Notice of Privacy Practices

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.

If you have questions about this notice or want more information, please contact: Karel Mitchell at SurgOne, P.C. The effective date of this notice is April 14, 2003.

To appropriately treat you and receive payment for the services we provide, we need to obtain information from you including your full name and address, insurance company, family medical history, current medical history, and current medical condition. We will use and disclose this
information and other information we collect in the ways described below. To help you understand how we will use and disclose your information we have put the different uses and disclosures into categories and give examples of each. All of the ways we use or disclose your information will fit into one of the categories listed below, but we cannot list all of the uses and discloses in each category.

We may use and disclosure your health information for treatment, payment, and health care operations.

  • Treatment We may use and disclose your information to provide you with medical treatment and services. Your information may be disclosed to individuals providing care to you and different departments in the hospital. These individuals and departments need your information to provide care, and to coordinate and provide services (such as prescriptions, lab tests, meals, and x-rays). We may also disclose your information to individuals outside the hospital that may be involved in your care after you leave.
  • Payment We may use and disclose your information to receive payment for the services and treatment provided to you. We use your information to create a bill and disclose your information when we send the bill to your insurance company, you, or a third party. The individual or entity paying the bill may request more information to determine whether the bill is covered by your insurance. We may tell your health plan about a treatment you are going to receive to get approval for payment or to determine whether your health plan will cover the treatment.
  • Health Care Operations We may use and disclose your information for health care operation purposes. Health care operations includes review of the care you receive for quality assessment, educational, business planning, and compliance plan purposes.
  • We may disclose and use your health information and you authorize us to use and disclose your information for:
    • Appointment Reminders We may provide appointment reminders to you. You may request in writing that we send reminders to a confidential or alternative address.
    • Treatment Alternatives We may provide you with information about treatment alternatives and other health related benefits and services.
    • We may also disclose your health information to outside entities without your consent or authorization in the following circumstances:
      • Required by Law We disclose information as required by law. For example, we are required to report gunshot wounds to the police.
      • Public Health Purposes We disclose information to health agencies as required by law for preventing or controlling disease. Examples are reporting of sexually transmitted, communicable, and infectious diseases.
      • To Prevent a Serious Threat to Health or Safety We may disclose information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.
      • Research Your information may be used by or disclosed to researchers for research approved by a privacy board or an institutional review board.
      • Health Oversight Activities Your health information may be disclosed to governmental agencies and boards for investigations, audits, licensing, and compliance purposes.
      • Judicial and Administrative Proceedings We may be required to disclose your healt information to a court or for an administrative proceeding.
      • Law Enforcement Activities We may be required to disclose your information as required by law, pursuant to a court order, warrant, subpoena, or summons.
      • In Emergency Circumstances
      • Deceased Individual We may disclose information for the identification of the body or to determine the cause of death.
      • Military and Veterans If you are a member of the armed forces we may release information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.
      • Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official. This release must be necessary (1) for the institution 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 or security of the correctional institution.
      • Protective Services for the President and Others
      • Organ and Tissue Donation If you are an organ donor, we may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ bank:, as necessary to facilitate organ or tissue donation. Workers’ Compensation We may release medical information about you for workers’ compensation or similar programs.
      • National Security and Intelligence Activities We may release information about you to authorized Federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

We will give you the opportunity to object to the following uses and disclosure of your information:

  • Notification We may tell your friends, relatives and other caretakers information which is relevant to their involvement in your care.
  • Disaster Relief We may disclose information about you to public or private agencies for disaster relief purposes.

Your Rights

  • You have the right to request a restriction on how information about you is used and disclosed. If you want to request a restriction of a use or disclosure of your information, contact the Medical Records Department at the Highline Surgical office of Sur gOne, P .C. (303/789-1877) to obtain the form to make your request. We are not required to agree to any restriction on the use or disclosure of your information.
  • You have the right to request communications with you be made at an alternative address or phone number. To request that communications be made at a different address or phone number, contact the Front Desk Department at the Highline Surgical office of SurgOne, P .C. (303/789-1877) to obtain the form to make your request.
  • You have the right to inspect and obtain a copy of your medical record. To inspect and obtain a copy of your medical record a request must be made in writing on the form provided by Practice. To obtain a form, contact the Medical Records Department at the Highline Surgical office of SurgOne, P.C. (303/789-1877).
  • If you believe the information we have about you is incorrect or incomplete you may request that we amend your medical record. To amend your medical record your request must be made in writing on the form provided by Practice. To request a form, contact the Nursing Department at the Highline Surgical office of SurgOne, P.C. (303/789-3751).
  • You have the right to receive an accounting of disclosures, a list of individuals and entities that received your health information for reasons other than treatment, payment, or healthcare operations. You may receive one (1) free accounting during a twelve (12) month period. If you request more than one (1) accounting you will be charged a fee of $20.00 for a one (1) year accounting and $20.00 for each additional year up to six (6) years. An accounting is not provided for disclosures prior to April 14, 2003. To request an accounting of disclosures, contact the Medical Records Department at the Highline Surgical office of SurgOne, P. C. (303/789-1877) to obtain the form to make your request.
  • You have the right to request a paper copy of this Notice.

Our Duties

  • We are required by law to maintain the privacy of protected health information and to provide individuals with this Notice of our legal duties and privacy practice regarding health information.
  • We are required to follow the terms of the current Notice.
  • We may change the terms of this Notice and the revised Notice will apply to all health information in our possession. If we revise this Notice, a copy of the revised Notice willbe posted in our office and a copy may be requested from the Front Desk Department at the Highline Surgical office of Sur gOne, P.C.

Complaints

If you believe your privacy rights have been violated you may contact:

Karel Mitchell at SurgOne, P.C. (303/957-1310) or the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

©2002 Shughart ‘Thomson & Kilroy

SurgOne, P.c.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE

USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO TIDS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have questions about this notice or want more information, please contact: Karel Mitchell at SurgOne, P.C. The effective date of this notice is April 14, 2003.

To appropriately treat you and receive payment for the services we provide, we need to obtain

information from you including your full name and address, insurance company, family medical

history, current medical history, and current medical condition. We will use and disclose this

information and other information we collect in the ways described below. To help you understand how we will use and disclose your information we have put the different uses and disclosures into categories and give examples of each. All of the ways we use or disclose your information will fit into one of the categories listed below, but we cannot list all of the uses and discloses in each category.

We may use and disclosure your health information for treatment, payment, and health care operations.

Treatment We may use and disclose your information to provide you with medical

treatment and services. Your information may be disclosed to individuals providing care

to you and different departments in the hospital. These individuals and departments need

your information to provide care, and to coordinate and provide services (such as

prescriptions, lab tests, meals, and x-rays). We may also disclose your information to

individuals outside the hospital that may be involved in your care after you leave.

Payment We may use and disclose your information to receive payment for the services

and treatment provided to you. We use your information to create a bill and disclose

your information when we send the bill to your insurance company, you, or a third party.

The individual or entity paying the bill may request more information to determine

whether the bill is covered by your insurance. We may tell your health plan about a

treatment you are going to receive to get approval for payment or to determine whether

your health plan will cover the treatment.

Health Care Operations We may use and disclose your information for health care

operation purposes. Health care operations includes review of the care you receive for

quality assessment, educational, business planning, and compliance plan purposes.

We may disclose and use your health information and you authorize us to use and disclose

your information for:

©2002 Shughart Thomson & Kilroy 1

Appointment Reminders We may provide appointment reminders to you. You may

request in writing that we send reminders to a confidential or alternative address.

Treatment Alternatives We may provide you with information about treatment

alternatives and other health related benefits and services.

We may also disclose your health information to outside entities without your consent or

authorization in the following circumstances:

Required by Law We disclose information as required by law. For example, we are

required to report gunshot wounds to the police.

Public Health Purposes We disclose information to health agencies as required by law

for preventing or controlling disease. Examples are reporting of sexually transmitted,

communicable, and infectious diseases.

To Prevent a Serious Threat to Health or Safety We may disclose information about

you to law enforcement or an identified victim to prevent a serious threat to your health

or safety or the health or safety of another individual or the public.

Research Your information may be used by or disclosed to researchers for research

approved by a privacy board or an institutional review board.

Health Oversight Activities Your health information may be disclosed to governmental

agencies and boards for investigations, audits, licensing, and compliance purposes.

Judicial and Administrative Proceedings We may be required to disclose your health

information to a court or for an administrative proceeding.

Law Enforcement Activities We may be required to disclose your information as

required by law, pursuant to a court order, warrant, subpoena, or summons.

In Emergency Circumstances

Deceased Individual We may disclose information for the identification of the body or

to determine the cause of death.

Military and Veterans If you are a member of the armed forces we may release

information about you as required by military command authorities. We may also release

information about foreign military personnel to the appropriate foreign military authority.

Inmates If you are an inmate of a correctional institution or under the custody of a law

enforcement official. This release must be necessary (1) for the institution 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 or security of the correctional institution.

Protective Services for the President and Others

Organ and Tissue Donation If you are an organ donor, we may release your medical

information to organizations that handle organ procurement or organ, eye or tissue

transplantation or to an organ bank:, as necessary to facilitate organ or tissue donation.

Workers’ Compensation We may release medical information about you for workers’

compensation or similar programs.

National Security and Intelligence Activities We may release information about you

to authorized Federal officials for intelligence, counterintelligence, and other national

security activities authorized by law.

©2002 Shughart Thomson & Kilroy 2

We will give you the opportunity to object to the following uses and disclosure of your

information:

Notification We may tell your friends, relatives and other caretakers information which

is relevant to their involvement in your care.

Disaster Relief We may disclose information about you to public or private agencies for

disaster relief purposes.

Your Rights

• You have the right to request a restriction on how information about you is used and

disclosed. If you want to request a restriction of a use or disclosure of your information,

contact the Medical Records Department at the Highline Surgical office of Sur gOne, P .C.

(303/789-1877) to obtain the form to make your request. We are not required to agree

to any restriction on the use or disclosure of your information.

• You have the right to request communications with you be made at an alternative address

or phone number. To request that communications be made at a different address or

phone number, contact the Front Desk Department at the Highline Surgical office of

SurgOne, P .C. (303/789-1877) to obtain the form to make your request.

· You have the right to inspect and obtain a copy of your medical record. To inspect and

obtain a copy of your medical record a request must be made in writing on the form

provided by Practice. To obtain a form, contact the Medical Records Department at the

Highline Surgical office of SurgOne, P.C. (303/789-1877).

• If you believe the information we have about you is incorrect or incomplete you may

request that we amend your medical record. To amend your medical record your request

must be made in writing on the form provided by Practice. To request a form, contact the

Nursing Department at the Highline Surgical office of SurgOne, P.C. (303/789-3751).

• You have the right to receive an accounting of disclosures, a list of individuals and

entities that received your health information for reasons other than treatment, payment,

or healthcare operations. You may receive one (1) free accounting during a twelve (12)

month period. If you request more than one (1) accounting you will be charged a fee of

$20.00 for a one (1) year accounting and $20.00 for each additional year up to six (6)

years. An accounting is not provided for disclosures prior to April 14, 2003. To request

an accounting of disclosures, contact the Medical Records Department at the Highline

Surgical office of SurgOne, P. C. (303/789-1877) to obtain the form to make your request.

• You have the right to request a paper copy of this Notice.

©2002 Shughart Thomson & Kilroy 3

Our Duties

• Weare required by law to maintain the privacy of protected health information and to

provide individuals with this Notice of our legal duties and privacy practice regarding

health information.

• We are required to follow the terms of the current Notice.

• We may change the terms of this Notice and the revised Notice will apply to all health

information in our possession. If we revise this Notice, a copy of the revised Notice will

be posted in our office and a copy may be requested from the Front Desk Department at

the Highline Surgical office of Sur gOne, P.C.

Complaints

If you believe your privacy rights have been violated you may contact:

Karel Mitchell at SurgOne, P.C. (303/957-1310) or the Secretary of the Department of Health

and Human Services. You will not be penalized for filing a complaint.

©2002 Shughart ‘Thomson & Kilroy 4