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 we 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.
Uses and Disclosures of Protected Health Information
Wooster Ambulatory Surgery Center may use your protected health information for
purposes of providing treatment, obtaining payment for treatment, and conducting
health care operations. Your protected health information may be used or
disclosed only for these purposes unless Athens Surgery Center 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.
We will 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 laboratory, pharmacy or treating
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 (i.e. pre authorization or prior approval). We may also disclose
protected health information to your health insurance company to determine your
eligibility for benefits or whether a particular service is covered under your
plan or to demonstrate medical necessity of the services or as required by your
insurance company, for utilization review. We may also disclose protected health
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.
We may use or disclose your protected health information, as necessary for our
own health care operations to facilitate the function of the ASC and to provide
quality care to all patients. Health care operations include such activities as:
quality assessment and improvement activities, employee review activities, post operative patient assessment,
training programs including those in which students, trainees, or practitioners
in health care learn under supervision, accreditation, certification, licensure
or credentialing activities, review and auditing, including compliance reviews,
medical reviews, legal services and maintaining compliance programs, and
business management and general administrative activities.
Other Uses and Disclosures
As part of your 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, provide pre op instructions and discuss
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:
When Legally Required
- We will disclose your protected health information when we are required to do
so by any federal, state or local law.
When There are Risks to Public Healthh - 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
To report vital events such as birth or death as permitted by 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 Suspended Abuse, Neglect or Domestic Violencece - We may notify government authorities if we believe that a patient is the victim of
abuse, neglect or domestic violence when specifically required or authorized by
law or when the patient agrees to the disclosure.
D. To Conduct Health Oversight Activitieses - 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 directly related to your receipt of healthcare or
E. In Connection with Judicial and Administrative Proceedingsgs - 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 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 Purposeses
- 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
Pursuant to court order, court-ordered warrant, subpoena, summons or similar
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 a crime.
In an emergency to report a crime.
G. To Coroners, Funeral Directors, and for Organ Donationon - 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 our their duties.
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 and 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
- The facility may release your health information to comply with worker’s
compensation laws or similar programs.
Uses and Disclosures Permitted without Authorization but with Opportunity to
We may disclose your protected health information
to your family member or a close family 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.
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 action in reliance upon the authorization.
You have the following rights regarding your health
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” contain medical and billing records and any other records that your surgeon
and the facility uses for making decisions about you. Under federal law, however, you may not
inspect or copy the following records.
Psychotherapy notes; information complied 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.n. 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 is likely to cause substantial harm
to another person reference with the information.
Your have the right to request a review of this decision.
To inspect and copy your medical information, your 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. These costs will be made known to you
at the time of your request.
Please contact our Privacy Officer if you have questions about access to your medical records.
B. The Right to Request a Restriction on Uses and Disclosures of your Protected
- 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 of 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 requited to agree to a
restriction that you may request.
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 may have the right to request that we
communicate with you in certain ways.
will accommodate reasonable requests.
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 Official. In this written request, you must also
provide a reason to support the requested amendment.
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 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-bases fee.
F. The Right to Obtain a 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.
Wooster Ambulatory Surgery Center is 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 Wooster
Ambulatory Surgery Center 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.
You have the right to express complaints to Wooster
Ambulatory Surgery Center 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 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.
This 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:
Wooster Ambulatory Surgery Center
3373 Commerce Parkway, Suite 1
Wooster, Ohio 44691
The Privacy Officer can be contacted by telephone at
(330)804-2000 extension 9503
This Notice is effective April 14, 2003