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 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 Nebraska Surgery Center, Star
Anesthesia, P.C. 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.
I.
Uses and Disclosures of Protected Health Information
The surgery center
and it’s affiliated anesthesia providers may use your protected health
information for purposes of providing treatment and obtaining payment for
treatment provided at the Nebraska Surgery Center facility and for
conducting health care operations. Your
protected health information may be used or disclosed only for these purposes
unless the surgery center or it’s
affiliated anesthesia providers has obtained your authorization or the use
or disclosure is otherwise permitted by the HIPAA privacy regulations or state
law. Disclosures of your protected
health information for the purposes described in this Privacy Notice may be made
in writing, orally, or by facsimile.
A.
Treatment. We will share and jointly use and disclose your protected
health information to provide, coordinate, or manage your health care and any
related services. This
includes the coordination or management of your health care with a third party
for treatment purposes. For
example, we may disclose your protected health information to a pharmacy to fill
a prescription or to a laboratory to order a blood test.
We may also disclose protected health information to physicians who may
be treating you or consulting with the facility with respect to your care.
In some cases, we may also disclose your protected health information to
an outside treatment provider for purposes of the treatment activities of the
other provider.
B.
Payment. Your protected health information will be used, as
needed, to obtain payment for the services that we provide. This may include certain communications to your health
insurance company to get approval for the procedure that we have scheduled.
For example, we may need to disclose information to your health insurance
company to get prior approval for the surgery.
We may also disclose protected health information to your health
insurance company to determine whether you are eligible for benefits or whether
a particular service is covered under your health plan.
In order to get payment for the services we provide to you, we may also
need to disclose your protected health information to your health insurance
company to demonstrate the medical necessity of the services or, as required by
your insurance company, for utilization review.
We may also disclose patient information to another provider involved in
your care for the other provider’s payment activities.
This may include disclosure of demographic information to anesthesia care
providers for payment of their services.
C.
Operations. We may use or disclose your protected health information, as
necessary, for our own health care operations to facilitate the function of the surgery
center and it’s affiliated anesthesia providers and to provide quality
care to all patients. Health care
operations include such activities as: quality assessment and improvement
activities, employee review activities, training programs including those in
which students, trainees, or practitioners in health care learn under
supervision, accreditation, certification, licensing or credentialing
activities, review and auditing, including compliance reviews, medical reviews,
legal services and maintaining compliance programs, and business management and
general administrative activities.
In
certain situations, we may also disclose patient information to another provider
or health plan for their health care operations.
D.
Other Uses and Disclosures. As part of treatment, payment and health care operations,
we may also use or disclose your protected health information for the following
purposes: to remind you of your surgery date, 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, or to contact you to raise funds for
the facility or an institutional foundation related to the facility.
If you do not wish to be contacted regarding fundraising, please contact
our Privacy Officer.
II.
Uses and Disclosures Beyond Treatment, Payment, and Health Care
Operations Permitted Without Authorization or Opportunity to Object
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:
A.
When Legally Required.
We will disclose your protected health information when we are required
to do so by any federal, state or local law.
B.
When
There Are Risks to Public Health. We
may disclose your protected health information for the following public
activities and purposes:
To prevent, control, or report disease, injury or disability as
permitted by law.
To report vital events such as birth or death as permitted or
required by law.
To conduct public health surveillance, investigations and
interventions as permitted or required by law.
To collect or report adverse events and product defects, track FDA
regulated products; enable product recalls, repairs or replacements to the
FDA and to conduct post marketing surveillance.
To notify a person who has been exposed to a communicable disease
or who may be at risk of contracting or spreading a disease as authorized by
law.
To report to an employer information about an individual who is a member of the workforce as legally permitted or required.
C.
To Report Suspected Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe that a
patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required
or authorized by law or when the patient agrees to the disclosure.
D.
To Conduct Health Oversight Activities.
We may disclose your protected health information to a health oversight
agency for activities including audits; civil, administrative, or criminal
investigations, proceedings, or actions; inspections; licensure or disciplinary
actions; or other activities necessary for appropriate oversight as authorized
by law. We will not disclose your health information under this
authority if you are the subject of an investigation and your health information
is not directly related to your receipt of health care or public benefits.
E.
In Connection With Judicial And Administrative Proceedings. We may disclose your protected health information in the
course of any judicial or administrative proceeding in response to an order of a
court or administrative tribunal as expressly authorized by such order.
In certain circumstances, we may disclose your protected health
information in response to a subpoena to the extent authorized by state law if
we receive satisfactory assurances that you have been notified of the request or
that an effort was made to secure a protective order.
F.
For Law Enforcement Purposes. We may disclose your protected health information to a law
enforcement official for law enforcement purposes as follows:
As
required by law for reporting of certain types of wounds or other physical
injuries.
Pursuant
to court order, court-ordered warrant, subpoena, summons or similar
process.
For
the purpose of identifying or locating a suspect, fugitive, material
witness or missing person.
Under
certain limited circumstances, when you are the victim of a crime.
To
a law enforcement official if the facility has a suspicion that your
health condition was the result of criminal conduct.
In an emergency to report a crime.
G.
To Coroners, Funeral Directors, and for Organ Donation. We
may disclose protected health information to a coroner or medical examiner for
identification purposes, to determine cause of death or for the coroner or
medical examiner to perform other duties authorized by law.
We may also disclose protected health information to a funeral director,
as authorized by law, in order to permit the funeral director to carry out their
duties. We may disclose such
information in reasonable anticipation of death.
Protected health information may be used and disclosed for cadaveric
organ, eye or tissue donation purposes.
H.
For Research Purposes.
We may use or disclose your protected health information for research
when the use or disclosure for research has been approved by an institutional
review board that has reviewed the research proposal and research protocols to
address the privacy of your protected health information.
I.
In the Event of a Serious Threat to Health or Safety. We
may, consistent with applicable law and ethical standards of conduct, use or
disclose your protected health information if we believe, in good faith, that
such use or disclosure is necessary to prevent or lessen a serious and imminent
threat to your health or safety or to the health and safety of the public.
J.
For Specified Government Functions. In certain circumstances,
federal regulations authorize the facility to use or disclose your protected
health information to facilitate specified government functions relating to
military and veterans activities, national security and intelligence activities,
protective services for the President and others, medical suitability
determinations, correctional institutions, and law enforcement custodial
situations.
K.
For Worker's Compensation. We may release your
health information to comply with worker's compensation laws or similar
programs.
III.
Uses and Disclosures Permitted without Authorization but with Opportunity
to Object
We may disclose your protected health information to your
family member or a close personal friend if it is directly relevant to the
person’s involvement in your surgery or payment related to your surgery.
We can also disclose your information in connection with trying to locate
or notify family members or others involved in your care concerning your
location, condition or death.
You
may object to these disclosures. 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 for us to make disclosure of
information that is directly relevant to the person’s involvement with your
care, we may disclose your protected health information as described.
IV.
Uses and Disclosures which you Authorize
Other than as stated above, we will not disclose your
health information other than with your written authorization.
You may revoke your authorization in writing at any time except to the
extent that we have taken action in reliance upon the authorization.
You have the following rights regarding your health
information:
A.
The right to inspect and copy your protected health information.
You may inspect and obtain a copy of your protected health information that is
contained in a designated record set for as long as we maintain the protected
health information. A “designated
record set” contains medical and billing records and any other records that
your surgeon and the facility use for making decisions about you.
Under federal law,
however, you may not inspect or copy the following records:
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.
We may deny your
request to inspect or copy your protected health information if, in our
professional judgment, we determine that the access requested is likely to
endanger your life or safety or that of another person, or that it is likely to
cause substantial harm to another person referenced within the information.
You have the right to request a review of this decision.
To inspect and
copy your medical information, you must submit a written request to the Privacy
Officer whose contact information is listed on the last page of this Privacy
Notice. 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.
Please contact our
Privacy Officer if you have questions about access to your medical record.
B.
The right to request a restriction on uses and disclosures of your
protected health information.
You may ask us not to use or disclose certain parts of your protected
health information for the purposes of treatment, payment or health care
operations. You may also request
that we not disclose your health information to family members or friends who
may be involved in your care or for notification purposes as described in this
Privacy Notice. Your request must
state the specific restriction requested and to whom you want the restriction to
apply.
The facility is
not required to agree to a restriction that you may request.
We will notify you if we deny your request to a restriction.
If the facility does agree to the requested restriction, we may not use
or disclose your protected health information in violation of that restriction
unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement
to a restriction. You may request a
restriction by contacting the Privacy Officer.
C.
The right to request to receive confidential communications from us by
alternative means or at an alternative location.
You have the right to request that we communicate with you in certain
ways. We will accommodate
reasonable requests. We may condition this accommodation by asking you for
information as to how payment will be handled or specification of an alternative
address or other method of contact. We
will not require you to provide an explanation for your request.
Requests must be made in writing to our Privacy Officer.
D.
The right to request amendments to your protected health information.
You may request an amendment of protected health information about you in
a designated record set for as long as we maintain this information.
In certain cases, we may deny your request for an amendment.
If we deny your request for amendment, you have the right to file a
statement of disagreement with us and we may prepare a rebuttal to your
statement and will provide you with a copy of any such rebuttal.
Requests for amendment must be in writing and must be directed to our
Privacy Officer. In this written
request, you must also provide a reason to support the requested amendments.
E.
The right to receive an accounting.
You have the right to request an accounting of certain disclosures of
your protected health information made by the facility.
This right applies to disclosures for purposes other than treatment,
payment or health care operations as described in this Privacy Notice.
We are also not required to account for disclosures that you requested,
disclosures that you agreed to by signing an authorization form, disclosures for
a facility directory, to friends or family members involved in your care, or
certain other disclosures we are permitted to make without your authorization.
The request for an accounting must be made in writing to our Privacy
Officer. The request should specify
the time period sought for the accounting.
We are not required to provide an accounting for disclosures that take
place prior to April 14, 2003. Accounting
requests may not be made for periods of time in excess of six years.
We will provide the first accounting you request during any 12-month
period without charge. Subsequent accounting requests may be subject to a reasonable
cost-based fee.
F.
The right to obtain a paper copy of this notice.
Upon request, we will provide a separate paper copy of this notice even
if you have already received a copy of the notice or have agreed to accept this
notice electronically.
VI.
Our Duties
The surgery center
and it’s affiliated anesthesia provider are required by law to maintain the
privacy of your health information and to provide you with this Privacy Notice
of our duties and privacy practices. We
are required to abide by terms of this Notice as may be amended from time to
time. We reserve the right to
change the terms of this Notice and to make the new Notice provisions effective
for all future protected health information that we maintain.
If the facility changes its Notice, we will provide a copy of the revised
Notice by sending a copy of the revised Notice via regular mail or through
in-person contact.
VII.
Complaints
You have the right
to express complaints to the facility and to the Secretary of Health and Human
Services if you believe that your privacy rights have been violated.
You may complain to the facility by contacting the facility’s Privacy
Officer verbally or in writing, using the contact information below. We encourage you to express any concerns you may have
regarding the privacy of your information.
You will not be retaliated against in any way for filing a complaint.
The facility’s contact person for all issues
regarding patient privacy and your rights under the federal privacy standards is
the Privacy Officer. Information
regarding matters covered by this Notice can be requested by contacting the
Privacy Officer. If you feel that
your privacy rights have been violated by this facility you may submit a
complaint to our Privacy Officer by sending it to:
The Privacy Officer can be contacted by telephone at
(402) 484-6600.
This Notice is effective April 14, 2003.