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Please bring the following with you to Tri City Surgery Center: - page 4 / 15





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Uses and Disclosures of "protected health information"

The Facility may use your "protected health information" for purposes of providing treat- ment, obtaining payment for treatment, and conducting health care operations. Your "pro- tected health information" may be used or disclosed only for these purposes unless the Facility has obtained your authorization for the use or disclosure or it is otherwise permit- ted by the HIPAA privacy regulations or state law. Disclosures of your "protected health information" for the purposes described in this Privacy Notice may be made in writing, oral- ly, or by facsimile.

Treatment. We may use and disclose your "protected health information" to provide, coor- dinate, or manage your health care and any related services. This includes the coordina- tion or management of your health care with anesthesia providers, nurses, technicians, lab personnel, radiology personnel, other facility staff involved in your care or a third party for treatment purposes. For example, we may disclose your "protected health information" to a laboratory to order pre-operative tests or to a pharmacy to fill a prescription. We may also disclose “protected health information” to health care providers who may be treating you or consulting with the Facility with respect to your care. In some cases, we may also disclose your “protected health information” to people outside the Facility who may be involved in your medical care while you are in the Facility, such as your personal or refer- ring physician; or after you leave the Facility, such as other physicians, health care work- ers, family members, or others who care for you or who may provide services that are part of your care.

Payment. Your "protected health information" will be used, as needed, to obtain payment for the services that we provide. This may include certain communications to your health insurance company to get approval for the procedure that we have scheduled. For exam- ple, we may need to disclose information to your health insurance company to get prior approval for the surgery. We may also disclose "protected health information" to your health insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. In order to get payment for the ser- vices we provide to you, we may also need to disclose your "protected health information" to your health insurance company to demonstrate the medical necessity of the services or, as required by your insurance company, for utilization review. We may also disclose patient information to another provider involved in your care for the other provider’s pay- ment activities. This may include disclosure of demographic information to anesthesia care providers for payment of their services.

Operations. We may use or disclose your "protected health information", as necessary, for our own health care operations to facilitate the function of the Facility and to provide qual- ity care to all patients. Health care operations include such activities as: quality assess- ment and improvement activities, employee review activities, training programs including those in which students, trainees, or practitioners in health care learn under supervision, accreditation, certification, licensing or credentialing activities, review and auditing, includ- ing compliance reviews, medical reviews, legal services and maintaining compliance pro- grams, and business management and general administrative activities.

In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.

Other uses and disclosures for health care operations may include:

  • Care management

  • Protocol Development

  • Training, accreditation, certification, licensing, credentialing or other related activities

  • Activities related to improving health care or reducing health care costs

  • Underwriting and other insurance related activities

  • Medical review and auditing

  • Business planning and/or development

  • Internal grievance resolution

Appointment Reminders. We may use or disclose your "protected health information" to contact you, a family member or friend involved in your health care or as authorized by you as a reminder that you have an appointment for treatment or medical care at our facility. We may also leave a message on your answering machine / voicemail system or send you mail unless you tell us not to.


Treatment Alternatives. We may use or disclose your "protected health information" to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health Related Benefits and Services. We may use or disclose your "protected health information" to tell you about health related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment of Your Care. We may use or disclose your “protected health information” to a friend or family member who is involved in your med- ical care and/or present during your medical care and treatment in our Facility. We may also give information to someone assisting you in the payment for your care. We may also tell your family or friends that you are in the Facility at the time of your care, or that infor- mation may be communicated to an entity assisting in a disaster relief effort in order to communicate your condition status and location to your family. If you want any of this information restricted you must communicate that to us using the appropriate procedure which can be explained to you by Facility staff.

Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one procedure to those who received another procedure for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with the patients’ need for pri- vacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process, but we may, however, disclose health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific health needs, so long as the health information they review does not leave the hospital. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the Facility.

As Required By Law. We will disclose health information about you when required to do so by federal, state, or local law. This may include reporting of communicable diseases, wounds, abuse, disease/trauma registries, health oversight matters and other public poli- cy requirements. We may be required to report this information without your permission.

To Avert a Serious Threat to Health or Safety. We may use and disclose health informa- tion for the following public activities and purposes:

  • To prevent, control, or report disease, injury or disability as permitted by law.

  • To report vital events such as birth or death as permitted or required by law.

  • To conduct public health surveillance, investigations and interventions as permitted or required by law.

  • To collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.

  • To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.

  • To report to an employer information about an individual who is a member of the workforce as legally permitted or required.

To Conduct Health Oversight Activities. We may disclose your "protected health infor- mation" to a health oversight agency (i.e. State Health Department) for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspec- tions; licensure or disciplinary actions; or other activities necessary for appropriate over- sight as authorized by law. We will not disclose your health information under this author- ity if you are the subject of an investigation and your health information is not directly relat- ed to your receipt of health care or public benefits.


In Connection With Judicial And Administrative Proceedings. We may disclose your "protected health information" in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order. In certain circumstances, we may disclose your "protected health informa- tion" in response to a subpoena to the extent authorized by state law if we receive satis- factory assurances that you have been notified of the request or that an effort was made to secure a protective order.

For Law Enforcement Purposes. We may disclose your "protected health information" to a law enforcement official for law enforcement purposes as follows:

  • As required by law for reporting of certain types of wounds or other physical injuries.

  • Pursuant to court order, court-ordered warrant, subpoena, summons or similar process.

  • For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.

  • Under certain limited circumstances, when you are the victim of a crime.

  • To a law enforcement official if the facility has a suspicion that your health condition was the result of criminal conduct.

  • In an emergency to report a crime.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the insti- tution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

To Coroners, Funeral Directors, and for Organ Donation. We may disclose "protected health information" to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose "protected health information" to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. We may disclose such information in reasonable anticipation of death. "Protected health information" may be used and disclosed for cadaveric organ, eye or tis- sue donation purposes.

For Specified Government Functions. In certain circumstances, federal regulations authorize the facility to use or disclose your "protected health information" to facilitate specified government functions relating to military and veterans activities, national secu- rity and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situ- ations.

For Worker's Compensation. The Facility may release your health information to com- ply with worker's compensation laws or similar programs. Many HIPAA Privacy provi- sions do not apply to health care delivered under Workers’ Compensation coverage or to the health information generated as part of that care and treatment.

Employers. We may release health information about you to your employer if we pro- vide health care services to you at the request of your employer, and the health care ser- vices are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such cir- cumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.

Uses and Disclosures which you Authorize. Other than as stated above, we will not dis- close your health information without your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon your past authorization and have already released your "personal health information".

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