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Please bring the following with you to Tri City Surgery Center: - page 3 / 15





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Your Rights

Although your health record is the physical property of the healthcare practitioner or Facility that compiled it, the information belongs to you. You have the following rights regarding your health information:

Right to Inspect and copy "your protected health information". You may inspect and obtain a copy of your "protected health information" that is contained in a designated record set for as long as we maintain the "protected health information". A "designated record set" contains medical and billing records and any other records that your physi- cian and the Facility use for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and "protected health information" that is subject to a law that pro- hibits access to "protected health information". Depending on the circumstances, you may have the right to have a decision to deny access reviewed.

We may deny your request to inspect or copy your "protected health information" if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.

To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on the first page of this Privacy Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request.

Please contact our Privacy Officer if you have questions about access to your medical record.

Right to Request amendments to your "protected health information". If you feel the health information we have in your record is incorrect or incomplete, you may request an amendment of the information for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebut- tal. In addition, we may deny your request if you ask us to amend information that:

  • Was not created by this Facility;

  • Is not part of the health information kept by or prepared for our Facility;

  • Is not part of the information which you would be permitted to inspect and copy; or

  • Is accurate and complete.

Requests for amendment must be in writing and must be directed to our Privacy Officer. In this written request, you must also provide a reason to support the requested amend- ments.

Right to Request a restriction on uses and disclosures of your "protected health infor- mation". You may ask us not to use or disclose certain parts of your "protected health information" for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in this Privacy Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply. For example, you could ask that (1) we not use or dis- close information about a surgery you had or (2) that certain people not be told of cer- tain information.

The facility is not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If the facility does agree to the requested restriction, we may not use or disclose your "protected health information" in violation of that restriction unless it is needed to provide emergency treatment. Under certain cir- cumstances, we may terminate our agreement to a restriction. You may request a restric- tion by contacting the Privacy Officer.

Right to Receive an accounting. You have the right to request an accounting of certain disclosures of your "protected health information" made by the facility. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclo- sures for a facility directory, to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. We are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

Federal Law (the Health Insurance Portability and Accountability Act or “HIPAA”) requires that health care providers inform patients of their rights regarding how “protected health informa- tion” (or “PHI”) may be used and disclosed to complete treatment, payment, health care oper- ations and other purposes that are permitted or required by law. This Privacy Notice describes our privacy practices as they relate to your “PHI” and as allowed by law. It also describes your rights in regard to accessing and controlling your “protected health information” in some cases. “Protected health information” means any written or verbal health information about you that includes individually identifiable data that can be used to identify the health informa- tion directly as yours. (For example, your social security number or birthdate with your name.) “PHI” refers to any and all information created or received by your health care providers that relates to your past, present or future physical or mental health care and treatment.

Right to obtain a paper copy of this notice. Upon request, we will provide a separate paper copy of this notice even if you have already received a copy of the notice or have agreed to accept this notice electronically.

Contact Person


Right to Request to receive confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accom- modation by asking you for information as to how payment will be handled or for an alter- native address or other method of contact. We will not require you to provide an explana- tion for your request. Requests must be made in writing to our Privacy Officer.





5430 Distinction Way / Prescott, AZ 86301 Tel: 928-445-1919 / Fax: 928-445-5672

5430 Distinction Way / Prescott, AZ 86301 Tel: 928-445-1919 / Fax: 928-445-5672

Our Responsibilities

The Facility is required by law to maintain the privacy of your health information and to pro- vide you with this Privacy Notice that outlines our duties and privacy practices. We are required to:

  • Keep your health information private and only disclose it when required to do so by law;

  • Explain our legal duties and privacy practices in connection with your health records;

  • Obey the rules found in the law and this notice;

  • Accommodate your reasonable request for an alternative means of

delivery or destination when sending your health information; and,

  • Inform you when we are unable to agree to a requested restriction that you have given us.

We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provi- sions effective for all future “protected health information” that we maintain. If the Facility changes its Notice, we will provide a copy of the revised Notice to current patients by send- ing a copy of the revised Notice via regular mail or through in-person contact at the next patient visit.


You have the right to express complaints to the Facility and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the facility by contacting the Facility’s Privacy Officer ver- bally or in writing, using the contact information provided on the first page of this Privacy Notice. We encourage you to express any concerns you may have regarding the privacy of your information.


The facility’s contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. If you feel that your pri- vacy rights have been violated by this facility you may submit a complaint to our Privacy Officer by calling or sending it to:

Tri City Surgery Center 5430 Distinction Way Prescott, AZ 86301 Tel: 928-445-1919

Your Health Record and "protected health information"

Each time you receive medical care from a physician, surgical center, hospital, or other healthcare provider, a record of your visit is created. This record typically includes, but is not limited to, information such as your name, age, address, a history of your illness, injury or symptoms, any test results, x-rays and laboratory work, the treatment provided to you and treatment plans devised for your care, and notes on follow-up care to be performed. How your health care information may be used and what controls you may exercise over the use of your healthcare information is described in this Privacy Notice. Any changes that you wish to make must be put in writing and sent directly to the person listed above.

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