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.
Who Presents this Notice
This Notice describes the privacy practices of Lone Star Endoscopy Center, LLC (the “Center”) and members of its workforce, as well as the physician members of the medical staff and allied health professionals who practice at the Center. The Center and the individual health care providers together are sometimes called “the Center and Health Professionals” in this Notice. While the Center and Health Professionals engage in many joint activities and provide services in a clinically integrated care setting, the Center and Health Professionals each are separate legal entities. This Notice applies to services furnished to you at Lone Star Endoscopy Center, LLC as a Center outpatient or any other services provided to you in a Center-affiliated program involving the use or disclosure of your health information.
The Center and Health Professionals each are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of legal duties and privacy practices with respect to your Protected Health Information. The Center and Health Professionals use computerized systems that may subject your Protected Health Information to electronic disclosure for purposes of treatment, payment and/or health care operations as described below. When the Center and Health Professionals use or disclose your Protected Health Information, the Center and Health Professionals are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
Permissible Uses and Disclosures Without Your Written Authorization
In certain situations your written authorization must be obtained in order to use and/or disclose your PHI. However, the Center and Health Professionals do not need any type of authorization from you for the following uses and disclosures:
Uses and Disclosures for Treatment, Payment and Health Care Operations. Your PHI, may be used and disclosed to treat you, obtain payment for services provided to you and conduct “health care operations” as detailed below:
Use or Disclosure for Directory of Individuals in the Center. The Center may include your name, location in the Center, general health condition and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory. Information in the directory may be disclosed to anyone who asks for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or minister, even if they do not ask for you by name. If you do not wish to be included in the facility directory, you will be given an opportunity to object at the time of admission.
Disclosure to Relatives, Close Friends and Other Caregivers. Your PHI may be disclosed to a family member, other relative, a close personal friend or any other person identified by you who is involved in your health care or helps pay for your care. If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, the Center and/or Health Professionals may exercise professional judgment to determine whether a disclosure is in your best interests. If information is disclosed to a family member, other relative or a close personal friend, the Center and/or Health Professionals would disclose only information believed to be directly relevant to the person’s involvement with your health care or payment related to your health care. Your PHI also may be disclosed in order to notify (or assist in notifying) such persons of your location or general condition.
Public Health Activities. Your PHI may be disclosed for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
Victims of Abuse, Neglect or Domestic Violence. Your PHI may be disclosed to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence if there is a reasonable belief that you are a victim of abuse, neglect or domestic violence.
Health Oversight Activities. Your PHI may be disclosed to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
Judicial and Administrative Proceedings. Your PHI may be disclosed in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
Law Enforcement Officials. Your PHI may be disclosed to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena. For example, your PHI may be disclosed to identify or locate a suspect, fugitive, material witness, or missing person or to report a crime or criminal conduct at the facility.
Correctional Institution. Your PHI may be disclosed to a correctional institution if you are an inmate in a correctional institution and if the correctional institution or law enforcement authority makes certain requests to us.
Business Associates. Your PHI may be disclosed to business associates or third parties that the Center and Health Professionals have contracted with to perform agreed upon services.
Decedents. Your PHI may be disclosed to a coroner or medical examiner as authorized by law.
Organ and Tissue Procurement. Your PHI may be disclosed to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
Research. Your PHI may be used or disclosed without your consent or authorization if an Institutional Review Board approves a waiver of authorization for disclosure.
Health or Safety. Your PHI may be used or disclosed to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
Specialized Government Functions. Your PHI may be disclosed to units of the government with special functions, such as the U.S. military, the U.S. Department of State under certain circumstances such as the Secret Service or NSA to protect, for example, the country or the President.
Workers’ Compensation. Your PHI may be disclosed as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.
As Required by Law. Your PHI may be used and disclosed when required to do so by any other law not already referred to in the preceding categories; such as required by the FDA, to monitor the safety of a medical device.
Appointment Reminders. Your PHI may be used to tell or remind you about appointments.
Fundraising. Your PHI may be used to contact you as a part of fundraising efforts, unless you elect not to receive this type of information.
USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION
Use or Disclosure with Your Authorization. For any purpose other than the ones described above, your PHI may be used or disclosed only when you provide your written authorization on an authorization form (“Your Authorization”). For instance, you will need to execute an authorization form before your PHI can be sent to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
Marketing. Your written authorization (“Your Marketing Authorization”) also must be obtained prior to using your PHI to send you any marketing materials. (However, marketing materials can be provided to you in a face-to-face encounter without obtaining Your Marketing Authorization. The Center and/or Health Professionals are also permitted to give you a promotional gift of nominal value, if they so choose, without obtaining Your Marketing Authorization). The Center and/or Health Professionals may communicate with you in a face-to-face encounter about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.
In addition, the Center and/or Health Professionals may send you treatment communications, unless you elect not to receive this type of communication, for which the Center and/or Health Professionals may receive financial remuneration.
Sale of PHI. The Center and Health Professionals will not disclose your PHI without your authorization in exchange for direct or indirect payment except in limited circumstances permitted by law. These circumstances include public health activities; research; treatment of the individual; sale, transfer, merger or consolidation of the Center; services provided by a business associate, pursuant to a business associate agreement; providing an individual with a copy of their PHI; and other purposes deemed necessary and appropriate by Health and Human Services (HHS).
Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental illness, mental retardation and developmental disabilities; (3) is about alcohol or drug abuse or addiction; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about communicable disease(s), including venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult; or (9) is about sexual assault. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization is required.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Right to Request Additional Restrictions. You may request restrictions on the use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While all requests for additional restrictions will be carefully considered, the Center and Health Professionals are not required to agree to these requested restrictions.
You may also request to restrict disclosures of your PHI to your health plan for payment and healthcare operations purposes (and not for treatment) if the disclosure pertains to a healthcare item or service for which you paid out-of-pocket in full. The Center and Health Professionals must agree to abide by the restriction to your health plan EXCEPT when the disclosure is required by law.
If you wish to request additional restrictions, please obtain a request form from the Center’s Management Office and submit the completed form to the Center’s Management Office. A written response will be sent to you.
Right to Receive Confidential Communications. You may request, and the Center and Health Professionals will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your PHI, except to the extent that the Center and/or Health Professionals have taken action in reliance upon it, by delivering a written revocation statement to the Center’s Management Office identified below.
Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by the Center and Health Professionals in order to inspect and request copies of the records. Under limited circumstances, you may be denied access to a portion of your records. If you desire access to your records, please obtain a record request form from the Center’s Management Office and submit the completed form to the Center’s Management Office. If you request copies of paper records, you will be charged in accordance with federal and state law. To the extent the request for records includes portions of records which are not in paper form (e.g., x-ray films), you will be charge the reasonable cost of the copies. You also will be charged for the postage costs, if you request that the copies be mailed to you. However, you will not be charged for copies that are requested in order to make or complete an application for a federal or state disability benefits program.
Right to Amend Your Records. You have the right to request that PHI maintained in your medical record file or billing records be amended. If you desire to amend your records, please obtain an amendment request form from the Center’s Management Office and submit the completed form to the Center’s Management Office. Your request will be accommodated unless the Center and/or Health Professionals believe that the information that would be amended is accurate and complete or other special circumstances apply.
Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, you will be charged for the accounting statement.
Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
For Further Information or Complaints. If you desire further information about your privacy rights, are concerned that your privacy rights have been violated or disagree with a decision made about access to your PHI, you may contact the Center. You may also file written complaints with the Office for Civil Rights of the U.S. Department of Health and Human Services or online at http://www.hhs.gov/ocr/office/file/index.html. Upon request, the Center will provide you with the correct address for the Office for Civil Rights of the U.S. Department of Health and Human Services. The Center and Health Professionals will not retaliate against you if you file a complaint with the Center or the Director.
Effective Date and Duration of This Notice
Effective Date. This Notice is effective on July 1, 2016.
Right to Change Terms of this Notice. The terms of this Notice may be changed at any time. If this Notice is changed, the new notice terms may be made effective for all PHI that the Center and Health Professionals maintain, including any information created or received prior to issuing the new notice. If this Notice is changed, the new notice will be posted in waiting areas around the Center and on our Internet site at lonestartx.com. You also may obtain any new notice by contacting the Center.
Eric Dow: Privacy Officer
180 Bear Creek Parkway Keller, TX 76248
Telephone Number: 817-337-3671
Corporate Compliance & Privacy Office
United Surgical Partners International
15305 Dallas Parkway, Suite 1600
Addison, Texas 75001
Compliance Hotline: 1-800-8-ETHICS