THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
“Protected health information” (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health condition and related healthcare services. Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your healthcare bills, to support the operation of the physician’s practice, and any other use required by law.
• Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
• Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
• Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.
There are uses and disclosures you have the opportunity to object or opt out of.
• Unless you object, we may disclose to a member of your family, a relative, or close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine it is in your best interest based on our professional judgment.
• We may disclose your Protected Health Information to disaster relief organizations that seek your PHI to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so.
The following uses and disclosures of your PHI will be made only with your written authorization:
- Uses and disclosures of PHI for marketing purposes; and
- Disclosures that constitute a sale of your PHI.
- Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose PHI under the authorization. However, any disclosure we made in reliance on your authorization before you revoked it will not be affected by the revocation.
Patient Rights Regarding Protected Health Information
• Right to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make decisions about your care or payment for your care. We have up to 30 days to make your PHI available to you under Nevada Law and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.
• Right to a Summary or Explanation. We can also provide you with a summary of your PHI, rather than the entire record, or we can provide you with an explanation of the PHI which has been provided to you, so long as you agree to this alternative form and pay the associated fees.
• Right to an Electronic Copy of Electronic Medical Records. Because your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request, your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
• Right to be notified of a Breach. You have the right to be notified upon a breach of any of your unsecured PHI.
• Right to Request Amendments. If you feel that the PHI we have 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 us. A request for amendment must be made in writing to the Privacy Officer at the address provided at the end of this notice and it must tell us the reason you for your request. In certain cases, we may deny your request for an amendment. If we deny your request for an 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 rebuttal.
• Right to an Accounting of Disclosures. You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures we made of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this notice. It excludes disclosures we may have made to you, for a resident directory, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations. Additionally, limitations are different for electronic health records. The first accounting of disclosures you request within any 12-month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting. We will tell what the costs are, and you may choose to withdraw or modify your request before the costs are incurred.
• Right to Request Restrictions. You have right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. To request a restriction on who may have access to your PHI, you must submit a written request to the Privacy Officer. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request, unless you are asking us to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.
• Out-of-Pocket Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
• Right to Request Confidential Communications. You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you. We will accommodate all reasonable requests. We will not ask you the reason for your request.
• Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice, even if you have agreed to receive this notice electronically. You may request a copy of this notice at any time.
To exercise your rights described in this notice, send your request, in writing, to our Privacy Officer at the address listed at the end of this notice. We may ask you to fill out a form that we will supply. To exercise your right to inspect or copy your PHI, you may also contact your physician directly. To get a paper copy of this notice, contact our Privacy Officer by phone or mail.
Changes to this Notice
We reserve the right to change this notice. We reserve the right to make the changed notice effective for PHI we already have as well as for any PHI we create or receive in the future. A copy of our current notice is posted in our office and on our website.
You may file a complaint with SpineNevada or with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated.
• To file a complaint with our office, contact our Privacy Officer at the address listed at the end of this notice. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of a suspected violation. There will be no retaliation against you for filing a complaint.
• To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201, or call (202) 619-0257 (or toll-free at (877) 696-6775), or go to the website of the Office for Civil Rights, www.hhs.gov/ocr/hipaa/
, for more information. There will be no retaliation against you for filing a complaint.
Alaska Surgical Group
3851 Piper Street, Suite U230
Anchorage, AK 99508