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 Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Examples of uses of your health information for TREATMENT purposes are:
- A nurse obtains treatment information about you and records it in a health record.
- We may need to share your health information in consultation with another physician specialist.
- We may disclose your health information to a pharmacy to fulfill a prescription.
- We may disclose your health information to a laboratory to order a blood test.
- We may disclose your health information to a home health agency that is providing care in your home.
Examples of use of your health information for PAYMENT purposes:
We submit requests for payment to your health insurance company. The health insurance company (or business
associate helping us obtain payment) requests information from us regarding your medical care given. We will
provide information to them about you and the care given.
We may also disclose your health information to your insurance company to determine whether you are eligible for
benefits or whether a particular service is covered under your health plan.
Examples of use of your information for HEALTH CARE OPERATIONS:
We may obtain services from business associates such as quality assessment, quality improvement, outcome
evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal
services, and insurance. We will share information about you with such business associates as necessary to obtain
these services.
Your Health Information Rights
The health and billing records we maintain are the physical property of University Surgical Associates. You have the following rights with respect to your Protected Health Information:
1. Request a restriction on certain uses and disclosures of your health information by delivering the request in writing
to our office. We are not required to grant the request but we will comply with any request granted;
2. Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information by making a request to our
office.
3. Right to inspect and copy your health record and billing record. You may exercise this right by delivering the
request in writing to our front office staff or medical records department, using the form we provide to you upon
request. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other
costs incurred by us in complying with your request.
Be advised that under federal law, you may not inspect or copy 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.
4. Right to request that your health care record be amended to correct incomplete or incorrect information by
delivering a written request to our Privacy Officer. We are not required to make such amendments and in certain
cases, we may deny your request for an amendment. You may file a statement of disagreement if your amendment
is denied, and require that the request for amendment and any denial be attached in all future disclosures of your
health information;
5. Right to receive an accounting of disclosures of your health information by delivering a written request to the
Privacy Officer. An accounting will NOT include internal uses of information for treatment, payment or operations,
disclosures made to you or made at your request, or disclosures made to family members or friends in the course of
providing care;
6. Right to confidential communication by requesting that communication of your health information be made by
alternative means or at an alternative location by delivering the request in writing to our office or, by using the form we
provide during the office registration process.
Our Responsibilities
This office is required to:
- Maintain the privacy of your health information as required by law
- Provide you with a Notice as to our duties and privacy practices as to the information we collect and maintain about you
- Abide by the terms of this Notice
- Notify you if we cannot accommodate a requested restriction or request
- Accommodate your reasonable requests regarding methods to communicate health information with you
- Accommodate your request for an accounting of disclosures
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the
protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the
Notice by calling and requesting a copy of our Notice or by visiting our office and picking up a copy.
To Request Information or File a Complaint:
If you have questions, would like additional information, or want to report a problem regarding the handling of your health information, you may contact our Privacy Officer at the following address:
University Surgical Associates
979 E. 3rd St., Suite C-300
Additionally, if you believe your privacy rights have been violated, you may file a complaint with the Secretary of Health and Human Services. You will not be retaliated against in any way for filing a complaint.
Following is a List of Other Uses and Disclosures Allowed by the Privacy Rule:
Patient Contact
As a part of treatment, payment and health care operations, we may also disclose your protected health
information for the following purposes:
To remind you of an appointment.
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.
To inform you as a part of a fund raising effort.
Notification – Opportunity to Agree or Object
Unless you object, we may use or disclose your health information to notify or assist in notifying a family member,
personal representative, or other person responsible for your care, about your location, and about your general
condition, or your death.
Communication with Family – Using our best judgment, we may disclose to a family member, other relative, close
personal friend, or any other person you identify, health information relevant to that person’s involvement in your care
or in payment for such care if you do not object, or in an emergency.
Opportunity to Agree or Object NOT Required
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:
1. PUBLIC HEALTH ACTIVITIES
Controlling Disease – As required by law, we may disclose your protected health information to public health or legal
authorities charged with preventing or controlling disease, injury, or disability.
Child Abuse & Neglect – We may disclose protected health information to public authorities as allowed by law to report
child abuse or neglect.
Food and Drug Administration (FDA) – We may disclose to the FDA your protected health information relating to
adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance
information to enable product recalls, repairs, or replacements.
2. VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE
We can disclose protected health information to government authorities to the extent the disclosure is authorized by
statute or regulation and in the exercise of professional judgment, the physician believes the disclosure is necessary to
prevent serious harm to the individual or other potential victim.
3. OVERSIGHT AGENCIES
Federal law allows us to release your protected health information to appropriate health oversight agencies or for
health oversight activities to include audits, civil, administrative or criminal investigations: inspections; licensure's or
disciplinary actions, and for similar reasons related to the administration of health care.
4. JUDICIAL/ADMINISTRATIVE PROCEEDINGS
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed
or required by law, with your consent, or as directed by a proper court order or administrative tribunal, provided that
only the protected health information released is expressly authorized by such order, or in response to a subpoena,
discovery request or other lawful process.
5. LAW ENFORCEMENT
We may disclose your protected health information for law enforcement purposes as required by law, such as when
required by court order, including laws that require reporting of certain types of wounds or other physical injury.
6. CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
We may disclose your protected health information to funeral directors or coroners consistent with applicable law to
allow them to carry out their duties.
7. ORGAN PROCUREMENT ORGANIZATIONS
Consistent with applicable law, we may disclose your protected health information to organ procurement organizations
or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of
donation and transplant.
8. RESEARCH
We may disclose information to researchers when their research has been approved by an Institutional Review Board
that has reviewed the research proposal and established protocols to ensure the privacy of your protected health
information.
9. THREAT TO HEALTH AND SAFETY
To avert serious threat to health or safety, we may disclose your protected health information consistent with applicable
law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
10. FOR SPECIALIZED GOVERNMENT FUNCTIONS
We may disclose your protected health information for specialized government functions as authorized by law such as
to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
11. CORRECTIONAL INSTITUTIONS
If you are an inmate of a correctional institution, we may disclose to the institution or it’s agents the protected health
information necessary for your health and the health and safety of other individuals.
12. WORKERS COMPENSATION
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to
the extent necessary to comply with laws relating to Workers Compensation.
