HIPAA NOTICE OF PRIVACY PRACTICES SUMMIT SURGERY CENTER 7015 HWY 190 E. SERVICE ROAD, SUITE 101B COVINGTON, LA 70433 (985) 809-1997 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. Written Authorization Requirement: We may use your health information or share it with others in order to treat your condition, obtain payment for that treatment, and run our business operations. (See page 2, Treatment, Payment and Business Operations.) We generally need your written authorization for other uses and disclosures of your health information, unless an exception described in this Notice applies. Authorizing Transfer of Your Records: You may request that we transfer your records to another person or organization by completing a written authorization form. This form will specify what information is being released, to whom, and for what purpose. The authorization will have an expiration date. Canceling Your Written Authorization: If you provide us with written authorization, you may revoke, or cancel, it at any time, except to the extent that we have already relied upon it. To revoke a written authorization, please write Summit Surgery Center. Exceptions to Written Authorization Requirement: There are some situations in which we do not need your written authorization before using your health information or sharing it with others. They include: Treatment, Payment and Operations. As mentioned above, we may use your health information or share it with others in order to treat your condition, obtain payment for that treatment, and run our business operations. (See page 2). Research. Although we will generally try to obtain your written authorization before using your health information for research purposes, there may be certain situations in which we are not required to obtain your written authorization. (See page 3) De-Identified Information. We may use or disclose your health information if we have removed any information that might identify you. When all identifying information is removed, we say that the health information is “completely de-identified.” We may also use and disclose “partially de-identified” information if the person who will receive it agrees in writing to protect your privacy when using the information. (See page 3.) Incidental Disclosures. We may inadvertently use or disclose your health information despite having taken all reasonable precautions to protect the privacy and confidentiality of your health information. (See page 3). Emergencies or Public Need. We may use or disclose your health information in an emergency or for important public health needs. For example, we may share your information with Louisiana Department of Health and Hospitals who are authorized to investigate and control the spread of diseases. (See page 3.) How To Access Your Health Information: You generally have the right to inspect and get copies of your health information. (See page 4.) How To Correct Your Health Information: You have the right to request that we amend your health information if you believe it is inaccurate or incomplete. (See page 5.) How To Identify Others Who Have Received Your Health Information. You have the right to receive an “accounting of disclosures.” This is a report that identifies certain persons or organizations to which we have disclosed your health information. All disclosures are made according to the protections described in this Notice of Privacy Practices. Many routine disclosures we make (for treatment, payment, or business operations among others) will not be included in this report. However, it will identify many non-routine disclosures of your information. (See page 5.) How to Request Additional Privacy Protections: You have the right to request further restrictions on the way we use your health information or share it with others. However, we are not required to agree to the restriction you request. If we do agree with your request, we will be bound by our agreement. (See page 6.) How To Request Alternative Communications: You have the right to request that we contact you in a way that is more confidential for you, such as at home instead of at work. We will try to accommodate all reasonable requests. (See paragraph 5 on page 11.) How Someone May Act On Your Behalf: You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control the privacy of health information about minors unless the minors are permitted by law to act on their own behalf. How to Learn about Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information: Special privacy protections apply to HIV-related information, alcohol and substance abuse treatment information, mental health information, psychotherapy notes and genetic information. (See page 6). How To Obtain A Copy of This Notice: If you have not already received one, you have the right to a paper copy of this notice. You may request a paper copy at any time by asking a staff member, calling 985-809-1997, or writing to Summit Surgery Center, 7015 HWY 190 E Service Road, Suite 101b, Covington, La 70433. How To Obtain A Copy of Revised Notice: We may change our privacy practices from time to time. If we do, we will revise this notice so you will have an accurate summary of our practices. You will be able to obtain your own copy of the revised notice by, calling 985-809-1997, or writing to Summit Surgery Center, 7015 HWY 190 E Service Road, Suite 101b, Covington, La 70433. You may also ask for one at the time of your next visit. The effective date of the notice is noted in the bottom right corner of each page. We are required to abide by the terms of the notice that is currently in effect. How To File A Complaint: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the United States, Department of Health and Human Services. To file a complaint with us, please contact our Privacy Officer at 985-809-1997 HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION: Treatment, Payment, and Business Operations We may use your health information or share it with others in order to treat your condition, obtain payment for that treatment, and run our business operations. Treatment: We may share your health information with doctors or nurses who are involved in taking care of you. They may, in turn, use that information to diagnose or treat you. A doctor may share your health information with another doctor inside our hospital, or with a doctor at another hospital, to determine how to diagnose or treat you. We may also share your health information with other doctors who referred you to us and/or to whom you have been referred for further health care. Payment: We may use your health information or share it with others so that we may obtain payment for your health care services. For example, we may share information about you with your health insurance company. This will help us obtain reimbursement after we have treated you, or determine whether your health insurance will cover your treatment. We might also need to inform your health insurance company about your health condition in order to obtain pre-approval for your treatment, such as admitting you to the hospital for a particular type of surgery. Finally, we may share your information with other health care providers and payers for their payment activities. We may ask for your consent to use or disclose your health information for some or all of these payment activities. Business Operations: We may use your health information or share it with others in order to conduct our business operations. For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also use it to educate our staff or medical students and other health care students on how to improve the care they provide for you. We may also share your health information with other health care providers to help them with their business operations. Appointment Reminders, Treatment Alternatives, Benefits, and Services: In the course of providing treatment to you, we may use your health information to contact you with a reminder that you have an appointment for treatment or services at our facility. We may also use your health information in order to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you. Business Associates: We may disclose your health information to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations. For example, we may share your health information with a billing company that helps us to obtain payment from your insurance company. Another example is that we may share your health information with an insurance company, law firm, or a risk management organization in order to obtain professional advice about how to manage risk and legal liability, including insurance or legal claims. We may also share your health information with an accounting firm. If we do disclose your health information to a business associate, we will have a written contract to ensure that our business associate also protects the privacy of your health information. Electronic Communications: In order to communicate information in order to treat you, obtain payment for services, or conduct our business operations, our staff may communicate information about you via email over our network. However, you will not be contacted by email unless we have obtained your authorization to do so, or we are responding to an inquiry that you initiated via email. Research: In most cases, we will ask for your written authorization before using your health information or sharing it with others in order to conduct research. However, under some circumstances, we may use and disclose your health information without your written authorization. To do this, we are required to obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. We may also release your health information without your written authorization to people who are preparing a future research project, so long as any information identifying you does not leave our facility. In the unfortunate event of your death, we may share your health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facility any information that identifies you. Completely De-identified or Partially De-identified Information: We may use and disclose your health to identify you, so that the health information is “completely de-identified.” We may also use and disclose “partially de-identified” health information about you for certain purposes if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified health information will not contain any information that would directly identify you(such as your name, street address, social security number, phone number, fax number, electronic mail address, website address, or license number). Incidental Disclosures: While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during or as an unavoidable result of our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information. Public Need As Required By Law: We may use or disclose your health information if we are required by law to do so. We also will notify you of these uses and disclosures if notice is required by law. Public Health Activities: We may disclose your health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities. For example, we may share your health information with government officials who are responsible for controlling disease, injury, or disability. We may also disclose your health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease, if a law permits us to do so. And finally, we may release some health information about you to your employer if your employer hires us to provide you with a physical exam. This could happen if we were to discover that you have a work-related injury or disease that your employer must know about in order to comply with employment laws. Victims of Abuse, Neglect, or Domestic Violence. We may release your health information to a public health authority or other authorized governmental authority if we reasonably believe you have been a victim of abuse, neglect, or domestic violence. We will make every effort to obtain your permission before releasing this information, but in some cases we may be required or authorized to act without your permission. Health Oversight Activities: We may release your health information to government agencies authorized to conduct audits, investigations, and inspections of our facility. These government agencies monitor the operation of the health care system, government benefit programs such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws. Product Monitoring, Repair, and Recall: We may disclose your health information to a person or company that is regulated by the Food and Drug Administration for the purpose of: (1) reporting or tracking product defects or problems; (2) repairing, replacing, or recalling defective or dangerous products; or (3) monitoring the performance of a product after it has been approved for use by the general public. Lawsuits and Disputes: We may disclose your health information if we are ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute. Law Enforcement: We may disclose your health information to law enforcement officials for the following reasons: To comply with court orders or laws that we are required to follow: To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person; If you have been the victim of a crime and we determine that: (1) we have been unable to obtain your agreement because of an emergency or your incapacity; (2) law enforcement officials need this information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these officers is in your best interests; If we suspect that your death resulted from criminal conduct; If necessary to report a crime that occurred on our property; or If necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical technicians at the scene of a crime). To Avert A Serious And Imminent Threat to Health or Safety: We may use your health information or share it with others when necessary to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public. In such cases, we will only share your information with someone able to help prevent the threat. We may also disclose your health information to law enforcement officers: 1) if you tell us that you participated in a violent crime that may have caused serious physical harm to another person (unless you admitted that fact while in counseling), or 2) if we determine that you escaped from lawful custody (such as a prison or mental health institution). National Security and Intelligence Activities or Protective Services: We may disclose your health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials. Military and Veterans: If you are in the Armed Forces, we may disclose health information about you to appropriate military command authorities for activities they deem necessary to carry out their military mission. We may also release health information about foreign military personnel to the appropriate foreign military authority. Workers’ Compensation: We may disclose your health information for workers’ compensation or similar programs that provide benefits for work-related injuries. Coroners, Medical Examiners, and Funeral Directors: In the unfortunate event of your death, we may disclose your health information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release this information to funeral directors as necessary to carry out their duties. Organ and Tissue Donation: In the unfortunate event of your death, we may disclose your health information to organizations that procure or store organs, eyes, or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws. SPECIAL PROTECTIONS FOR CERTAIN TYPES OF INFORMATION: Some kinds of information are considered so sensitive that state or federal laws provide special protections for them. That means that we may have to get your written authorization to disclose (and sometimes to use) these types of information for treatment, payment or health care operations. We may also be required to obtain your written authorization before we can use or disclose these types of information to the government, to law enforcement officers, to courts, to researchers, and to others in the ways that we have explained above in this Notice. The following types of information are subject to special protections under state or federal law: Information about genetic testing or the results of genetic testing Information about HIV testing or test results Information about substance abuse rehabilitation treatment Information about mental health treatment or status Information contained in certain confidential psychotherapy notes Your written authorization will generally be required before we may disclose these types of information. However, some exceptions apply. YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION: We want you to know that you have the following rights to access and control your health information. These rights are important because they will help you make sure that the health information we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you about your medical matters. To exercise these rights, please submit your requests to Summit Surgery Center front desk. Your Right To Inspect and Obtain Copies of Your Records: You have the right to inspect and obtain a copy of any of your health information that may be used to make decisions about you and your treatment for as long as we maintain this information in our records. This includes medical and billing records. How to Make Your Request: To inspect or obtain a copy of your health information, please submit your request in writing to Summit Surgery Center. Cost: If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies we use to fulfill your request. Response Time: We will respond to your request for inspection of records within 10 days. We ordinarily will respond to requests for copies within 30 days. If we need additional time to respond to a request for copies, we will notify you in writing within the time frame above to explain the reason for the delay and when you can expect to have a final answer to your request. If Your Request is Denied: Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If we do, we will provide you with a summary of the information instead. We will also provide a written notice that explains our reasons for providing only a summary and a complete description of your rights to have that decision reviewed and how you can exercise those rights. The notice will also include information on how to file a complaint about these issues with us or with the Secretary of the Department of Health and Human Services. If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we cannot let you inspect or copy. Your Right To Amend Records: If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept in our records. How to Make Your Request: To request an amendment, please write to the Director of Nursing at Summit Surgery Center Your request should include the reasons why you think we should make the amendment. Response Time: Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request. If Your Request is Denied: If we deny a part of or your entire request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement, which we will include in your records. We will also include information on how to file a complaint with us or with the Secretary of the United States Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you. Your Right To An Accounting Of Disclosures: After April 14, 2003, you have a right to request an “accounting of disclosures.” This report identifies certain other persons or organizations to whom we have disclosed your health information. The accounting does not include routine disclosures made for treatment, payment and operations or pursuant to a patient authorization. It also does not include certain other disclosures set forth in Section 3.d. below. How to Make Your Request: To request an accounting of disclosures, please write directly to your doctor’s office. Your request must state a time period within the past six years (but after April 14, 2003) for the disclosures you want us to include. For example, you may request a list of the disclosures that we made between January 1, 2011 and January 1, 2012. Cost: You have a right to receive one accounting within every 12-month period for free. However, we may charge you for the cost of providing any additional accounting in that same 12-month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred. Response Time: Ordinarily we will respond to your request for an accounting within 60 days. If we need additional time to prepare the accounting you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting. In rare cases, we may have to delay providing you with the accounting without notifying you because a law enforcement official or government agency has asked us to do so. What is Not Included in the Accounting of Disclosures: An accounting of disclosures does not describe every instance in which your health information has been shared. Specifically, an accounting of disclosures does not include information about the following disclosures: Disclosures we made to you or your personal representative; Disclosures we made pursuant to your written authorization; Disclosures we made for treatment, payment or business operations; Disclosures made to your friends and family involved in your care or payment for your care; Disclosures that were incidental to permissible uses and disclosures of your health information (for example, when information is overheard by another patient passing by); Disclosures for purposes of research, public health, or our business operations of limited portions of your health information that do not directly identify you; Disclosures made to federal officials for national security and intelligence activities; Disclosures made before April 14, 2003. Your Right To Request Additional Privacy Protections: You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, or run our business operations. You may also request that we limit how we disclose information about you to family or friends involved in your care. For example, you could request that we not disclose information about a surgery you had. How to Make Your Request: To request restrictions, please write to Summit Surgery Center. Your request should include (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply. We are Not Required to Agree: We are not required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction. Your Right To Request Alternative Communications: You have the right to request that we communicate with you about your medical matters in a more confidential way by requesting that we communicate with you by alternative means or at alternative locations. For example, you may ask that we contact you at home instead of at work. How to Make Your Request: To request alternative communications, please write directly to Summit Surgery Center We will not ask you the reason for your request, and we will try to accommodate all reasonable requests. Please specify in your request how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location.