THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
We are required by law to protect the privacy of your medical information that may reveal your identity, and to provide you with a copy of this notice, which describes the health information privacy practices of the Island Ambulatory Surgery Center, LLC (“IASC”), IASC’s medical staff, and the employees, trainees, students and volunteers.
If you have any questions about this notice, please contact Privacy Officer:
2279-83 Coney Island Avenue
Brooklyn, N.Y. 11223
or via email: firstname.lastname@example.org
Our Commitment to Your Privacy
We are committed to protecting the privacy of your medical information. In conducting our business, we will create records about you and the treatment and services we provide to you. These records are our property. However, we are required by law to:
- Maintain the confidentiality of your medical information
- Provide you with this notice of our legal duties and privacy practices concerning your medical information
- Follow the terms of our notice of privacy practices in effect at the time
This notice provides you with the following important information:
- How we may use and disclose your medical information
- Your privacy rights in regard to your medical information
- Our obligations concerning the use and disclosure of your medical information
Who will follow this notice
In handling your medical information, Island Ambulatory Surgery Center, LLC (IASC) may share your medical information as needed to treat you, to seek payment for services, and to conduct day-to-day operations.
The privacy practices described in this notice will be followed by:
- Any health care professional who treats you at IASC;
- All employees, trainees, students, and volunteers at IASC;
- All IASC medical staff members; and
- Any business associates of IASC.
When you receive services at Island Ambulatory Surgery, LLC, you may receive certain professional services from physicians on IASC medical staff who are independent practitioners and not employees or agents of IASC. These independent practitioners have agreed to abide by the terms of this notice when providing services at IASC. Therefore, this notice applies to all of your medical information that is created or received as a result of being a patient at IASC. However, this notice does not apply to the members of IASC medical staff for their medical practice in their private offices. As a result, you will also receive a notice of privacy practices from these independent practitioners with respect to their private offices.
Changes to this notice
The terms of this notice apply to all records containing your medical information that are created or retained by us. We may change our privacy practices at any time. If we do, we will revise this notice so you will have an accurate summary of our practices. The new notice will be effective for all of the information that we maintain at that time, as well as any medical information that we may receive, create or maintain in the future. We will post a copy of our current notice in our offices in a prominent location. You may request a copy of the current notice during your visit or you may obtain a copy by visiting www.IslandASC.com. We are required to abide by the terms of the notice that is currently in effect.
(A) How We May Use And Disclose Your Medical Information
The following categories describe the different ways in which we may use and disclose your medical information. Please note that each particular use or disclosure is not listed below. However, the different ways we are permitted to use and disclose your medical information do fall within one of the categories. Special privacy protections may further restrict how we use or disclose confidential HIV-related information, genetic information, alcohol and substance abuse treatment information or mental health information. Some parts of this general notice may not apply to these types of information.
We may use and disclose your medical information to provide, coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others. For example, we may use and disclose your medical information when you need a prescription, lab work, x-rays or health care services. In addition, we may use and disclose medical information when we refer you to another health care provider.
We may use and disclose your medical information in order to bill and collect payment for the services and items you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. This may include reviewing services provided for medical necessity and/or undertaking utilization review activities. We also may use and disclose your medical information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your medical information to bill you directly for services and items.
Health Care Operations.
We may use and disclose your medical information to operate our business. These uses and disclosures include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use your medical information to evaluate the competence and performance of our staff in caring for you, or to educate our staff on how to improve the care they provide for you. We may also use your medical information to conduct cost-management and business planning activities. In addition, we may share your health information with other health care providers and payors for certain of their business operations if the information is related to a relationship the provider or payor currently has or previously had with you, and if the provider or payor is required by federal law to protect the privacy of your health information.
Sign in Sheets – We may use a sign-in sheet at the registration desk where you will be asked to sign your name. Your name will be called in the waiting room when it is time for your provider to see you.
Incidental Disclosures – While we will take reasonable steps to safeguard the privacy of your medical information, certain disclosures of your medical information may occur during, or as an unavoidable result of, our otherwise permissible uses and disclosures of your health information. For example, during the course of your visit, other patients or staff may see, or overhear discussion of, your medical information.
Business Associate – We may disclose your medical information to contractors, agents and other business associates who need the information in order to assist us in obtaining payment or carrying out our business operations. For example, we may share your medical information with a billing company that helps us to obtain payment from your insurance company. Another example is that we may share your medical information with an accounting firm, law firm or risk management organization that provides professional advice to us about how to improve our health care services and comply with the law. If we do disclose your medical information to a business associate, we will have a written contract to ensure that the business associate also protects the privacy of your medical information.
Appointment and Account Balance Reminders.
We may use and disclose your medical information to remind you that you have an appointment or a balance on your account. This may occur by phone, letter, automated telephone system, email, text messaging or other methods.
Treatment Alternatives/Health-Related Benefits and Services.
We may use and disclose your medical information to inform you of treatment alternatives and/or health-related benefits and services that may be of interest to you.
Release of Information to Family/Friends.
If you do not object, we may release your medical information to a friend or family member who is involved in your care or who assists in taking care of you. For example, a parent or guardian may ask that a family member go to the pharmacy and pick up a prescription. In this example, the family member may have access to another family member’s medical information.
Required by Law.
We will use or disclose medical information about you when required by federal, state or local law.
Public Health Activities and Food and Drug Administration.
We may disclose your medical information for public health and adverse event or product monitoring activities, including generally to: prevent or control disease, injury or disability; maintain vital records, such as births and deaths; report child abuse or neglect; notify a person regarding potential exposure to a communicable disease; notify a person regarding a potential risk for spreading or contracting a disease or condition; report reactions to drugs or problems with products or devices; notify individuals if a product or device they are using has been recalled; and notify your employer under limited circumstances, related primarily to workplace injury or illness or medical surveillance.
Abuse, Neglect or Domestic Violence.
We may disclose your medical information to a government authority if we believe you are a victim of abuse, neglect or domestic violence. If we make such a disclosure, we will inform you of it, unless we think that informing you places you at risk of serious harm or, if we were to inform your personal representative, it is otherwise not in your best interest. We will make every effort to obtain your permission before releasing this information, but in some cases we may be required or authorized to act without your permission.
Health Oversight Activities.
We may disclose your medical information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general.
Lawsuits and Administrative Proceedings.
Excluding certain conditions, we may disclose your medical information in response to a court order or subpoena if you are involved in a lawsuit or administrative proceeding.
We may disclose your health information to law enforcement officials, so long as applicable legal requirements are met, for law enforcement purposes. These purposes include: to comply with court orders or laws; to assist law enforcement officers with identifying or locating a suspect, fugitive, witness or missing person; if you have been the victim of a crime and (1) we have been unable to obtain your agreement because of an emergency or your incapacity, (2) law enforcement officials represent that they need this information immediately to carry out their law enforcement duties, and (3) in our professional judgment disclosure to these officers is in your best interests; if we suspect that your death resulted from criminal conduct; if necessary to report a crime that occurred on our property; or if necessary to report a crime discovered during an offsite medical emergency.
Coroners, Medical Examiners, and Funeral Directors.
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.
Organ and Tissue Donation.
We may disclose your medical information to organizations that handle organ and tissue procurement, banking or transplantation.
In most cases, we will ask for your written authorization before using your health information or sharing it with others in order to conduct research. However, under some circumstances, we may use and disclose your health information without your written authorization. To do this, we are required to obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. In the unfortunate event of your death, we may share your health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facility any information that identifies you.
Serious Threats to Health or Safety.
We may use and disclose your medical information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to someone able to help prevent the threat, for example, to law enforcement officers if you participated in a violent crime that might have caused serious physical harm to another person.
Specialized Government Functions.
We may disclose your medical information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. In addition, we may disclose your medical information to federal officials for intelligence and national security activities authorized by law. We also may disclose your medical information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
Inmates and Correctional Institutions.
If you are an inmate or under the custody of law enforcement officials, we may disclose your medical information to the correctional institution or law enforcement officials if necessary: (i) to provide you with health care, (ii) for the safety and security of the institution, and/or (iii) to protect your health and safety or the health and safety of other individuals.
We may release your medical information for workers’ compensation and similar programs.
Completely De-Identified or Partially De-Identified Information.
We may use and disclose your medical information if we have removed any information that has the potential to identify you so that the medical information is “completely de-identified.” We also may use and disclose “partially de-identified” medical information about you if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified medical information will not contain any information that would directly identify you (such as your name, street address, social security number, phone number, fax number, electronic mail address, website address or license number).
Data Breach Notification Purposes.
We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.
We may disclose PHI to family members or others involved in a decedent’s healthcare or payment for care when the disclosure is relevant to their involvement and not inconsistent with the decedent’s previously expressed wishes. Also, health information of persons deceased for more than 50 years is not considered PHI and therefore is not regulated under HIPAA.
(B) Other limitations
The following uses and disclosures of your Protected Health Information will be made only with your written authorization:
- Uses and disclosures of Protected Health Information for marketing purposes, where the authorization clearly discloses that we will receive payment; and
- Disclosures that constitute a sale of your Protected Health Information, whether by direct or indirect remuneration, unless one of several exceptions applies. In addition to sales, this includes PHI access and licensing agreements. The written authorization must disclose that the exchange will result in remuneration.
Other uses and disclosures of Protected Health Information 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 Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.
In accordance with state law, we will further limit the disclosures to third parties of protected confidential HIV-related information and information concerning genetic testing, mental health services and certain alcohol and substance abuse treatment.
(C) Your Rights Regarding Your Medical Information
You have the following rights regarding the medical information we maintain about you:
Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your medical information for treatment, payment or health care operations. Additionally, you have the right to request that we limit our disclosure of your medical information to individuals involved in your care or the payment for your care, such as family members and friends.
We are not required to agree to your request to restrict or limit our use of disclosure of your medical information. If we agree to your request, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat to you.
Unless the disclosure is required by law, we will abide by your request to restrict disclosures of your health information to health plans for payment or operations purposes where the health information pertains solely to a health care item or service for which you, or someone on your behalf, paid us out of pocket in full.
To request a restriction in our use or disclosure of your medical information, you must make a request in writing to the Privacy Officer, 2279-83 Coney Island Avenue, First Floor, Brooklyn, N.Y. 11223 or email: email@example.com. Your request must describe in a clear and concise fashion: (i) the information you wish restricted; (ii) whether you are requesting to limit our use, disclosure or both; and (iii) to whom you want the limits to apply.
You have the right to request that we communicate with you about your health and related issues in a particular manner, or at a certain location. For instance, you may ask that we contact you by mail, rather than by telephone, or at home, rather than work. You do not need to give a reason for your request. In order to request a type of confidential communication, you must make a written request to the Privacy Officer, 2279-83 Coney Island Avenue, First Floor, Brooklyn, N.Y. 11223 or by email: firstname.lastname@example.org. Please specify in your request how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location. We will accommodate reasonable requests.
Inspection and Copies.
You have the right to inspect and obtain a paper or electronic copy of the health information we retain that may be used to make decisions about you, including medical and billing records, but not including psychotherapy notes. You must submit your request in writing to the Privacy Officer, 2279-83 Coney Island Avenue, First Floor, Brooklyn, N.Y. 11223 or by email: email@example.com in order to inspect and/or obtain a copy of your medical information. We will produce the information in the format requested if readily producible within 30 days or contact you to negotiate an alternative format. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. The fee must generally be paid before or at the time we give you the copies. We may deny your request to inspect and/or receive a copy in certain limited circumstances; however, you may request a review of our denial. Reviews will be conducted not by the person that denied your initial request, but by another licensed health care professional chosen by us.
You may ask us to amend your medical information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for us. To request an amendment, you must make a written request to the Privacy Officer, 2279-83 Coney Island Avenue, First Floor, Brooklyn, N.Y. 11223 or email: firstname.lastname@example.org. You must provide us with a reason that supports your request for amendment. We will deny your request if you fail to submit your request (specifying the reason) in writing. Also, we may deny your request if you ask us to amend information that is: accurate and complete; not part of the medical information kept by or for us; not part of the medical information which you would be permitted to inspect and copy; or not created by us, unless the individual or entity that created the information is not available to amend the information. A written statement of your challenge to the accuracy of the information in the record will become a permanent part of your medical record and will be released with the record.
Accounting of Disclosures.
You have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain disclosures we have made of your medical information. In order to obtain an accounting of disclosures, you must make a written request to the Privacy Officer, 2279-83 Coney Island Avenue, First Floor, Brooklyn, N.Y. 11223 or by e-mail at email@example.com. All requests for an accounting of disclosures must state a time period that may not be longer than six years. The first list you request within a 12-month period is free of charge, but we may charge you for additional lists within the same 12-month period. We will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. We are not required to include disclosures: for treatment, payment or health care operations; requested by you, that you authorized, or which are made to individuals involved in your care; or allowed by law.
Right to a Paper Copy of This Notice.
You have a right to receive a paper copy of this Notice of Privacy practices at any time. To obtain a paper copy of this notice, you may contact the Privacy Officer, 718.998.9400, obtain a copy during your visit, or review it on our website at www.IslandASC.com
Right to File a Complaint.
If you believe your privacy rights have been violated, you may file a complaint with IASC or with the Office of Civil Rights at the U.S. Department of Health and Human Services. To file a complaint with the Privacy Officer, please use the following contact information. Please note that will not retaliate or take action against you for filing a complaint.
2279-83 Coney Island Avenue, First Floor
Brooklyn, NY 11223
Right to Provide an Authorization for Other Uses and Disclosures.
We will obtain your written authorization for uses and disclosures that are not identified by this notice or are not permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your medical information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your medical information for the reasons described in the authorization. Of course, we are unable to take back any disclosures that we have already made with your authorization. We are required to retain records of the care that we provided to you.
Right to Be Notified of a Breach.
You have the right to be notified of a breach of unsecured Protected Health Information in the event you are affected by such a breach.