Effective Date: April 14, 2003
Notice of Privacy Practices of UNITED SURGICAL ASSOCIATES, P.S.C.
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.CONTACT
PERSON: If you have any questions about this notice, please contact the Privacy
Officer in our Administrative Offices of United Surgical Associates at 701 Bob-O-Link
Drive, Suite 120, Lexington, KY 40504. The phone number of the Privacy Officer
is (859) 277-5934.
This notice describes our organizations practices as they relate to the use and
disclosure of your medical information.WHO WILL FOLLOW THIS NOTICE.Any health
care professional authorized to enter information into your medical chart.
Any member of a volunteer group we allow to help you while you are our patient.
All employees, staff and other professional personnel of our organization.
The persons listed above may share your medical information with each other for
the treatment, payment or heath care operation purposes described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal.
We are committed to protecting medical information about you. We create a record
of the care and services you receive at our organization. We need this record
to provide you with quality care and to comply with certain legal requirements.
This notice applies to all of the records of your care generated or maintained
by us, whether made by our personnel or other health care providers.
This notice will tell you about the ways in which we may use and disclose medical
information about you. We also describe your rights and certain obligations we
have regarding the use and disclosure of medical information.
We are required by law to: (1) make sure that medical information that identifies
you is kept private; (2) give you this notice of our legal duties and privacy
practices with respect to medical information about you; and (3) follow the terms
of the notice that is currently in effect.
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 we
mean and try to give some 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, or other health care personnel who are involved in taking care
of you at our organization. For example, a physician who is treating you for a
broken leg may need to know if you have diabetes because diabetes may slow the
healing process. We also may disclose medical information about you to people
outside our organization who may be involved in your medical care 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 from us 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 treatment information about any treatment you receive
so your health plan will pay us or reimburse you for the treatment. We may also
tell your health plan about a treatment you are going to receive to obtain prior
approval, authorization, or to determine whether your health plan will cover the
treatment. For Health Care Operations. We may use and disclose medical information
about you for our administrative operations. These uses and disclosures are necessary
to run our organization 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 of our patients to decide what additional
services our organization should offer, what services are not needed, and whether
certain new treatments are effective. We may also disclose information to doctors,
nurses, technicians, and other health care personnel for review and learning purposes.
We may also combine the medical information we have with medical information from
other organizations 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.Appointment
Reminders. We may use and disclose medical information to contact you as a reminder
that you have an appointment for treatment or medical care.Treatment Alternatives.
We may use and disclose medical information to recommend or tell you about possible
treatment options 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 health-related benefits or services 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. We
may also give information to someone who helps pay for your care. We may also
tell your family or friends your condition if you are hospitalized. In addition,
we may disclose medical information about you to an entity assisting in a disaster
relief effort so that your family can be notified about your condition, status
and location.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 SITUATIONSMilitary 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. Workers' Compensation. We may release
medical information about you for workers' 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.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. Coroners, Medical Examiners and Funeral Directors.
We may release medical information to a coroner or medical examiner. This may
be necessary, for example, to identify a deceased person or determine the cause
of death. We may also release medical information about patients of the hospital
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.
YOU HAVE CERTAIN RIGHTS REGARDING MEDICAL INFORMATION WE MAINTAIN ABOUT YOU:Right
to Inspect and Copy. You have the right to inspect and copy medical information
that may be used to make 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, you must submit your request in writing to the contact person listed on page
one of this notice. If you request a copy of the information, 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 organization
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 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 our organization.
To request an amendment, your request must be made in writing and submitted to
the contact person listed on page one of this notice. 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 our organization;
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 make of medical information about you without your authorization or unrelated
to your treatment, payment for your treatment, or our organizations health care
operations.
To request this list or accounting of disclosures, you must submit your request
in writing to the contact person listed on page one of this notice. Your request
must state a time period that may not be longer than six years and may not include
dates before April 14, 2003. Your request should indicate in what form you want
the list (for example, on paper or electronically). 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. 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 to the contact person
listed on page one of this notice. 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
to the contact person listed on page one 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.Right to a Paper Copy of This
Notice. You have the right to a paper copy of this notice. You may ask us to give
you a copy of this notice at any time. Even if you have agreed to receive this
notice electronically, you are still entitled to a paper copy of this notice.
CHANGES TO THIS NOTICEWe 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 prominently post a copy of the current notice in our organization. The
notice will contain on the first page, in the top right-hand corner, the effective
date. In addition, each time you register at our offices, we will offer you a
copy of the current notice in effect.
COMPLAINTS (You will not be penalized for filing a complaint.)
If you believe your privacy rights have been violated, you may file a complaint
with our organization or with the address shown below. All complaints must be
submitted in writing.
Region IV, Office for Civil Rights
U.S. Dept. of Health and Human Services
Atlanta Federal Center, Suite 3B70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
Voice Phone: 404-562-7886
Fax: 404-562-7881
OTHER USES OF MEDICAL INFORMATION AND WRITTEN AUTHORIZATION.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 authorization. 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 acknowledge and 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.
S:\MED 2003\Usa\HIPAA\NPP Form w Ackn 5 page - complete.docACKNOWLEDGEMENT OF
RECEIPT OF NOTICE OF PRIVACY PRACTICES
UNITED SURGICAL ASSOCIATES, P.S.C.Our Notice of Privacy Practices provides
information about how we may use and disclose protected health information about
you. By signing this receipt, you acknowledge that you have reviewed, or have
been given the opportunity to review, our Notice of Privacy Practices. As provided
in our Notice, the terms of our Notice may change. If we change our notice,
you may obtain a revised copy by contacting:Patients printed name
_____________________________________________________Patients signature (or
signature of personal representative)
______________________________________________________
Notice Provided by:
______________________________________________________
Date of Notice Provided:
______________________________________________________
If patient did not acknowledge receipt of Notice of Privacy Practices, patients
reason for non-acknowledgment:
______________________________________________________