Marietta Surgical Center
NOTICE OF PRIVACY PRACTICES
Effective Date: 02/17/2010
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact the Facility Privacy Official by dialing the main
facility number.
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically,
this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or
treatment, and billing-related information. This notice applies to all of the records of your care generated by the
facility, whether made by facility personnel, agents of the facility, or your personal doctor. Your personal
doctor may have different policies or notices regarding the doctor’s use and disclosure of your health
information created in the doctor’s office or clinic.
Our Responsibilities
We are required by law to maintain the privacy of your health information and provide you a description of our
privacy practices. We will abide by the terms of this notice.
Uses and Disclosures
How we may use and disclose Health Information about you.
The following categories describe examples of the way we use and disclose health information:
For Treatment:
We may use health information about you to provide you treatment or services. We may
disclose health information about you to doctors, nurses, technicians, medical students, or other facility
personnel who are involved in taking care of you at the facility. For example: a doctor treating you for a broken
leg may need to know if you have diabetes because diabetes may slow the healing process. Different
departments of the facility also may share health information about you in order to coordinate the different
things you may need, such as prescriptions, lab work, meals, and x-rays.
We may also provide your physician or a subsequent healthcare provider with copies of various reports that
should assist him or her in treating you once you’re discharged from this facility.
For Payment:
We may use and disclose health information about your treatment and services to bill and
collect payment from you, your insurance company or a third party payer. For example, we may need to give
your insurance company information about your surgery so they will pay us or reimburse you for the treatment.
We may also tell your health plan about treatment you are going to receive to determine whether your plan will
cover it.
For Health Care Operations:
Members of the medical staff and/or quality improvement team may use
information in your health record to assess the care and outcomes in your case and others like it. The results
will then be used to continually improve the quality of care for all patients we serve. For example, we may
combine health information about many patients to evaluate the need for new services or treatment. We may
disclose information to doctors, nurses, and other students for educational purposes. And we may combine
health information we have with that of other facilities to see where we can make improvements. We may
remove information that identifies you from this set of health information to protect your privacy.
We may also use and disclose health information:
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To business associates we have contracted with to perform the agreed upon service and billing for it;
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To remind you that you have an appointment for medical care;
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To assess your satisfaction with our services;
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To tell you about possible treatment alternatives;
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To tell you about health–related benefits or services;
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To contact you as part of fundraising efforts, unless you elect not to receive any such communications;
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To inform Funeral Directors consistent with applicable law;
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For population based activities relating to improving health or reducing health care costs; and
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For conducting training programs or reviewing competence of health care professionals.
When disclosing information, primarily appointment reminders and billing/collections efforts, we may leave
messages on your answering machine/voice mail.
Business Associates:
There are some services provided in our organization through contracts with business
associates. Examples include physician services in the emergency department and radiology, certain laboratory
tests, and a copy service we use when making copies of your health record. When these services are contracted,
we may disclose your health information to our business associates so that they can perform the job we’ve
asked them to do and bill you or your third-party payer for services rendered. To protect your health
information, however, business associates are required by federal law to appropriately safeguard your
information.
Directory:
We may include certain limited information about you in the facility directory while you are a
patient at the facility. The information may include your name, location in the facility, your general condition
(
e.g., good, fair) and your religious affiliation. This information may be provided to members of the clergy and,
except for religious affiliation, to other people who ask for you by name. If you would like to opt out of being
in the facility directory please request the Opt Out Form from the admission staff or Facility Privacy Official.
Individuals Involved in Your Care or Payment for Your Care:
We may release health information about
you to a friend or family member who is involved in your medical care or who helps pay for your care. In
addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that
your family can be notified about your condition, status and location.
Research:
We may disclose information to researchers when an institutional review board that has reviewed
the research proposal and established protocols to ensure the privacy of your health information has approved
their research and granted a waiver of the authorization requirement.
Future Communications:
We may communicate to you via newsletters, mail outs or other means regarding
treatment options, health related information, disease-management programs, wellness programs, or other
community based initiatives or activities our facility is participating in.
Organized Health Care Arrangement:
This facility and its medical staff members have organized and are
presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment,
payment and health care operations. Physicians and caregivers may have access to protected health information
in their offices to assist in reviewing past treatment as it may affect treatment at the time.
Affiliated Covered Entity: Protected health information will be made available to facility personnel at local
affiliated facilities as necessary to carry out treatment, payment and health care operations. Caregivers at other
facilities may have access to protected health information at their locations to assist in reviewing past treatment
information as it may affect treatment at this time. Please contact the Facility Privacy Official for further
information on the specific sites included in this affiliated covered entity.
As required by law
, we may also use and disclose health information for the following types of entities,
including but not limited to:
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Food and Drug Administration
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Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability
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Correctional Institutions
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Workers Compensation Agents
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Organ and Tissue Donation Organizations
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Military Command Authorities
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Health Oversight Agencies
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Funeral Directors, Coroners and Medical Directors
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National Security and Intelligence Agencies
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Protective Services for the President and Others
Law Enforcement/Legal Proceedings:
We may disclose health information for law enforcement purposes as
required by law or in response to a valid subpoena.
State-Specific Requirements:
Many states have requirements for reporting including population-based
activities relating to improving health or reducing health care costs. Some states have separate privacy laws that
may apply additional legal requirements. If the state privacy laws are more stringent than federal privacy laws,
the state law preempts the federal law.
Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it,
you have the
Right to:
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Inspect and Copy: You have the right to inspect and obtain a copy of the health information that may be
used to make decisions about your care. Usually, this includes medical and billing records, but does not
include psychotherapy notes. We may deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to health information, you may request that the denial be reviewed.
Another licensed health care professional chosen by the facility will 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.
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Amend: If you feel that 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 by or for the facility. Any request for an amendment must be sent in writing to the Facility Privacy
Official.
We may deny your request for an amendment and if this occurs, you will be notified of the reason for the
denial.
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An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of
certain disclosures we make of your health information for purposes other than treatment, payment or health
care operations where an authorization was not required.
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Request Restrictions: You have the right to request a restriction or limitation on the health 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 health 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 you had. Any request for a restriction must be sent in writing to the
Facility Privacy Official.
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We are required to agree to your request only if 1) except as otherwise required by law, the disclosure is to
your health plan and the purpose is related to payment or health care operations (and not treatment
purposes),
and 2) your information pertains solely to health care services for which you have paid in full.
For other requests, we are not required to agree.
If we do agree, we will comply with your request
unless the information is needed to provide you emergency treatment.
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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 may ask that we contact
you at work instead of your home. The facility will grant reasonable requests for confidential
communications at alternative locations and/or via alternative means only if the request is submitted in
writing and the written request includes a mailing address where the individual will receive bills for services
rendered by the facility and related correspondence regarding payment for services. Please realize, we
reserve the right to contact you by other means and at other locations if you fail to respond to any
communication from us that requires a response. We will notify you in accordance with your original
request prior to attempting to contact you by other means or at another location.
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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. Even if you have agreed to receive this notice electronically, you are
still entitled to a paper copy of this notice.
If the facility has a website you may print or view a copy of the notice by clicking on the Notice of Privacy
Practices link.
To exercise any of your rights, please obtain the required forms from the Privacy Official and submit your
request in writing.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and the revised or changed notice will be effective for information we
already have about you as well as any information we receive in the future. The current notice will be posted in
the facility and on our website and include the effective date. In addition, each time you register at or are
admitted to the facility for treatment or health care services as an inpatient or outpatient, we will offer you a
copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the facility by following
the process outlined in the facility’s Patient Rights documentation. You may also file 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 for filing a complaint.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be
made only with your written permission. If you provide us permission to use or disclose health information
about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no
longer use or disclose health information about you for the reasons 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 that we provided to you.
FACILITY PRIVACY OFFICIAL
Telephone Number: 770-422-1579
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