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.
We are required by federal law to maintain the privacy of your medical information
and to give you our Notice of Privacy Practices (this "Notice") that
describes our privacy practices, our legal duties and your rights concerning
your medical information.
This is required privacy Notice of Lakeview Surgery Center (the "Facility")
and its organized health care arrangement. This Notice applies to and will be
followed by: (1) all employees, staff, volunteers and other personnel of the
Facility, and (2) the physicians and other practitioners who are not employed
by the Facility, but who have privileges to treat patients at the Facility, and
who are members of the Facility's organized health care arrangement (see
description of the Facility's organized health care arrangement, below)
How We May Use And Disclose Your Medical Information
The Facility is permitted or required to use or disclose your medical information
without your authorization (permission) in the following situations. Some, but
not all, specific examples of the different types of disclosures have been listed.
TREATMENT. To provide you with medical treatment or services (e.g., provide information
to doctors, nurses, technicians, students or other personnel who are involved
in your care).
PAYMENT. To collect payment from you, an insurance company or a third party for
the treatment and services you receive (e.g., submitting a claim to your insurance
company).
HEALTH CARE OPERATIONS. Health care operations are the uses and disclosures of
information that are necessary to run the surgery center and to make sure that
all of our patients receive quality care. For example, we may use medical information
to review our treatment and services, and to evaluate the performance of our
staff and physicians in caring for you. We may use your name and address to send
you a newsletter or a patient satisfaction survey. We will get your written consent
before making disclosures to others outside the facility for health care operations
purposes.
APPOINTMENTS AND HEALTH CARE SERVICES. To provide you with appointment reminders
or to notify you of possible treatment alternatives or health-related benefits
or services.
FACILITY DIRECTORY. While you are a patient, your name, location in the Facility,
general condition (e.g., fair, serious, etc.), may be given to friends, family,
or a member of the clergy. You have the right to request that your name not be
included in the directory.
FRIENDS AND FAMILY. To a friend or a family member involved in your medical care
or payment for your care. If you are available, such disclosures will be made
only if we have obtained your permission, if you do not object to the disclosure
after having the opportunity, or if it is reasonable to us, based on the circumstances,
to assume you have no objection to such disclosure. If you are unavailable, incapacitated
or in an emergency situation, the Facility may disclosure limited information
to these persons if the Facility determines disclosure is in your best interest.
HEATH CARE PROVIDERS. To another health care provider involved in your treatment
in order for that provider to treat you, bill for services and conduct its health
care operations.
DISASTER RELIEF. To a public or private entity assisting in a disaster relief
effort (e.g., to notify your family about your location, condition or death).
PUBLIC HEALTH ACTIVITIES. To public health authorities for public health activities
as permitted or required by law (e.g., to report births, deaths, child abuse
and neglect, immunizations and communicable diseases).
ABUSE, NEGLECT AND DOMESTIC VIOLENCE. The Facility may notify the appropriate
government authority if it believes that you have been the victim of abuse, neglect
or domestic violence. Unless such disclosure is required by law, the Facility
will only make this disclosure if you agree or under other limited circumstances
when such disclosure is authorized by law.
HEALTH SAFETY RISKS. Under certain circumstances, when necessary to prevent a
serious threat to your health and safety or to the health and safety of the public
or another person.
ORGAN DONATIONS. To organ procurement or organ, eye or tissue transplantation
organizations, or to organ donation banks to facilitate organ or tissue donation
and transplantation.
MILITARY AND NATIONAL SECURITY. If you are a member of the armed forces, as required
by military command authorities. We may also release medical information about
foreign military personnel to the appropriate foreign military authority. The
Facility may also release your medical information to authorized federal officials
for intelligence, counterintelligence, and other authorized national security
activities.
WORKER'S COMPENSATION. To persons (e.g., employers, insurance carriers,
attorneys) in order to comply with workers' compensation laws or other
similar programs providing benefits for work-related injuries.
HEALTH OVERSIGHT ACTIVITIES. To a health oversight agency for activities authorized
by law to monitor the health care system, government programs and compliance
with civil rights laws (e.g., fraud and abuse investigations, inspections and
licensure, or disciplinary actions).
LEGAL PROCEEDINGS. If you are involved in a lawsuit or dispute, in response to
a court or administrative order. The Facility may also disclose medical information
about you in response to subpoena or other lawful process by someone else involved
in the dispute, but only if the party seeking the information demonstrates that
reasonable efforts have been made to notify you of the request or to obtain a
protective order from court.
LAW ENFORCEMENT. To law enforcement authorities for law enforcement purposes,
such as (1) in response to a court order, subpoena, warrant, summons or similar
process, (2) identify or locate suspect, fugitive, material witness or missing
person, (3) if you are a victim of a crime, but only if your agreement is obtained
or, under certain limited circumstances, if the Facility premises, and (6) in
emergency circumstances, to report a crime, the location of the crime or victims,
or the identity, description or location of the person who committed the crime.
The Facility must comply with federal and state laws in making such disclosures.
DECEASED INDIVIDUALS. To a corner or medical examiner (e.g., to identify a deceased
person or determine the cause of death), or to funeral directors as necessary
to carry out their duties.
CORRECTIONAL INSTITUTIONS. To a correctional institution where you are an inmate
or to law enforcement official who has custody of you for certain limited purposes
(e.g., to provide you with health care).
RESEARCH. Federal law permits the surgery center to use and disclose medical
information about you for research purposes, either with your specific, written
authorization or when the study has been reviewed for privacy protection by an
Institutional Review Board or Privacy Board before the research begins.
LIMITED MEDICAL INFORMATION. Limited medical information to a third party for
research purposes, public health activities and Facility health care operations.
The party to whom we disclosure the information is requires to keep it confidential.
REQUIRED BY LAW. When required to do so by federal, state or local law (e.g.,
to report child or dependent adult abuse and violent wounds).
INCIDENTAL DISCLOSURES. Occasional incidental, unintended disclosures of your
medical information which might occur during a permitted use or disclosure (e.g.,
information overheard during a discussion regarding your care with you or a member
of your family). We will take reasonable steps to avoid these types of disclosures.
BUSINESS ASSOCIATES. Some of the activities describes above are performed through
contracts with outside persons or organizations ("business associates"),
such as legal services. It may be necessary for the Facility to provide some
of your medical information to outside business associates who assist the Facility
with these activities. The Facility requires that its business associates appropriately
safeguard the privacy of your information.
ORGANIZED HEALTH CARE ARRANGEMENT. The Facility is a clinically integrated care
setting where patients receive care from Facility personnel and from independent
doctors and other practitioners who provide care to patients at the Facility
(collectively called "practitioners"). The Facility and these practitioners
need to share medical information freely to provide care to patients, and to
conduct Facility health care operations. Therefore, the Facility and the practitioners
have agreed to follow uniform information practices when using or disclosing
medical information related to inpatient or outpatient hospital services. This
arrangement is called an "organized health care arrangement" and
only covers information practices for services rendered through the Facility.
It does not cover the information practices of the practitioners in their offices
or at other care settings. It does not alter the independent status of the Facility
and the practitioners or make them jointly responsible for the clinical services
provided to them. In other words, the Facility is not responsible for (1) the
negligence (or mistakes) of the independent practitioners providing care at the
Facility; or (2) any violations of your privacy rights by the independent practitioners.
YOU AND YOUR AUTHORIZATION. Uses and disclosures medical information not covered
by this Notice or the laws that apply to us will be made only with your written
permission. If you give us permission to use or disclose medical information
about you, you may revoke (take back) that permission, we will no longer use
or disclose medical information about you for the reasons set forth in your written
authorization. We are unable to take back any disclosures we have already made
with your permission.
ACCESS TO MEDICAL INFORMATION. You may request to inspect and copy much of the
medical information we maintain about you, with some exceptions. This includes
most medical and billing records. Your request must be in writing. We may charge
a fee for the cost of copying, mailing, and other supplies associated with your
request.
REQUEST FOR RESTRICTIONS. You have the right to request a restriction on how
we use or disclose your medical information for treatment, payment, or health
care operations, or to certain family members or friends identified by you who
are involved in your care or the payment for your care.
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, if you want to prohibit disclosures to your spouse. We are
not required to agree to your request, but will notify you if we are unable to
agree.
AMENDMENT. You may request that we change part of your medical information if
you believe that it is incorrect or incomplete. You must provide a reason that
supports your request. We are not required to make all requested amendments,
but we will give each request careful consideration. If we deny your request,
we will provide you with written explanation of the reasons and your rights.
ACCOUNTING. You have the right to receive a list of certain disclosures of your
medical information made by us or our business associates. You must state a time
period for your request, which may not be longer than six years and may not include
dates before April 14, 2003. The first list in any 12-month period will be provided
to you for free; you may be charged a fee for each subsequent list you request
within the same 12-month period.
CONFIDENTIAL COMMUNICATIONS. You have the right to request that we communicate
with you about medical matters in a certain location. For example, you can ask
that we contact you only at work or only by mail. You request must specify how
or where you wish to be contacted, and we may require you to provide information
about how payment will be handled. We will agree to your request if it is reasonable.
PAPER NOTICE. You have the right to receive paper copy of this notice. You may
ask us to give you a copy of this Notice any time.
HOW TO EXERCISE THESE RIGHTS. All requests to exercise your privacy rights must
be in writing. We will follow written policies to handle requests, and we will
notify you of our decision or actions and your rights. Contact the Privacy Officer
at the contact information at the end of this Notice or to obtain request forms.
COMPLAINTS. If you believe your privacy rights have been violated, you may file
a complaint with the Facility using the contact information at the end of this
Notice. You may also submit a complaint with the Secretary of the Department
of Health and Human Services. All complaints must be submitted in writing. You
will not be penalized or retaliated against for filing a complaint.
QUESTIONS. If you have questions about this Notice, please contact the Privacy
Officer or the Executive Director of the Center at the telephone number listed.
The Facility is required to abide by the terms of the Notice currently in effect.
The Facility reserves the right to change terms of this Notice and make the new
Notice provisions effective for all of your medical information that it maintains,
including that which it created or received while prior Notice was in effect.
If the Facility makes a material change to its privacy practices, it will amend
its Notice. We will post a copy of the current Notice in the Facility. The Notice
will state the effective date.
PRIVACY OFFICER
Lakeview Surgery Center
1750 60th Street
West Des Moines, IA 50266-5733
515-273-5240
|
