Pocono Ambulatory Surgery
Center
PATIENT NOTICE OF PRIVACY PRACTICES
[Effective Date: April 14, 2003]
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 FEDERAL LAW UNDER THE
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) TO PROVIDE
YOU WITH THIS PRIVACY NOTICE.
"Protected Health Information" is defined
as any written or oral health information about you, which includes
demographic data by which you can be identified. This is the health
information created or received by your health care provider which
can relate to your past, present or future physical or mental health
or condition.
YOUR RIGHTS:
The right to request a restriction or
limitation on the use or disclosure of the medical information for
your treatment, payment or health care operations. You must make
written request specifying restrictions requested and to whom the
restrictions apply. We are not required to grant all restriction
requests.
The right to obtain a paper copy of this
notice which is also posted in our waiting room.
The right to
inspect and obtain a copy of your health care record upon written
request to the Administrative Director listed on the last page of
this notice. We may, in certain instances, deny your request. You
then have the right, to request in writing. Certain denials are
not reviewable.
The right to
request an amendment to your health care record upon written request
to the Administrative Director. The request must include the reason
for the request. We may, in certain instances, deny your request.
You then have the right to file a statement of disagreement with
us and we may prepare a rebuttal. We will provide you with a copy
of the rebuttal.
The right to
request, in writing, a disclosure history, specifying the time period
involved, listing entities that obtained information unrelated to
treatment or payment or health care operations. We must provide this
within 60 days of the request. We are not required to account for
disclosures requested by you, disclosures you agreed to by signing
an authorization form, disclosures to friends or family members involved
in your care, or certain other disclosures we are permitted to make
with out your authorization.
The right to
request in writing, that we communicate with you about your medical
information by alternative means. We will attempt to accommodate
reasonable requests. We may ask you for the information about payment
methods, alternative address, or other method of contact.
The right to
revoke your authorization to PASC to use and disclose medical information.
Any written revocation request will have no effect on information
already released under your prior authorization.
The right to request release of your health
information to another entity, for example a doctor or other agency.
This release will be honored by PASC upon you signing a release.
The released information may no longer be protected by federal privacy
regulations.
OUR RESPONSIBLITIES:
We are required by law to:
Maintain the privacy of your health information.
Provide you with a copy of our "Notice of Privacy Practices".
Abide by the terms of the "Notice of Privacy Practices".
Notify you if we are unable to agree to a restriction you request.
Accommodate reasonable requests you make to communicate
your health information to you by alternative means.
Inform you of the effective date of this notice.
We reserve the right to change this notice
and to make the revised notice effective for medical information
we already have about you, as well as future information. We must
post a copy of the current notice, which will contain an effective
date. Each time you register at PASC, we will offer you a copy of
the current notice in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION
ABOUT YOU
Each time you are a patient at PASC, we
make a record of your visit and may use your protected health information
for purposes of providing treatment, obtaining payment for treatment
and conducting health care operations as described below:
Treatment: Doctors, nurses and
other PASC personnel involved in your care will use and disclose
health information to determine your course of treatment. This includes
coordinating and managing your health care with third parties, such
as your medical doctor, a laboratory, or other facilities.
Payment: Use and disclosure for purposes
of billing and payment collection from you, your insurance companies
or a third party. We may also disclose patient information to another
provider involved in your care, for example an anesthesia care provider.
Healthcare Operations: We may use your
health information as a tool to assess the function of the ASC and
improve our delivery of patient care services. This can include quality
review and improvement, staff, training, accreditation, certification,
licensing and credentialing, audit process, medical reviews, legal
services, compliance programs, and business management and general
administrative activities.
Other Uses: To remind you, or a contact
person designated by you, by telephone or U.S. Postal Service, of
an appointment or surgery date, potential treatment alternatives
or health related services.
Federal privacy rules allow us to use
or disclose your protected health information without your permission
or authorization as described below:
As Required By Law: We will disclose your
protected health information when required to comply with federal
and state laws.
Public Health Risks: Public
health reporting must be done as required by law to prevent, control
or report disease, injury or disability, to report vital events,
such as death, to conduct public health investigations, and to track
adverse events, product defects and recalls, FDA regulated products
and surveillance.
To Report Suspected
Abuse, Neglect or Domestic Violence: As required by law, or when the patient agrees
to the disclosure.
Health Oversight
Activities: For government
monitoring of the health care system, government programs and civil
rights laws.
In Connection With
Judicial and Administrative Proceedings: In response to an order of the court or authorized tribunal,
we may disclose medical information about you. Efforts will be made
by us to contact you prior to release of information in response
to a subpoena.
Law Enforcement: Health information may
be disclosed in such instances as reporting certain types of wounds
or other injuries, court orders or other process, identification
or location of suspect, fugitive, material witness or missing person,
crime victim, in emergency crime reporting or to a law enforcement
official if your condition is suspect of criminal conduct.
Coroners, Medical
Examiners and Funeral Directors: As directed by law,
for identification purposes, to determine or funeral duties. Health
information may be used or disclosed for cadaver ic donation purposes.
Emergency: To prevent or lessen a serious
threat to your health and safety, or the health and safety of the
public, we will, consistent with applicable law and ethics, only
use and disclose information to prevent or lessen the threat.
Workers' Compensation: We must comply
with laws relating to release of health information.
For Specified Government
Functions: Relative
to military and veterans activities, national security and intelligence
activities, protective services, correctional institutions or law
enforcement custody.
USES AND DISCLOSURES PREMITTED WITHOUT
AUTHORIZATION, BUT WITH OPPORTUNITY FOR YOU TO OBJECT:
Individuals Involved in Your Care or Care
Payment: We may disclose your protected health information to a family
member or close personal friend if it is directly relevant to the
person's involvement in your surgery or payment related to your surgery.
You may object to these disclosures, but if you do not object, or
we infer from circumstances that you do no object or we determine,
in exercising our professional judgment, that 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.
OTHER USES:
Use or disclosure not covered by this Patient Notice of Privacy Practices,
or other laws, will be made only after specific written authorization
by you. Form is available upon request. You may revoke your authorization,
but this will have no effect on any action already taken by us.
In certain cases, your refusal of information
release may negate our ability to treat. If this occurs, we will
make alternative suggestions for care.
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