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Tri-State
Surgery Center, LLC
Notice of Privacy Practices
THIS NOTICE DESCRIBES
HOW MEDICAL 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
the Privacy Officer at (563) 584-4500.
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.
HOW WE MAY
USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories
describe different ways that we use and disclose medical information.
For each category of uses or disclosures, we will explain what is meant
and give examples. Not every use or disclosure in a category will be listed.
However, all of the ways we are permitted to use and disclose information
will fall within one of the categories.
For Treatment:
- We
may use medical information about you to provide you with medical treatment
or services.
- We
may disclose medical information about you to doctors, nurses, technicians,
medical students, anesthesia, or other Center personnel who are involved
in taking care of you at the Center. 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.
- The
Center may share medical information about you with other departments
of the Clinic such as Pharmacy, Lab, and X-Ray.
- We
also may disclose medical information about you to people outside the
Center who may be involved in your medical care after you leave the
Center, such as family members, clergy or others we use to provide services
that are part of your care.
For Payment:
- We
may use and disclose medical information about you so that the treatment
and services you receive at the Center may be billed to and payment
may be collected from you, an insurance company or a third party. For
example, we may need to give your health plan information about surgery
you received at the Center so your health plan will pay us or reimburse
you for the surgery.
- 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 treatment.
For Health
Care Operations:
- We
may use and disclose medical information about you for Center operations.
These uses and disclosures are necessary to run the Center and make
sure that all of our patients receive quality care. For example, we
may use medical information to review our treatment and services and
to evaluate the performance of our staff in caring for you.
-
We may also combine medical information about many surgical patients
to decide what additional services the Center should offer, what services
are not needed, and whether certain new treatments are effective.
-
We may also disclose information to doctors, nurses, technicians, medical
students, and other personnel for review and learning purposes.
-
We may also combine the medical information we have with medical information
from other Centers to compare how we are doing and see where we can
make improvements in the care and services we offer.
-
We may remove information that identifies you from this set of medical
information so others may use it to study health care and health care
delivery without learning who the specific patients are.
Treatment
Alternatives:
- We
may use and disclose medical information to tell you about or recommend
possible treatment operations or alternatives that may be of interest
to you.
Health-Related
Benefits and Services:
- We
may use and disclose medical information to tell you about or recommend
possible treatment options or alternatives that may be of interest to
you.
Individuals
Involved In Your Care Or Payment For Your Care:
- We
may release medical information about you to a friend or family member
who is involved in your medical care or payment for care. 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, we may disclose your protected
health information as described.
As Required
By Law:
- We
will disclose medical information about you when required to do so by
federal, state, or local law.
To Avert
A Serious Threat To Health Or Safety:
- We
may use and disclose medical information about you 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.
SPECIAL SITUATIONS
(Federal privacy
rules allow us to use or disclose your protected health information without
your permission or authorization when situations as below arise.)
Military
And Veterans:
- If
you are a member of the armed forces, we may release medical information
about you as required by military command authorities. We may also release
medical information about foreign military personnel to the appropriate
foreign military authority.
Worker’s
Compensation:
- We
may release medical information about you for worker’s compensation
or similar programs. These programs provide benefits for work-related
injuries or illness.
Public Health
Risks:
- We
may disclose medical information about you for public health activities.
These activities generally include the following: 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 a person who may have been exposed to a disease or may be
at risk for contracting or spreading a disease or condition; 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).
Health Oversight
Activities:
- We
may disclose medical information 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.
Lawsuits
And Disputes:
- If
you are involved in a lawsuit or a dispute, we may disclose medical
information about you in response to a court or administrative order.
- We
may also disclose medical information about you 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 information requested.
Law
Enforcement:
- We
may release medical information if asked to do so by a law enforcement
official:
- In
response to a court order, subpoena, warrant, summons, or similar process;
- To
identify or locate a suspect, fugitive, material witness, or missing
person;
- About
the victim of a crime, if, under certain limited circumstances, we are
unable to obtain the person’s agreement;
- About
criminal conduct at the Center; 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.
Coroners,
Medical Examiners, And Funeral Directors:
- We
may release medical information to a coroner or medical examiner, for
example to identify a deceased person or determine the cause of death.
- We
may also release information about patients of the Center to funeral
directors as necessary to carry out their duties.
National
Security And Intelligence Activities:
- We
may release medical information about you to authorized federal officials
for intelligence, counterintelligence, and other national security activities
authorized by law.
Protective
Services For The President And Others:
- We
may disclose medical information about you to authorized federal officials
so they may provide protection to the President, other authorized persons
or foreign heads of state or conduct special investigations.
Inmates:
- If
you are an inmate of a correctional institution or under the custody
of a law enforcement official, we may release medical information about
you 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 correctional
institution.
Other Uses
of Medical Information:
- Other
uses and disclosures of medical information 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 medical 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 medical
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
records of the care that we provided to you.
YOUR RIGHTS
REGARDING MEDICAL INFORMATION ABOUT YOU
Right To
Inspect And Copy:
- You
have the right to inspect and copy medical information that may be used
to made decisions about your care. Usually, this includes medical and
billing records, but does not include psychotherapy notes.
-
To inspect and copy medical information that may be used to make decisions
about you, submit your request in writing to the Center. We may charge
a fee for the costs of copying, mailing or other supplies associated
with your request. We may deny your request to inspect and copy in certain
very limited circumstances. If you are denied access to medical information,
you may request that the denial be reviewed. Another licensed health
care professional chosen by the Center will review your request and
the denial. The person conducting the review will not be the person
who denied your request. We will comply with the outcome of the review.
Right To
Request Restrictions:
- You
have the right to request a restriction or limitation on the medical
information we use or disclose about you for treatment, payment, or
health care operations. You also have the right to request a limit on
the medical information we disclose about you to someone who is involved
in your care or the payment for your care, like a family member or friend.
For example, you could ask that we not use or disclose information about
a surgery you had.
-
We are not required to agree to your request. If we do agree, we will
comply with your request unless the information is needed to provide
you emergency treatment.
-
To request restrictions, you must make your request in writing. In your
request, you must tell us (1) what information you want to limit; (2)
whether you want to limit our use, disclosure or both; and (3) to whom
you want the limits to apply, for example, disclosures to your spouse.
Right To
Request Confidential Communications:
- You
have the right to request that we communicate with you about medical
matters in a certain way or at a certain location. For example, you
can ask that we only contact you at work or by mail. To request confidential
communications, you must make your request in writing. 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.
Right To
Amend:
- If
you feel that medical information we have about you is incorrect or
incomplete, you may ask us to amend the information. You have the right
to request an amendment for as long as the information is kept by or
for the Center. To request an amendment, your request must be made in
writing and submitted to the Center. In addition, you must provide a
reason that supports your request. We 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 that:
-
Was not created by us, unless the person or entity that created the
information is no longer available to make the amendment;
-
Is not part of the medical information kept by or for the Center;
-
Is not part of the information which you would be permitted to inspect
and copy; or
-
Is accurate and complete.
Right To
An Accounting Of Disclosures:
- You
have the right to request an accounting of disclosures. This is a list
of the disclosures we made of medical information about you. To request
this list or accounting of disclosures, you must submit your request
in writing to the Center. 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. You may choose to
withdraw or modify your request at that time before any costs are incurred.
CHANGES TO
THIS NOTICE
We reserve the right
to change this notice. We reserve the right to make the revised or changed
notice effective for medical information we already have about you as
well as any information we receive in the future. We will post a copy
of the current notice (including an effective date) in the facility. In
addition, each time you register for treatment for health care services
a copy of the current notice will be offered.
COMPLAINTS
If you believe your
privacy rights have been violated, you may file a complaint with the Privacy
Officer, or with the Secretary of the Department of Health and Human Services.
Submit complaints in writing to the below address and contact. You will
not be penalized or retaliated against for filing a complaint.
Tri-State
Surgery Center
Attn: Privacy Officer
1500 Associates Drive
Dubuque, Iowa 52002
(563) 584-4500
This
Notice is Effective: 04/04/2003
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