Notice
of Privacy Practices for Protected Health
Information
Arizona Associated Surgeons, PLLC
The HIPAA Privacy Rule gives an individual
a right to adequate notice of the uses and
disclosures of protected health information
(PHI) that may be made by this office,
and of the individual’s rights and the office’s
legal duties with respect to PHI.
Procedure for Content of Notice of
Privacy Practices
The Notice will be in plain language
and inform the individual of the uses and
disclosures of PHI that this office may
make, and of the individual’s rights and
the office’s legal duties with respect to
their PHI as required by the HIPAA Privacy
Rule and contained in our office Notice,
which is incorporated into this procedure. The Notice will contain the
mandatory elements required by the HIPAA
Privacy Rule. The Notice will
contain the mandatory elements required
by the HIPAA Privacy Rule. The Notice will
contain the following optional elements
for certain uses and disclosures: The office
may contact the individual to provide appointment
reminders or information about treatment
alternatives or other health-related benefits
and services that may be of interest to
the individual. The Notice will
reserve the right to change its policy and
procedures, and the office will make the
Notice available on request to individuals
whenever there is a material change to it.
Procedure for Providing Notice The Notice will
be posted in a clear and prominent place
in the office where individuals seeking
service will be able to read it. The Notice will
be prominently posted on our office website
and electronically available.
This office will make available on or before
the first date of service after April 14,
2003 to each patient or prospective patient
its “Notice of Privacy Practices.”
The
office person[s] responsible for obtaining
the signed acknowledgment or documentation
of good faith efforts to obtain it is: Front
Desk Receptionist
All current or new patients after April
14, 2003 will be requested to sign a written
acknowledgment of Receipt of Privacy Notice,
which will be maintained in their medical
record.
For patients or their representatives who
either refuse or are unable to sign the
acknowledgment, the appropriate staff person
will prepare a documentation of good faith
efforts to obtain acknowledgment of Receipt
of Privacy Notice, reflecting why the patient
or representative did not sign, which will
be maintained in their medical record.
For those patients who cannot sign due to
an emergency condition, the responsible
staff person for follow-up is:
Procedure on Documentation This office will keep samples
of its Notice of Privacy Practices for 6
years. This office will maintain
in the individual’s medical record all acknowledgments
and/or documentation of good faith efforts
to obtain the acknowledgment
Procedure for Revising Notice This office will, as necessary
and at least annually, review its Notice
of Privacy Practices and related policy
and procedures for possible revision: References:
HIPAA Privacy Rule, 45 C.F.R. § 164.520.
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 office is
required by a federal regulation, known
as the HIPAA Privacy Rule,
to maintain the privacy of your health information
and to provide you with notice of its legal
duties and privacy practices.
This office will
not use or disclose your health information
except as described in this Notice.
The office is
permitted by federal privacy laws to make
uses and disclosures of your health information
for purposes of treatment, payment, and
health care operations. Protected health
information is the information we create
and obtain in providing our services to
you. The health information about you is
documented in a medical record and on a
computer. Such information may include documenting
your symptoms, medical history, examination
and test results, diagnoses, treatment,
and applying for future care or treatment.
It also includes billing documents for those
services.
Examples of uses of your health
information for treatment purposes
are:
A nurse or medical assistant obtains treatment
information about you and records it in
a health record.
During the course of your treatment, the
physician determines he/she will need to
consult with another specialist in the area.
He/she will share the information with such
specialist and obtain his/her input.
Example of use of your health information
for payment purposes:
We submit requests for payment to your health
insurance company. The health insurance
company (or other business associate helping
us obtain payment) requests health information
from us regarding medical care given. We
will provide information to them about you
and the care given, which may include copies
or excerpts of your medical record which
are necessary for payment of your account.
For example, a bill sent to your health
insurance company may include information
that identifies your diagnosis, and the
procedures and supplies used.
Example of use of your health information
for health care operations:
We obtain services from our insurers or
other business associates (an individual
or entity under contract with us to perform
or assist us in a function or activity that
necessitates the use or disclosure of health
information) such as quality assessment,
quality improvement, outcome evaluation,
protocol and clinical guidelines development,
training programs, credentialing, medical
transcription, medical review, legal services,
and insurance. We will share health information
about you with our insurers or other business
associates as necessary to obtain these
services. We require our insurers and other
business associates to protect the confidentiality
of your health information.
Your Health Information Rights
The health and billing records we maintain
are the physical property of the doctor’s
office. The information in it, however,
belongs to you. You have a right to:
Request
a restriction on certain uses and disclosures
of your health information by delivering
the request in writing to our office—we
are not required to grant the request
but we will comply with any request
granted;
Obtain
a paper copy of the Notice of Privacy
Practices for Protected Health Information
(“Notice”) by making a request at our
office;
Request
that you be allowed to inspect and copy
your medical record and billing record—you
may exercise this right by delivering
the request in writing to our office
using the form we provide to you upon
request;
Appeal
a denial of access to your protected
health information except in certain
circumstances;
Request
that your medical record be amended
to correct incomplete or incorrect information
by delivering a written request, including
a reason to support it, to our office
using the form we provide to you upon
request. (We are not required to make
such amendments);
File
a statement of disagreement if your
amendment is denied, and require that
the request for amendment and any denial
be attached in all future disclosures
of your protected health information;
Obtain
an accounting of disclosures of your
health information as required to be
maintained by law by delivering a written
request to our office using the form
we provide to you upon request. An accounting
will not include uses and disclosures
of information for treatment, payment,
or health care operations; disclosures
or uses made to you or made at your
request; uses or disclosures made pursuant
to an authorization signed by you; or
to family members or friends or uses
relevant to that person’s involvement
in your care or in payment for such
care; or uses or disclosures to notify
family or others responsible for your
care of your location, condition, or
your death; we may charge a cost-based
fee for more than one accounting in
a 12-month period.
Request
that confidential communication of your
health information be made by alternative
means or at an alternative location
by delivering the request in writing
to our office using the form we provide
to you upon request; and,
Revoke
authorizations that you made previously
to use or disclose information except
to the extent information or action
has already been taken by delivering
a written revocation to our office.
If
you want to exercise any of the above rights,
please contact a member of the management
staff at Arizona Associated Surgeons,
PLLC in person or in writing (see addresses
below) or call our offices at 602-258-9900
during normal business hours. Our
Privacy Officer will provide you with assistance
on the steps to take to exercise your rights. 2320 N 3rd Street Phoenix, AZ 85004Our Responsibilities
The office is required to:
Maintain
the privacy of your health information
as required by law;
Provide
you with a notice as to our duties and
privacy practices as to the information
we collect and maintain about you;
Abide
by the terms of this Notice;
Notify
you if we cannot accommodate a requested
restriction or request; and
Accommodate
your reasonable requests regarding methods
to communicate health information with
you.
We
reserve the right to amend, change, or eliminate
provisions in our privacy practices and
access practices and to enact new provisions
regarding the protected health information
we maintain. If our information practices
change, we will amend our Notice. You are
entitled to receive a revised copy of the
Notice by calling and requesting a copy
of our “Notice” or by visiting our office
and picking up a copy.
To Request Information or File
a Complaint
If you have questions, would like additional
information, want to report a problem regarding
the handling of your information, of if
you believe your privacy rights have been
violated and wish to file a written complaint
with our office, please contact
Cindy Leonard, Administrator, by calling
602-258-9900. You may
also file a complaint by mailing it or e-mailing
it to the Secretary of Health and Human
Services.
*We cannot, and will not, require you to
waive your rights under the Privacy Rule
including the right to file a complaint
with the Secretary of Health and Human Services
(HHS) as a condition of receiving treatment
from the office.
*We cannot, and will not, retaliate against
you for filing a complaint with the Secretary
of Health and Human Services. Other Disclosures and Uses We
Can Make Without Your Written Authorization
Notification of Family/Friends *Unless you object, we
may use or disclose your protected health
information to notify, or assist in notifying,
a family member, personal representative,
or other person responsible for your care,
about your location, and about your general
condition, or your death.
Communication with Family/Friends
*Using our best judgment, we may disclose
to a family member, other relative, close
personal friend, or any other person you
identify, health information relevant to
that person’s involvement in your care or
in payment for such care if you do not object
or in an emergency.
Disaster Relief *We may use and disclose
your health information to assist in disaster
relief efforts.
Employers
*We may release health information about
you to your employer if we provide health
care services to you at the request of your
employer, and the health care services are
provided either to conduct an evaluation
relating to medical surveillance of the
workplace or to evaluate whether you have
a work-related illness or injury. In such
circumstances, we will give you written
notice of such release of information to
your employer. Any other disclosures to
your employer will be made only if you execute
an authorization for the release of that
information to your employer.
Deceased Persons
*We may disclose your health information
to funeral directors, medical examiners,
or coroners consistent with applicable law
to allow them to carry out their duties.
This may be necessary, for example, to identify
a deceased person or determine the cause
of death. We may also release health information
about patients to funeral directors as necessary
for them to carry out their dutie
Organ Procurement Organizations
*Consistent with applicable law, we may
disclose your health information to organ
procurement organizations or other entities
engaged in the procurement, banking, or
transplantation of organs for the purpose
of tissue donation and transplant.
Appointment Reminders, Marketing
and Treatment Alternatives
*We may contact you to provide you with
appointment reminders, with information
about treatment alternatives, or with information
about other health-related benefits and
services that may be of interest to you.
We may also encourage you to purchase a
product or service when we see you. We will
not disclose your health information without
your written authorization.
Food and Drug Administration (FDA)
*We may disclose to the FDA your health
information relating to adverse events with
respect to food, supplements, products and
product defects, or post-marketing surveillance
information to enable product recalls, repairs,
or replacements.
Workers' Compensation
*If you are seeking compensation through
Workers’ Compensation, we may disclose your
health information to the extent necessary
to comply with laws relating to Workers’
Compensation.
Public Health
*As required by law, we may disclose your
health information to public health or legal
authorities charged with preventing or controlling
disease, injury, or disability; to report
reactions to medications or problems with
products; to notify people of recalls; to
notify a person who may have been exposed
to a disease or who is at risk for contracting
or spreading a disease or condition.
Abuse, Neglect & Domestic Violence
*We may disclose your health information
to public authorities as allowed by law
to report abuse, neglect, or domestic violence.
Sign in Sheet
*We may use and disclose your health information
by having you sign in when you arrive at
our office. We may also call
out your name when we are ready to see you.
Inmates *If you are an inmate of
a correctional institution or under the
custody of a law enforcement officer, we
may disclose to the institution or law enforcement
official health information necessary for
your health and the health and safety of
other individuals.
Law Enforcement
*We may disclose your health information
for law enforcement purposes as required
by law, such as when required by a court
order; for identification of a victim of
a crime if certain protective requirements
are met; to report a crime on our premises;
to report crime in emergencies; and other
appropriate situations permitted by law.
Health Oversight
*We may disclose your health information
to appropriate health oversight agencies
or for health oversight activities. .
Judicial/Administrative Proceedings
*We may disclose your health information
in the course of any judicial or administrative
proceeding as allowed or required by law
or as directed by a proper court order or
in response to a subpoena, with your authorization,
discovery request or other lawful process
if certain specific requirements are met.
Serious Threat
*To avert a serious threat to health or
safety, we may disclose your health information
consistent with applicable law to prevent
or lessen a serious, imminent threat to
the health or safety of a person or the
public.
For Specialized Governmental Functions
*We may disclose your health information
for specialized government functions as
authorized by law such as to Armed Forces
personnel, for national security purposes,
or to public assistance program personnel.
Other Uses
*Other uses and disclosures of your health
information besides those identified in
this Notice will be made only as otherwise
authorized by law or with your written authorization
and you may revoke the authorization as
previously provided in this Notice.
Website
*If we maintain a website that provides
information about our office, this Notice
will be on the website.
Research
*We may disclose your health information
to researchers when their research has been
approved by an institutional review board
that has reviewed the research proposal
and established protocols to ensure the
privacy of your protected health information.
Fund Raising
*We may contact you as part of a fund raising
effort. If you do not want to receive these
materials notify our Privacy Officer.
