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Athens Surgery Center

75 Hospital Drive
Suite 100
Athens, Ohio 45701
740-566-4500





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NOTICE OF PRIVACY PRACTICES
This Notice is effective September 23, 2013

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

WE ARE REQUIRED BY LAW TO PROTECT MEDICAL INFORMATION ABOUT YOU

We are required by law to protect the privacy of medical information about you and
that identifies you.  This medical information may be information about healthcare we
provide to you or payment for healthcare provided to you.  It may also be information
about your past, present, or future medical condition.

We are also required by law to provide you with this Notice of Privacy Practices
explaining our legal duties and privacy practices with respect to medical information.  
We are legally required to follow the terms of this Notice.  In other words, we are only
allowed to use and disclose medical information in the manner that we have described
in this Notice.  

We may change the terms of this Notice in the future.  We reserve the right to make
changes and to make the new Notice effective for all medical information that we
maintain. If we make changes to the Notice, we will:

•        Post the new Notice in our waiting area.
•        Have copies of the new Notice available upon request. Please contact our
Privacy Officer at 740-566-4504 to obtain a copy of our current Notice).

The rest of this Notice will:

•        Discuss how we may use and disclose medical information about you.
•        Explain your rights with respect to medical information about you.
•        Describe how and where you may file a privacy-related complaint.

If, at any time, you have questions about information in this Notice or about our privacy
policies, procedures or practices, you can contact our Privacy Officer at 740-566-4504.


WE MAY USE AND DISCLOSE MEDICAL INFORMATION
ABOUT YOU IN SEVERAL CIRCUMSTANCES




We use and disclose medical information about patients every day.  This section of our
Notice explains in some detail how we may use and disclose medical information about
you in order to provide healthcare, obtain payment for that healthcare, and operate
our business efficiently.  This section then briefly mentions several other
circumstances in which we may use or disclose medical information about you.  For
more information about any of these uses or disclosures, or about any of our privacy
policies, procedures or practices, contact our Privacy Officer at 740-566-4504.

1.  Treatment
We may use and disclose medical information about you to provide healthcare
treatment to you.  In other words, we may use and disclose medical information about
you to provide, coordinate or manage your healthcare and related services.  This may
include communicating with other healthcare providers regarding your treatment and
coordinating and managing your healthcare with others.  

Example:  Jane is a patient at the health department.  The receptionist may use
medical information about Jane when setting up an appointment.  The nurse
practitioner will likely use medical information about Jane when reviewing Jane’s
condition and ordering a blood test.  The laboratory technician will likely use medical
information about Jane when processing or reviewing her blood test results.  If, after
reviewing the results of the blood test, the nurse practitioner concludes that Jane
should be referred to a specialist, the nurse may disclose medical information about
Jane to the specialist to assist the specialist in providing appropriate care to Jane.  

2.  Payment
We may use and disclose medical information about you to obtain payment for
healthcare services that you received.  This means that, within the health department,
we may use medical information about you to arrange for payment (such as preparing
bills and managing accounts).  We also may disclose medical information about you to
others (such as insurers, collection agencies, and consumer reporting agencies).  In
some instances, we may disclose medical information about you to an insurance plan
before you receive certain healthcare services because, for example, we may need to
know whether the insurance plan will pay for a particular service.

Example:  Jane is a patient at the health department and she has private insurance.  
During an appointment with a nurse practitioner, the nurse practitioner ordered a
blood test.  The health department billing clerk will use medical information about
Jane when he prepares a bill for the services provided at the appointment and the
blood test.  Medical information about Jane will be disclosed to her insurance
company when the billing clerk sends in the bill.  

Example:  The nurse practitioner referred Jane to a specialist.  The specialist
recommended several complicated and expensive tests.  The specialist’s billing clerk
may contact Jane’s insurance company before the specialist runs the tests to
determine whether the plan will pay for the test.

3.  Healthcare Operations
We may use and disclose medical information about you in performing a variety of
business activities that we call “healthcare operations.”  These “healthcare
operations” activities allow us to, for example, improve the quality of care we provide
and reduce healthcare costs.  For example, we may use or disclose medical
information about you in performing the following activities:

•        Reviewing and evaluating the skills, qualifications, and performance of
healthcare providers taking care of you.
•        Providing training programs for students, trainees, healthcare providers or non-
healthcare professionals to help them practice or improve their skills.  
•        Cooperating with outside organizations that evaluate, certify or license
healthcare providers, staff or facilities in a particular field or specialty.
•        Reviewing and improving the quality, efficiency and cost of care that we provide
to you and our other patients.
•        Improving healthcare and lowering costs for groups of people who have similar
health problems and helping manage and coordinate the care for these groups of
people.  
•        Cooperating with outside organizations that assess the quality of the care others
and we provide, including government agencies and private organizations.
•        Planning for our organization’s future operations.
•        Resolving grievances within our organization.
•        Reviewing our activities and using or disclosing medical information in the event
that control of our organization significantly changes.
•        Working with others (such as lawyers, accountants and other providers) who
assist us to comply with this Notice and other applicable laws.

Example:  Jane was diagnosed with diabetes.  The health department used Jane’s
medical information – as well as medical information from all of the other health
department patients diagnosed with diabetes – to develop an educational program to
help patients recognize the early symptoms of diabetes.  (Note: The educational
program would not identify any specific patients without their permission).

Example:  Jane complained that she did not receive appropriate healthcare.  The
health department reviewed Jane’s record to evaluate the quality of the care provided
to Jane.  The health department also discussed Jane’s care with an attorney.

4.  Persons Involved in Your Care
We may disclose medical information about you to a relative, close personal friend or
any other person you identify if that person is involved in your care and the
information is relevant to your care.  If the patient is a minor, we may disclose medical
information about the minor to a parent, guardian or other person responsible for the
minor except in limited circumstances.  For more information on the privacy of minors’
information, contact our Privacy Officer at 740-566-4504.

We may also use or disclose medical information about you to a relative, another
person involved in your care or possibly a disaster relief organization (such as the
Red Cross) if we need to notify someone about your location or condition.  

You may ask us at any time not to disclose medical information about you to persons
involved in your care.  We will agree to your request and not disclose the information
except in certain limited circumstances (such as emergencies) or if the patient is a
minor.  If the patient is a minor, we may or may not be able to agree to your request.

Example:  Jane’s husband regularly comes to the health department with Jane for her
appointments and he helps her with her medication.  When the nurse practitioner is
discussing a new medication with Jane, Jane invites her husband to come into the
private room.  The nurse practitioner discusses the new medication with Jane and
Jane’s husband.  

5.  Required by Law
We will use and disclose medical information about you whenever we are required by
law to do so.  There are many state and federal laws that require us to use and
disclose medical information.  For example, state law requires us to report gunshot
wounds and other injuries to the police and to report known or suspected child abuse
or neglect to the Department of Social Services.  We will comply with those state laws
and with all other applicable laws.

6.  National Priority Uses and Disclosures
When permitted by law, we may use or disclose medical information about you without
your permission for various activities that are recognized as “national priorities.”  In
other words, the government has determined that under certain circumstances
(described below), it is so important to disclose medical information that it is
acceptable to disclose medical information without the individual’s permission.  We
will only disclose medical information about you in the following circumstances when
we are permitted to do so by law.  Below are brief descriptions of the “national
priority” activities recognized by law.  For more information on these types of
disclosures, contact our Privacy Officer at 740-566-4504.

•        Threat to health or safety:  We may use or disclose medical information about you
if we believe it is necessary to prevent or lessen a serious threat to health or safety.
•        Public health activities:  We may use or disclose medical information about you
for public health activities.  Public health activities require the use of medical
information for various activities, including, but not limited to, activities related to
investigating diseases, reporting child abuse and neglect, monitoring drugs or
devices regulated by the Food and Drug Administration, and monitoring work-related
illnesses or injuries.  For example, if you have been exposed to a communicable
disease (such as a sexually transmitted disease), we may report it to the State and take
other actions to prevent the spread of the disease.
•        Abuse, neglect or domestic violence: We may disclose medical information about
you to a government authority (such as the Department of Social Services) if you are
an adult and we reasonably believe that you may be a victim of abuse, neglect or
domestic violence.  
•        Health oversight activities:  We may disclose medical information about you to a
health oversight agency – which is basically an agency responsible for overseeing the
healthcare system or certain government programs.  For example, a government
agency may request information from us while they are investigating possible
insurance fraud.
•        Court proceedings:  We may disclose medical information about you to a court or
an officer of the court (such as an attorney).  For example, we would disclose medical
information about you to a court if a judge orders us to do so.
•        Law enforcement:  We may disclose medical information about you to a law
enforcement official for specific law enforcement purposes.  For example, we may
disclose limited medical information about you to a police officer if the officer needs
the information to help find or identify a missing person.
•        Coroners and others:  We may disclose medical information about you to a
coroner, medical examiner, or funeral director or to organizations that help with organ,
eye and tissue transplants.
•        Workers’ compensation: We may disclose medical information about you in order
to comply with workers’ compensation laws.
•        Research organizations:  We may use or disclose medical information about you
to research organizations if the organization has satisfied certain conditions about
protecting the privacy of medical information.
•        Certain government functions:  We may use or disclose medical information
about you for certain government functions, including but not limited to military and
veterans’ activities and national security and intelligence activities.  We may also use
or disclose medical information about you to a correctional institution in some
circumstances.  

7.  Authorizations
Other than the uses and disclosures described above (#1-6), we will not use or
disclose medical information about you without the “authorization” – or signed
permission – of you or your personal representative.  In some instances, we may wish
to use or disclose medical information about you and we may contact you to ask you to
sign an authorization form.  In other instances, you may contact us to ask us to
disclose medical information and we will ask you to sign an authorization form.  

If you sign a written authorization allowing us to disclose medical information about
you, you may later revoke (or cancel) your authorization in writing (except in very
limited circumstances related to obtaining insurance coverage).  If you would like to
revoke your authorization, you may write us a letter revoking your authorization or fill
out an Authorization Revocation Form.  Authorization Revocation Forms are available
from our Privacy Officer.  If you revoke your authorization, we will follow your
instructions except to the extent that we have already relied upon your authorization
and taken some action.

The following uses and disclosures of medical information about you will only be made
with your authorization (signed permission):

        Uses and disclosures for marketing purposes.
        Uses and disclosures that constitute the sales of medical information about you.
        Most uses and disclosures of psychotherapy notes, if we maintain
psychotherapy notes.
        Any other uses and disclosures not described in this Notice.

YOU HAVE RIGHTS WITH RESPECT
TO MEDICAL INFORMATION ABOUT YOU


You have several rights with respect to medical information about you.  This section of
the Notice will briefly mention each of these rights.  If you would like to know more
about your rights, please contact our Privacy Officer at 740-566-4504.

1.  Right to a Copy of This Notice
You have a right to have a paper copy of our Notice of Privacy Practices at any time.  In
addition, a copy of this Notice will always be posted in our waiting area.  If you would
like to have a copy of our Notice, ask the receptionist for a copy or contact our Privacy
Officer at 740-566-4504.

2.  Right of Access to Inspect and Copy
You have the right to inspect (which means see or review) and receive a copy of
medical information about you that we maintain in certain groups of records. If we
maintain your medical records in an Electronic Health Record (EHR) system, you may
obtain an electronic copy of your medical records. You may also instruct us in writing
to send an electronic copy of your medical records to a third party. If you would like to
inspect or receive a copy of medical information about you, you must provide us with a
request in writing.  You may write us a letter requesting access or fill out an Access
Request Form. Access Request Forms are available from our Privacy Officer.   

We may deny your request in certain circumstances.  If we deny your request, we will
explain our reason for doing so in writing.  We will also inform you in writing if you
have the right to have our decision reviewed by another person.

If you would like a copy of the medical information about you, we will charge you a fee
to cover the costs of the copy. Our fees for electronic copies of your medical records
will be limited to the direct labor costs associated with fulfilling your request.


We may be able to provide you with a summary or explanation of the information.  
Contact our Privacy Officer for more information on these services and any possible
additional fees.

3.  Right to Have Medical Information Amended
You have the right to have us amend (which means correct or supplement) medical
information about you that we maintain in certain groups of records.  If you believe
that we have information that is either inaccurate or incomplete, we may amend the
information to indicate the problem and notify others who have copies of the
inaccurate or incomplete information.  If you would like us to amend information, you
must provide us with a request in writing and explain why you would like us to amend
the information.  You may either write us a letter requesting an amendment or fill out
an Amendment Request Form.  Amendment Request Forms are available from our
Privacy Officer.   

We may deny your request in certain circumstances.  If we deny your request, we will
explain our reason for doing so in writing.  You will have the opportunity to send us a
statement explaining why you disagree with our decision to deny your amendment
request and we will share your statement whenever we disclose the information in the
future.  

4.  Right to an Accounting of Disclosures We Have Made
You have the right to receive an accounting (which means a detailed listing) of
disclosures that we have made for the previous six (6) years.  If you would like to
receive an accounting, you may send us a letter requesting an accounting, fill out an
Accounting Request Form, or contact our Privacy Officer.  Accounting Request Forms
are available from our Privacy Officer.

The accounting will not include several types of disclosures, including disclosures for
treatment, payment or healthcare operations. If we maintain your medical records in an
Electronic Health Record (EHR) system, you may request that include disclosures for
treatment, payment or healthcare operations. The accounting will also not include
disclosures made prior to April 14, 2003.   

If you request an accounting more than once every twelve (12) months, we may charge
you a fee to cover the costs of preparing the accounting.




5.  Right to Request Restrictions on Uses and Disclosures
You have the right to request that we limit the use and disclosure of medical
information about you for treatment, payment and healthcare operations. Under
federal law, we must agree to your request and comply with your requested restriction
(s) if:
1.        Except as otherwise required by law, the disclosure is to a health plan for
purpose of carrying out payment of healthcare operations (and is not for purposes of
carrying out treatment); and,
2.        The medical information pertains solely to a healthcare item or service for which
the healthcare provided involved has been paid out-of-pocket in full.

Once we agree to your request, we must follow your restrictions (except if the
information is necessary for emergency treatment).  You may cancel the restrictions at
any time.  In addition, we may cancel a restriction at any time as long as we notify you
of the cancellation and continue to apply the restriction to information collected
before the cancellation.

You also have the right to request that we restrict disclosures of your medical
information and healthcare treatment(s) to a health plan (health insurer) or other party,
when that information relates solely to a healthcare item or service for which you, or
another person on your behalf (other than a health plan), has paid us for in full. Once
you have requested such restriction(s), and your payment in full has been received,
we must follow your restriction(s).

6.  Right to Request an Alternative Method of Contact
You have the right to request to be contacted at a different location or by a different
method.  For example, you may prefer to have all written information mailed to your
work address rather than to your home address.

We will agree to any reasonable request for alternative methods of contact.  If you
would like to request an alternative method of contact, you must provide us with a
request in writing.  You may write us a letter or fill out an Alternative Contact Request
Form. Alternative Contact Request Forms are available from our Privacy Officer.

7.  Right to Notification if a Breach of Your Medical Information Occurs
You also have the right to be notified in the event of a breach of medical information
about you. If a breach of your medical information occurs and if that information is
unsecured (not encrypted), we will notify you promptly with the following information:

        A brief description of what happened;
        A description of the health information that was involved;
        Recommended steps you can take to protect yourself from harm;
        What steps we are taking in response to the breach; and,
        Contact procedures so you can obtain further information.

8.  Right to Opt-Out of Fundraising Communications
If we conduct fundraising and we use communications like the U.S. Postal Service or
electronic email for fundraising, you have the right to opt-out of receiving such
communications from us. Please contact our Privacy Officer to opt-out of fundraising
communications if you chose to do so.



YOU MAY FILE A COMPLAINT
ABOUT OUR PRIVACY PRACTICES


If you believe that your privacy rights have been violated or if you are dissatisfied with
our privacy policies or procedures, you may file a written complaint either with us or
with the federal government.

We will not take any action against you or change our treatment of you in any way if you
file a complaint.

To file a written complaint with us, you may bring your complaint directly to our Privacy
Officer, or you may mail it to the following address:

Tari McCulloch
75 Hospital Drive Suite 100
Athens, Ohio 45701


To file a written complaint with the federal government, please use the following
contact information:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201

Toll-Free Phone: 1-(877) 696-6775

Website: http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html

Email: OCRComplaint@hhs.gov