and
may use and disclose your PHI so that the treatment and services you
receive from us may be billed to and payment collected from you, an
insurance company, or a third party.
For example, we may need to give your health plan information about
your visit to our surgery center so your health plan will pay us or
reimburse you for the visit. We may
also tell your health plan about a treatment you are going to receive to
obtain prior approval or to determine whether your plan will cover the
Health Care Operations: We
may use and disclose your PHI for operations of our surgery center. These uses and disclosures are necessary
to run our surgery center and make sure that all of our patients receive
quality care. For example, we may
use health information to review our treatment and services and to
evaluate the performance of our staff in caring for you. We may also combine health information
about many patients to decide what additional services we should offer,
what services are not needed, whether certain new treatments are
effective, or to compare how we are doing with others and to see where we
can make improvements. We may
remove information that identifies you from this set of health information
so others may use it to study health care delivery without learning who
our specific patients are.
- For Research: We
may disclose your PHI for the purpose of research. We will only disclose your PHI for
research purposes upon your express authorization and only if the research
protocol has been approved by an institutional review board that has
reviewed the research proposal and established protocols to ensure the
privacy of your PHI.
- For Quality Improvement: We may use your PHI as a tool for
quality assurance and continuous quality improvement.
Required By Law: We may disclose your PHI when required
to do so by federal, state, or local law.
Avert a Serious Threat to Health or Safety: We
may use and disclose your PHI when necessary to prevent a serious threat
to your health and safety or the health and safety of the public or
another person. Any disclosure,
however, would only be to someone able to help prevent the threat.
and Veterans: If you are a member of the armed forces
or separated/discharged from military services, we may release your PHI as
required by military command authorities or the Department of Veterans
Affairs as may be applicable. We
may also release health information about foreign military personnel to
the appropriate foreign military authorities.
Compensation: We may release your PHI as authorized
by, and in compliance with, laws related to workers’ compensation and
similar programs established by law that provide benefits for work-related
illnesses and injuries without regard to fault.
Health Risks: We
may disclose your PHI for public health activities. These activities generally include the
to prevent or control disease,
injury, or disability;
to report births and deaths;
to report child abuse or neglect;
to report reactions to medications
or problems with products;
to notify people of recalls of
products they may be using;
to notify person or organization
required to receive information on FDA-regulated products;
to notify a person who may have been
exposed to a disease or may be at risk for contracting or spreading a disease
or condition; and
to notify the appropriate government
authority if we believe a patient has been the victim of abuse, neglect, or
domestic violence. We will only make
this disclosure if you agree or when required or authorized by law.
Oversight Activities: We
may disclose your PHI to a health oversight agency for activities
authorized by law. These oversight
activities include, for example, audits, investigations, inspections, and
licensure. These activities are
necessary for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
and Disputes: If
you are involved in a lawsuit or a dispute, we may disclose your PHI in
response to a court or administrative order. We may also disclose your PHI in
response to a subpoena, discovery request, or other lawful 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
may disclose your PHI to law enforcement officials for law enforcement
purposes including the following:
in reporting certain injuries, as
required by law, gunshot wounds, burns, injuries to perpetrators of crime;
in response to a court order,
subpoena, warrant, summons or similar process;
to identify or locate a suspect,
fugitive, material witness, or missing person:
Name and address
Date of birth or place of birth;
Social security number;
Blood type or Rh factor;
Type of injury;
Date and time of treatment and/or
death, if applicable; and
A description of distinguishing
about the victim of a crime, if the
victim agrees to disclose or under certain limited circumstances, we are unable
to obtain the person’s agreement;
about a death we believe may be the
result of criminal conduct;
about criminal conduct at our facility; and
in emergency circumstances to report
a crime; the location of the crime or victims; or the identity, description, or
location of the person who committed the crime.
- Organ and Tissue Donation: We
may disclose your PHI to organizations involved in the procurement,
banking, or transplantation of cadaveric organs, eyes or tissue, for the
purpose of facilitating organ and tissue donation where applicable.
- Abuse, Neglect and Domestic Violence: We may disclose your PHI to an
appropriate governmental authority if we reasonably believe that you may
be a victim of abuse, neglect, or domestic violence.
Health Examiners and Funeral Directors:
We may disclose your PHI to a coroner or health
examiner. This may be necessary,
for example, to identify a deceased person or determine the cause of
death. We may also disclose your
PHI to funeral directors as necessary to carry out their duties.
Security and Intelligence Activities:
We may disclose your PHI to
authorized federal officials for intelligence, counterintelligence, and
other national security activities authorized by law, or for the purpose
of providing protective services to the President or foreign heads of
Services for the President and Others:
We may disclose your PHI to
authorized federal officials so they may provide protection to the
President, other authorized persons or foreign heads of state or conduct
- Inmates: If
you are an inmate of a correctional institution or under the custody of a
law enforcement official, we may disclose your PHI to the correctional
institution or law enforcement official.
This release would be necessary (1) for the institution to provide
you with health care; (2) to protect your health and safety or the health
and safety of others; or (3) for the safety and security of the
EXAMPLES OF OTHER PERMISSIBLE OR REQUIRED DISCLOSURES OF
HEALTH INFORMATION ABOUT YOU WITHOUT YOUR AUTHORIZATION:
- Business Associates:
Some activities of Dublin Surgery Center, LLC. are provided on our behalf
through contracts with business associates. Examples of when we may use a business
associate include coding and claims submission performed by a third party
billing company, consulting and quality assurance activities provided by
an outside consultant, billing and coding audits performed by an outside
auditor, and other legal and consulting services provided in response to
billing and reimbursement issues which may arise from time to time. When we enter into contracts to obtain
these services, we may need to disclose your PHI to our business associate
so that the associate may perform the job which we have requested. To protect your PHI, however, we require
our business associate to appropriately safeguard your information.
We may use or disclose your PHI to notify or assist in notifying a family
member, personal representative, close personal friend, or other person
responsible for your care of your location and general condition. Dublin Surgery Center, LLC. will not disclose your PHI to your family members, personal
representative or close personal friends as described in this paragraph if
you object to such disclosure.
Please notify the Administrator at the number listed on the first
page of this notice if you object to such disclosures.
- Communication with family
Health professionals, including those employed by or under contract with Dublin
Surgery Center, LLC. may disclose to a family member, other relative,
close personal friend or any other person you identify, health information
relative to that person’s involvement in your care or payment related to
your care, unless you object to the disclosure.
law allows for the release of your PHI to appropriate health oversight
agencies, public health authorities or attorneys, provided that a work force
member or business associate believes in good faith that we have engaged in
unlawful conduct or otherwise violated professional or clinical standards and
are potentially endangering one or more patients, workers or the public.
Any use or disclosure of your PHI that is not described in this notice will be
made only with your written authorization.
WE MAY NOT
USE OR DISCLOSE YOUR HEALTH INFORMATION FOR THE FOLLOWING PURPOSES WITHOUT YOUR
1. We must obtain an authorization from you
to use or disclose psychotherapy notes unless it is for treatment, payment or
health care operations or is required by law, permitted by health oversight
activities, to a coroner or medical examiner, or to prevent a serious threat to
health or safety.
2. We must obtain an authorization for any
use or disclosure of your PHI for any marketing communications to you about a
product or service that encourages you to use or purchase the product or
service unless the communication is either (a) a face-to-face communication or;
(b) a promotional gift of nominal value. However, we do not need to obtain an
authorization from you to provide refill reminders, information regarding your
course of treatment, case management or care coordination, to describe a
health-related products or services that we provide, or to contact you in
regard to treatment alternatives. If the marketing involves financial
remuneration, we must notify you if such remuneration is involved.
3. We must obtain an authorization for any
disclosure of your PHI which constitutes a sale of such PHI.
[NAME OF ASC]’S RESPONSIBILITIES:
We are required by law to maintain
the privacy of your PHI, to provide you with this notice as to our legal duties
and privacy practices with respect to your PHI we maintain and collect, and
notify you if we discover a breach of any of your PHI that is not secured in
accordance with federal guidelines.
We are required by law to abide by
the terms of this notice as it is currently in effect.
CHANGES TO THIS NOTICE:
We reserve the right to change our
privacy practices for all PHI that we collect or maintain and any terms of this
notice. If our privacy practices
materially change, we will revise this notice and provide you with a copy of
the revised notice. We reserve the right
to make the revised or changed notice effective for PHI we already have about
you as well as any information we receive in the future. We will post a copy of the current notice in
our facility. The notice will contain at
the top of the first page, the effective date.
In addition, each time you register for treatment or health care
services, we will offer you a copy of the current notice in effect.
FOR MORE INFORMATION OR TO MAKE A
If you believe your privacy rights
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, contact our Administrator. All complaints must be submitted in
writing. There will be no retaliation
against you for filing a complaint.
If you have any questions or would
like additional information, or if you wish to file a complaint with us
regarding our use and disclosure of your PHI, you may contact our Administrator
OTHER USES AND DISCLOSURES OF
PROTECTED HEALTH INFORMATION:
uses and disclosures of your PHI 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 health 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 protected health 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 that we provided to you.
ACKNOWLEDGEMENT OF RECEIPT OF THIS
We will request that you sign a
separate form or notice acknowledging you have received a copy of this
notice. If you choose, or are not able
to sign, a staff member will sign their name, and date. This acknowledgement will be filed with your