notice of privacy practices
ERIE SHORES SURGERY CENTER
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices apply to the Erie Shores Surgery Center (“ESSC”) and each of its subsidiaries, affiliates, and entities managed or controlled by ESSC, including the business office and its employees. All of the entities will share the personal health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law. By law, ESSC is required to maintain the privacy of its patients’ personal health information and to provide patients with notice of its legal duties and privacy practices with respect to personal health information. ESSC is required to abide by the terms of this Notice of Privacy Practices for as long as it remains in effect. ESSC reserves the right to change the terms of this Notice of Privacy Practices as necessary and required by law and to make a new Notice of Privacy Practices effective for all personal health information maintained by ESSC. ESSC is also required to inform you that there may be a provision of Ohio law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”). A copy of any revised Notice of Privacy Practices or information pertaining to a specific Ohio law may be obtained by mailing a request to the Administrator, Erie Shores Surgery Center, 2800 Hayes Avenue, Building E, Sandusky, OH 44870.
USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION
Authorization and Consent: Except as outlined below, ESSC will not use or disclose your personal health information for any purpose other than treatment, payment, or health care operations unless you have signed a form authorizing the additional use or disclosure. You have the right to revoke such authorization in writing unless we have taken any action in reliance on such authorization.
Uses and Disclosures for Treatment: With your agreement, ESSC will make use and disclosures of your personal health information as necessary for your treatment. Doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history, etc. Your personal health information may be subject to electronic disclosures. By signing this Notice of Privacy Practices, you acknowledge and agree to such electronic disclosures.
Uses and Disclosures for Payment: With your agreement, ESSC will make uses and disclosures of your personal health information as necessary for payment purposes. During the normal course of business operations, ESSC may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. ESSC may use your information to prepare a bill to send to you or to the person responsible for your payment.
Uses and Disclosures for Health Care Operations: With your agreement, ESSC will use and disclose your personal health information as necessary, and as permitted by law, for ESSC’s health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, ESSC may use and disclose your personal health information for purposes of improving clinical treatment and patient care.
Individuals Involved in Your Care: With your written agreement, ESSC may, from time to time, disclose your personal health information to designated family, friends, and others who are involved in your care or payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and ESSC determines that a limited disclosure may be in your best interest, ESSC may share limited personal health information with involved individuals without your approval. ESSC may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.
Business Associates: Certain aspects and components of ESSC’s services are performed through contracts with outside persons or organizations, such as auditing, accreditation and licensing, outcomes data collection, legal services, etc. At times it may be necessary for ESSC to provide your personal health information to one or more of these outside persons or organizations who assist ESSC with its health care operations. In all cases, ESSC requires these business associates to appropriately safeguard the privacy of your information.
Appointments and Services: ESSC may contact you to provide appointment reminders or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request, and ESSC will accommodate, to the best of its ability, reasonable requests by you to receive communications regarding your personal health information from ESSC by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, ESSC will accommodate these reasonable requests. You also have the right to request that ESSC not send you any future marketing materials and ESSC will use its best efforts to honor such request. You may make your requests by sending your name and address to the Administrator, Erie Shores Surgery Center, 2800 Hayes Avenue, Building E, Sandusky, OH 44870.
Research: In limited circumstances, ESSC may use and disclose your personal health information for research purposes. In all cases where your specific authorization is not obtained, your privacy will be protected by the strict confidentiality requirements applied by an Institutional Review Board, which oversees the research, or by representations of the researchers that limit their use and disclosure of patient information.
Other Uses and Disclosures: ESSC is permitted and/or required by law to make certain other uses and disclosures of your personal health information without your consent or authorization for the following:
- any purpose required by law.
- public health activities, such as required reporting of disease, injury, birth, and death, or required public health investigations.
- suspected child abuse or neglect; or a belief that you are a victim of abuse, neglect, or domestic violence.
- to the Food and Drug Administration to report adverse events, product defects, or to participate in product recalls.
- to your employer when ESSC has provided health care to you at the request of your employer.
- to a government oversight agency conducting audits, investigations, or civil or criminal proceedings.
- court or administrative ordered subpoena or discovery requests.
- to law enforcement officials as required by law to report wounds, injuries, and crimes.
- to coroners and/or funeral directors, as consistent with the law.
- if necessary to arrange an organ or tissue donation from you or a transplant for you.
- if you are a member of the military, ESSC may also release your personal health information for national security or intelligence activities.
- to workers’ compensation agencies for workers’ compensation benefit determination.<strong
RIGHTS THAT YOU HAVE REGARDING YOUR PERSONAL HEALTH INFORMATION:
Access to Your Personal Health Information: You have the right to copy and/or inspect much of the personal health information that ESSC retains on your behalf. ESSC must make personal health information available in electronic format upon request and where available. All requests for access must be made in writing and signed by you or your legal representative. You may obtain a “Patient Access to Health Information Form” from the front office person or the Administrator.
Amendments to Your Personal Health Information: You have the right to request, in writing, that personal health information maintained by ESSC about you be amended or corrected. ESSC is not obligated to make all requested amendments but will give each request careful consideration. All amendment requests must be in writing, signed by you or your legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, ESSC may notify others who work with it if ESSC believes that such notification is necessary. You may obtain a “Request for Amendment Form” from the front office person or the Administrator.
Accounting for Disclosures of Your Personal Health Information: You have the right to receive an accounting of certain disclosures made by ESSC of your personal health information after April 14, 2003. Where electronic health records are used, you have the right to an accounting of disclosures made for uses and disclosures of your personal health information for treatment purposes, payment purposes, and health care operations, such as those required under law, for a 3-year period. Your right to accounting includes disclosures made by Business Associates. Requests must be made in writing and signed by you or your legal representative. “Request for an Accounting Forms” are available from the front office person or the Administrator. The first accounting in any twelve (12) month period is free; you will be charged a fee for each subsequent accounting you request within the same twelve (12) month period. You will be notified of the fee at the time of your request.
Restrictions on Use and Disclosure of Your Personal Health Information: You have the right to request restrictions on uses and disclosures of your personal health information for treatment, payment, or health care operations. You also have the right to request restrictions to your health plan when you intend to pay out of pocket, in full, for items or services provided by ESSC. ESSC is not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate. ESSC retains the right to terminate an agreed-to restriction if it believes such termination is appropriate. In the event of a termination by ESSC, it will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction by sending such termination notice to the Administrator.
Complaints: If you believe your privacy rights have been violated, you can file a complaint, in writing, with the HIPAA Privacy Officer, Erie Shores Surgery Center, 2800 Hayes Avenue, Building E, Sandusky, OH 44870. “Reporting Forms for Privacy Violations” are available from the front office person or the Administrator. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within one hundred and eighty (180) days of a violation of your rights. There will be no retaliation for filing a complaint.
FOR FURTHER INFORMATION:
If you have questions or need further assistance regarding this Notice, you may contact the:
Erie Shores Surgery Center, LLC
2800 Hayes Avenue, Building E
Sandusky, OH 44870