Lakeview Surgery Center and its organized health care arrangement
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 to maintain the privacy of your medical information and to give you our Notice of Privacy Practices (this “Notice”) that describes our privacy practices, our legal duties and your rights concerning your medical information. Your health information includes individually identifiable, medical, insurance, demographic and medical payment information. For example, it includes information about your diagnosis, medications, insurance status, medical claims history, address, and policy or social security number.
This is the required privacy Notice of Lakeview Surgery Center (the “Facility”) and its organized health care arrangement. This Notice applies to and will be followed by: (1) all employees, staff, volunteers and other personnel of the Facility, and (2) the physicians and other practitioners who are not employed by the Facility, but who have privileges to treat patients at the Facility and who are members of the Facility’s organized health care arrangement (see description of the Facility’s organized health care arrangement, below).
How We May Use And Disclose Your Medical Information
The Facility is permitted or required to use or disclose your medical information without your authorization (permission) in the following situations. Some, but not all, specific examples of the different types of disclosures have been listed.
TREATMENT. To provide you with medical treatment or services (e.g., provide information to doctors, nurses, technicians, students or other personnel who are involved in your care).
PAYMENT. To collect payment from you, an insurance company or a third party for the treatment and services you receive (e.g., submitting a claim to your insurance company).
HEALTH CARE OPERATIONS. Health care operations are the uses and disclosures of information that are necessary to run the surgery center and to make sure that all of our patients receive quality care. If State law requires, we will obtain your permission prior to disclosing your health information to other providers or health insurance companies for their health care operations. In some cases, we will furnish other qualified parties with your health information for their health care operations. For example, we may use medical information to review our treatment and services, and to evaluate the performance of our staff and physicians in caring for you. We may use your name and address to send you a patient satisfaction survey.
APPOINTMENTS AND HEALTH CARE SERVICES. ?To provide you with appointment reminders or to notify you of possible treatment alternatives or health-related benefits or services.
FACILITY DIRECTORY. While you are a patient, your name, location in the Facility, general condition (e.g., fair, serious, etc.), may be given to friends, family, or a member of the clergy. You have the right to request that your name not be included in the directory.
FRIENDS AND FAMILY. We may disclose your location or general condition to a family member, your personal representative or another person identified by you. If any of these individuals are involved in your care or payment for care, we may also discuss such health information as is directly relevant to their involvement. We will only release this information if you agree, are given the opportunity to object and do not, or if in our professional judgment, it would be in the best interest to allow the person to receive the information or act on your behalf. In addition, if you are unavailable, incapacitated or in an emergency situation, we may disclose limited information to these persons if we determine in our professional judgment that we believe it is in your best interest. We may also disclose your information to an entity assisting in disaster relief efforts so that your family or individual responsible for your care may be notified of your location and condition.
HEATH CARE PROVIDERS. To another health care provider involved in your treatment in order for that provider to treat you, bill for its services and conduct its health care operations.
DISASTER RELIEF. To a public or private entity assisting in a disaster relief effort (e.g., to notify your family about your location, condition or death).
PUBLIC HEALTH ACTIVITIES. To public health authorities for public health activities as permitted or required by law (e.g., to report births, deaths, child abuse and neglect, immunizations and communicable diseases).
ABUSE, NEGLECT AND DOMESTIC VIOLENCE. The Facility may notify the appropriate government authority if it believes you have been the victim of abuse, neglect or domestic violence. Unless such disclosure is required by law, the Facility will only make this disclosure if you agree or under other limited circumstances when such disclosure is authorized by law.
HEALTH SAFETY RISKS. Under certain circumstances, when necessary to prevent a serious threat to your health and safety or to the health and safety of the public or another person.
Military and National Security/Correctional Institutions. If you are a member of the armed forces, as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. The Facility may also release your medical information to authorized federal officials for intelligence, counterintelligence, and other authorized national security activities. Also we may release medical information to the correctional institution where you are an inmate or to a law enforcement official who has custody of you for certain limited purposes (e.g., to provide you with health care).
WORKER'S COMPENSATION. To persons (e.g., employers, insurance carriers, attorneys) in order to comply with workers’ compensation laws or other similar programs providing benefits for work-related injuries.
HEALTH OVERSIGHT ACTIVITIES. We may disclose health 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 health care system, government programs and compliance with civil right laws.
LEGAL PROCEEDINGS. If you are involved in a lawsuit or dispute, in response to a court or administrative order. The Facility may also disclose medical information about you in response to a subpoena or other lawful process by someone else involved in the dispute, but only if the party seeking the information demonstrates that reasonable efforts have been made to notify you of the request or to obtain a protective order from the court.
LAW ENFORCEMENT. To law enforcement authorities for law enforcement purposes, such as (1) in response to a court order, subpoena, warrant, summons or similar process, (2) to identify or locate a suspect, fugitive, material witness or missing person, (3) if you are the victim of a crime, but only if your agreement is obtained or, under certain limited circumstances, if the Facility is unable to obtain your agreement, (4) about a death which is believed to be the result of criminal conduct, (5) to report a crime that occurred on Facility premises, and (6) in emergency circumstances, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. The facility must comply with federal and State laws in making such disclosures.
DECEASED INDIVIDUALS. To a coroner or medical examiner (e.g., to identify a deceased person or determine the cause of death), or to funeral directors as necessary to carry out their duties. In addition, following your death, we may disclose health information to a personal representative (such as executor of your estate), and unless you have expressed a contrary preference, we may also release your health information to a family member or other person who acted as a personal representative or was relevant to such person’s involvement in your care or payment for care. We are required to apply safeguards to protect your health information for 50 years following your death.
RESEARCH. Federal law permits the surgery center to use and disclose medical information about you for research purposes, either with your specific, written authorization or when the study has been reviewed for privacy protection by an Institutional Review Board or Privacy Board before the research begins.
REQUIRED BY LAW. When required to do so by federal, state or local law (e.g., to report child or dependent adult abuse and violent wounds).
INCIDENTAL DISCLOSURES. Occasional incidental, unintended disclosures of your medical information which might occur during a permitted use or disclosure (e.g., information overheard during a discussion regarding your care with you or a member of your family). We will take reasonable steps to avoid these types of disclosures.
BUSINESS ASSOCIATES. Some of the activities described above are performed through contracts with outside persons or organizations (“business associates”), we will disclose your health information to our business associates and allow them to create, use and disclose your health information to perform their services for us. For example, we may disclose your health information to an outside billing company who assists us in billing insurance companies. We require business associates to appropriately safeguard the privacy of your information.
ORGANIZED HEALTH CARE ARRANGEMENT. The Facility is a clinically integrated care setting where patients receive care from Facility personnel and from independent doctors and other practitioners who provide care to patients at the Facility (collectively called “practitioners”). The Facility and these practitioners need to share medical information freely to provide care to patients, and to conduct Facility health care operations. Therefore, the Facility and the practitioners have agreed to follow uniform information practices when using or disclosing medical information related to surgical services. This arrangement is called an “organized health care arrangement” and only covers information practices for services rendered through the Facility.
It does not cover the information practices of the practitioners in their offices or at other care settings. It does not alter the independent status of the Facility and the practitioners or make them jointly responsible for the clinical services provided by them. In other words, the Facility is not responsible for (1) the negligence (or mistakes) of the independent practitioners providing care at the Facility; or (2) any violations of your privacy rights by the independent practitioners.
YOU AND YOUR AUTHORIZATION. 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 permission. If you give us permission to use or disclose medial information about you, you may revoke (take back) 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 set forth in your written authorization. We are unable to take back any disclosures we have already made with your permission.
ACCESS TO MEDICAL INFORMATION. You may request to inspect and copy much of the medical information we maintain about you, with some exceptions. If we maintain the information electronically and you ask for an electronic copy, we will provide the information to you in the form and format you requested, assuming it is readily producible. If we cannot readily produce the record in the form and format you request, we will produce it another readable electronic form we agree to. We may charge a cost based fee for producing copies or, if you request one, a summary. If you direct us to transmit your health information to another person, we will do so, provided your signed, written direction clearly designates the recipient and location for delivery. We may charge a fee for the costs of copying, mailing and other supplies or work associated with your request. We will respond to your requests to exercise and of the above rights on a timely basis in accordance with our policies and as required by law.
REQUEST FOR RESTRICTIONS. You have the right to request a restriction on how we use or disclose your medical information for treatment, payment, or health care operations, or to certain family members or friends identified by you who are involved in your care or the payment for your care. We are not required to agree to your request, with one exception explained in the next paragraph, but we will let you know whether we have agreed to your request.
We are required to agree to your request that we not disclose certain health information to your health plan for payment or health care operations purpose if (1) you pay out of pocket in full for all expenses related to that service either at the time of service or within timeframes specified by our written policies and (2) the disclosures is not otherwise required by law. Such a restriction will only apply to records that relate solely to the service for which you have paid in full. If we later receive an authorization from you dated after the date of your requested restriction which authorizes us to disclose all of your records to your health plan, we will assume you have withdrawn your request for restriction.
AMENDMENT. You may request that we change a part of your medical information if you believe that it is incorrect or incomplete. You must provide a reason that supports your request. We are not required to make all requested amendments, but we will give each request careful consideration. If we deny your request, we will provide you with a written explanation of the reasons and your rights.
ACCOUNTING. You have the right to receive a list of certain disclosures of your medical information made by us or our business associates. You must state a time period for your request, which may not be longer than six years. The first list in any 12-month period will be provided to you for free; you may be charged a fee for each subsequent list you request within the same 12-month period. Your right to an accounting of disclosures does not include disclosures for disclosures for treatment, payment or health care operations and certain other types of disclosures, for example; as part of a facility directory or disclosure in accordance with your authorization. Requests must be in writing. You may contact the Privacy Officer to obtain a form to request an accounting or disclosures.
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 contact you only at work or only by mail. Your request must specify how or where you wish to be contacted, and we may require you to provide information about how payment will be handled. We will agree to your request if it is reasonable.
PAPER NOTICE. You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice any time.
HOW TO EXERCISE THESE RIGHTS. All requests to exercise these rights must be in writing. We will follow written policies to handle requests, and we will notify you of our decision or actions and your rights. Contact the Privacy Officer at the contact information at the end of this Notice for more information or to obtain request forms.
NOTICE IN CASE OF BREACH. You have the right to receive notice of an access, acquisition, use or disclosure of your health information that is not permitted by HIPAA, if such access, acquisition, use or disclosure compromises the security or privacy of your PHI (we refer to this as a breach). We will provide such notice to you without unreasonable delay but in no case later than 60 days after we discover the breach.
COMPLAINTS. If you believe your privacy rights have been violated, you may file a compliant with the Facility using the contact information at the end of this Notice. You may also submit a compliant with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or retaliated against for filing a compliant.
QUESTIONS. If you have questions about this Notice, please contact the Privacy Officer or the Executive Director of the Center at the telephone number listed on the back of this brochure.
About This Notice
The Facility is required to abide by the terms of the Notice currently in effect. The Facility reserves the right to change the terms of this Notice and make the new Notice provisions effective for all of your medical information that it maintains, including that which it created or received while the prior Notice was in effect. If the Facility makes a material change to its privacy practices, it will amend its Notice. We will post a copy of the current Notice in the Facility. The Notice will state the effective date.
PRIVACY OFFICER/EXECUTIVE DIRECTOR, 515-273-5240
Lakeview Surgery Center
1750 60th Street
West Des Moines, IA 50266-5733
Effective Date: September 2013