Effective Date: January 1, 2019
This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this Notice carefully.
We care about our patient’s privacy and strive to protect the confidentiality of your medical information at Saint Clare Surgery Center. Federal legislation requires that we issue this official notice of our privacy practices. You have the right to the confidentiality of your medical information, and Saint Clare Surgery Center is required by law to maintain the privacy of that protected health information. This practice is required to abide by the terms of the Notice of Privacy Practices currently in effect, and to provide notice of its legal duties and privacy practices with respect to protected health information. If you have any questions about this Notice, please contact the Privacy Officer at Saint Clare Surgery Center.
Who Will Follow This Notice
Any health care professional authorized to enter information into your medical record, all employees, staff and other personnel at this practice who may need access to your information must abide by this Notice. All subsidiaries, Business associates (e.g. a billing service), sites and locations of this practice my share medical information with each other for treatment, payment purposes or health care operations described in this Notice. Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be share.
How We May Use & Disclose Medical Information About You
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories:
We may use medical information about you to provide you with medical treatment or services. Example: In treating you for a specific condition, we may need to know if you have allergies that could influence which medications we prescribe for the treatment process.
We may use and disclose medical information about you so that the treatment and services you received from us may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to send your protected health information, such as your name, address, office visit date, and codes identifying your diagnosis and treatment to your insurance company for payment.
For Health care Operations
We may use and disclose medical information about you for health care operations to assure that your received quality care. Example: We may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you.
Persons Involved in Your Care
We may disclose medical information about you to a relative, close personal friend or any other person you identify if that person is involved in your care and the information is relevant to your care. Example: if the patient is a minor, we may disclose medical information about the minor to a parent, guardian or other person responsible for the minor except in limited circumstances.
Required by Law
We will use and disclose medical information about you whenever we are required by law to do so. There are many state and federal laws that require us to use and disclose medical information. Example: state law requires us to report gunshot wounds and other injuries to the police and to report known or suspected child abuse or neglect to the Department of Social Services. We will comply with those state laws and with all other applicable laws.
National Priority Uses and Disclosures Made Without your Consent or Authorization
When permitted by law, we may use or disclose medical information about you without your permission for activities that are recognized as “national priorities”. The government has determined that under certain circumstances, it is so important to disclose medical information that is acceptable to disclose medical information without the individual’s permission. Some examples include:
- Law enforcement or correctional institutions, such as required during an investigation by a correctional institution of an inmate,
- Threat to health or safety, such as to avert or lessen a serious threat,
- Workers’ compensation or similar programs, such as for the processing of claims,
- Abuse, neglect or domestic violence, such as if you are an adult and we reasonably believe you may be a victim of abuse,
- Health oversight activities, such as to a government agency to investigate possible insurance fraud,
- Court or legal proceedings, such as if a judge orders us to do so,
- Research organizations, such as if the organization has satisfied certain conditions about protecting the privacy of medical information,
- Coroner or medical examiner for identification of a body,
- Public health activities, such as required by the US Food and Drug Administration,
- Certain government functions, such as using or disclosing for government functions like military and veterans’ activities and national security and intelligence activities.
Uses and Disclosures of Protected Health Information Requiring Your Written Authorization
The following uses and disclosures of medical information about you will only be made with your authorization (signed permission) from you or your personal representative:
- Uses and disclosures for marketing purposes
- Uses and disclosures that constitute the sales of medical information about you
- Most uses and disclosures of psychotherapy notes, if we maintain psychotherapy notes
- Any other use and disclosures not described in this Notice
You have several rights with respect to medical information about you. This section of the Notice will briefly mention each of these rights. If you would like to know more about your rights, please contact our Privacy Officer
Other 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 authorization. If you give us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will thereafter no longer use or disclose medical information about you for the reason covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care we have provided you.
Your Individual rights Regarding your Medical Information
You have the following rights regarding medical information we maintain about you:
- To inspect and obtain a copy of medical information that may be used to make decisions about your care. Usually, this includes medical, laboratory and billing records, but may not include all psychotherapy notes.
- Request in writing to inspect and copy medical information that may be used to make decisions about you.
- We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that another licensed health care professional chosen by us review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend
If you feel that medical information we have about you is incorrect or incomplete, you have the right to request in writing that we amend the information by providing the reason for the amendment. You have the right to request an amendment for as long as the information is kept by or for us.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the medical information kept by or for us;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
If we deny your request for an amendment, we will do so in writing and you have the right to file a statement of disagreement.
Right to an Accounting of Disclosure
You have the right to request in writing an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you to others, excepting disclosures relating to treatment, payment and health care operations.
Your request must state a time period which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, or; electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Receive Notice of Breaches
You have the right to receive notifications of breaches of your unsecured medical information.
Right to Request 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 only contact you at work or by mail.
Please advise the registration representative how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time by requesting a copy from the registration representative.
Changes to This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our facilities and this Notice will be available on the Saint Clare Surgery Center website. In addition, each time you register at or are admitted as a patient, you have the right to request a copy of the current Notice in effect.
Right to Request Restrictions, in General
You have the right to request in writing a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery performed.
- We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Restrictions to a Health Plan
You have the right to request in writing a restriction or limitation on the medical information we disclose about you to a health plan for purposes of payment or health care operations if you, or someone on your behalf, has paid for the health care item or service out of pocket in full.
- If you, or someone on your behalf, have paid for the health care item or service out of pocket in full, we are required to agree to your request if the disclosure to the health plan relates to payment or health care operations.
In your request, you must tell us (1) the name of the health plan that is not to receive the disclosure; (2) what health care item or service you wish to restrict from disclosure; (3) the location in which the health care item or service was provided to you; and (4) the date the health care item or service was provided to you.
Questions About This Notice or Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at Saint Clare Surgery Center or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint.
To file a written complaint with us, you may bring your complaint directly to our Privacy Officer.
To file a written complaint with the federal government, please use the following contact information:
Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Ave, S.W.
Room 509F, HHH building
Washington, D.C. 20201