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Notice of Privacy Practices

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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.


If you have questions about this notice or want more information, please contact: Rena Bach, HIPAA Privacy and Security Officer. The effective date of this notice is September 23, 2013.

To appropriately treat you and receive payment for the services we provide, we need to obtain information from you including your full name and address, insurance company, family medical history, current medical history, and current medical condition. We will use and disclose this information and other information we collect in the ways described below. To help you understand how we will use and disclose your information we have put the different uses and disclosures into categories and give examples of each. All the ways we use or disclose your information will fit into one of the categories listed below, but we cannot list all of the uses and discloses in each category.

We may use and disclose your health information for treatment, payment, and health care operations.

  • Treatment. We may use and disclose your information to provide you with medical treatment and services. Your information may be disclosed to individuals and facilities providing care to you. These individuals and facilities need your information to provide care, and to coordinate and provide services (such as prescriptions, lab tests, meals, and x-rays).
  • Payment. We may use and disclose your information to receive payment for the services and treatment provided to you. We use your information to create a bill and disclose your information when we send the bill to your insurance company, you, or a third party. The individual or entity paying the bill may request more information to determine whether the bill is covered by your insurance. We may tell your health plan about a treatment you are going to receive to get approval for payment or to determine whether your health plan will cover the treatment.
  • Health Care Operations. We may use and disclose your information for health care operation purposes. Health care operations includes review of the care you receive for quality assessment, educational, business planning, and compliance plan purposes.

We may disclose and use your health information and you authorize SurgOne, P.C. to use and disclose your information for:

  • Appointment Reminders. We may provide appointment reminders to you. You may request in writing that we send reminders to a confidential or alternative address.
  • Treatment Alternatives. We may provide you with information about treatment alternatives and other health related benefits and services.

We may also disclose your health information to outside entities without your consent or authorization in the following circumstances:

  • Required by Law. We disclose information as required by law. For example, we are required to report gunshot wounds to the police.
  • Public Health Purposes. We disclose information to health agencies as required by law for preventing or controlling disease. Examples are reporting of sexually transmitted, communicable, and infectious diseases.
  • To Prevent a Serious Threat to Health or Safety. We may disclose information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.
  • Research. Your information may be used by or disclosed to researchers for research approved by a privacy board or an institutional review board.
  • Health Oversight Activities. Your health information may be disclosed to governmental agencies and boards for investigations, audits, licensing, and compliance purposes.
  • Judicial and Administrative Proceedings. We may be required to disclose your health information to a court or for an administrative proceeding.
  • Law Enforcement Activities. We may be required to disclose your information as required by law, pursuant to a court order, warrant, subpoena, or summons.
  • In Emergency Circumstances.
  • Deceased Individual. We may disclose information for the identification of the body or to determine the cause of death.
  • Military and Veterans. If you are a member of the armed forces, we may release information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.
  • Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official. This release must 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 or security of the correctional institution.
  • Protective Services for the President and Others.
  • Organ and Tissue Donation. If you are an organ donor, we may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ bank, as necessary to facilitate organ or tissue donation.
  • Workers Compensation. We may release medical information about you for workers compensation or similar programs.
  • National Security and Intelligence Activities. We may release information about you to authorized Federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

We will give you the opportunity to object to the following uses and disclosure of your information:

  • Notification. We may tell your friends, relatives and other caretakers information which is relevant to their involvement in your care.
  • Disaster Relief. We may disclose information about you to public or private agencies for disaster relief purposes.

Except as provided above, we will obtain your written authorization prior to disclosure of your information for any other purpose. Specifically, written authorization is required prior to the disclosure of your information:

  • Psychotherapy Notes. We will not use or disclose your psychotherapy notes without a written authorization except as specifically permitted by law.
  • Marketing. We will not use or disclose your information for marketing purposes, other than face-to-face communications with you or promotional gifts of nominal value, without your written authorization.
  • Sale of Information. We will not sell your PHI without your written authorization, including notification of the payment we will receive.

Where a disclosure is made under your written authorization, you have the right to revoke the authorization at any time. Revocation of an authorization must be in writing. The revocation is effective as of the date you provide it to SurgOne, P.C. and does not affect any prior disclosures made under the authorization. If a state or federal law provides additional restrictions or protections to your information, we will comply with the most stringent requirement.


Your Rights

  • You have the right to request a restriction on how information about you is used and disclosed. If you want to request a restriction of a use or disclosure of your information, contact your SurgOne, P.C. physician’s office directly or our Privacy Officer at the number listed at the end of this form. We are required to agree to a request for a restriction related to disclosure of information to your health plan for payment or health care operations where you pay for the service in full. We are not otherwise required to agree to any restriction on the use or disclosure of your information.
  • You have the right to request communications with you be made at an alternative address or phone number. To request that communication be made at a different address or phone number contact your SurgOne, P.C. physician’s office directly or our Privacy Officer at the number listed at the end of this form to obtain the form to make your request.
  • You have the right to inspect and copy your medical record. To inspect and copy your medical record a request must be made in writing on the form provided by SurgOne, P.C.. To obtain a form contact your SurgOne, P.C. physician’s office directly or our Privacy Officer at the number listed at the end of this form.
  • If you believe the information we have about you is incorrect or incomplete, you may request that we amend your medical record. Your request must be made in writing on the form provided by SurgOne, P.C.. To request a form contact your SurgOne, P.C. physician’s office directly or our Privacy Officer at the number listed at the end of this form.
  • You have the right to receive an accounting of disclosures, a list of individuals and entities that received your health information for reasons other than treatment, payment, or health care operations. You may receive one (1) free accounting during a twelve (12) month period. If you request more than one (1) accounting in a twelve (12) month period, you will be charged a fee. An accounting is not provided for disclosures prior to April 14, 2003. To request an accounting of disclosures, contact your SurgOne, P.C. physician’s office directly or our Privacy Officer at the number listed at the end of this form.
  • You have the right to request a paper copy of this Notice.

Our Duties

  • We are required by law to maintain the privacy of PHI and to provide individuals with this Notice of our legal duties and privacy practice regarding health information.
  • We are required to notify you if there is a breach of your unsecured PHI.
  • We are required to follow the terms of the current Notice.
  • We may change the terms of this Notice and the revised Notice will apply to all health information in our possession. If we revise this Notice, a copy of the revised Notice will be posted and a copy may be requested from our Privacy Officer at the number listed at the beginning of this form.

Colorado Health Information Exchange

  • SurgOne, P.C. participates in the Colorado Health Information Exchange (HIE) as a means to improve the quality of your health and health care experience. HIE provides us with a way to share patient's clinical information electronically with other physicians and health care providers that participate in the HIE network. The HIE is designed to enable emergency medical personnel and other providers who are treating you to have access to your medical data that may be critical for your care. Making your health information available to your health care providers through the HIE may also help reduce your costs by eliminating unnecessary duplication of tests and procedures. However, you may choose to opt-out of participation in the (CORHIO) HIE, or cancel an opt-out choice, at any time. If you do not opt out, SurgOne, P.C. will access your information on the HIE and may make your medical information available to medical providers who access the HIE.

Complaints

  • If you believe your privacy rights have been violated you may contact:
  • Rena Bach HIPAA Privacy and Security Officer for SurgOne, P.C. via phone at 1-303-957-1310, or email hipaa@surgone.com, or you may contact the Office of Civil Rights. You will not be penalized for filing a complaint.