University Surgical Associates
Vascular Diagnostic Services
USA Breast Center
USA Special Procedures
USA Prosthetic Services
UTCOM Surgery Clinic

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.

This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations.

Protected health information is the information we create and obtain in providing our services to you.  Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for TREATMENT purposes are:

A nurse obtains treatment information about you and records it in a health record.

We may need to share your health information in consultation with another physician specialist.

We may disclose your health information to a pharmacy to fulfill a prescription.

We may disclose your health information to a laboratory to order a blood test.

We may disclose your health information to a home health agency that is providing care in your home.

Examples of use of your health information for PAYMENT purposes:

We submit requests for payment to your health insurance company. The health insurance company (or business associate helping us obtain payment) requests information from us regarding your medical care given. We will provide information to them about you and the care given.

We may also disclose your health information to your insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan.

Examples of use of your information for HEALTH CARE OPERATIONS:

We may obtain services from business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such business associates as necessary to obtain these services.

Your Health Information Rights

The health and billing records we maintain are the physical property of University Surgical Associates. You have the following rights with respect to your Protected Health Information (PHI):

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, like a friend or family member. Any request for a restriction or limitation must be made in writing. We are not required to grant your request;

Request restriction on certain disclosures of PHI to a health plan if the disclosure is for payment for a particular service and is paid out of pocket in full;

Notification of breach of PHI – We are required to notify you by first class mail of any breach of your unsecured PHI.

Right to inspect and copy your health record and billing record. You may exercise this right by delivering the request in writing to our front office staff or Health Information Department, using the form we provide to you upon request. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request;

Be advised that under federal law, you may not inspect or copy psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed;

Request PHI in electronic format. You have the right to request an electronic copy of your record be given to you or transmitted to another third party or entity. We will provide the electronic information in our format and media device. We may charge a reasonable, cost-based fee for the labor associated with copying or transmitting the electronic PHI.  If you chose to have your PHI transmitted electronically, you will need to provide a written request to this office listing the contact information of the individual or entity to receive your PHI;

Right to request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our Privacy Officer. We are not required to make such amendments and in certain cases, we may deny your request for an amendment. You may file a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your health information;

Right to receive an accounting of disclosures of your health information by delivering a written request to the Privacy Officer. An accounting will NOT include internal uses of information for treatment, payment or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;

Right to confidential communication by requesting that communication of your health information is made by alternative means or at an alternative location by delivering the request in writing to our office or, by using the form we provide during the office registration process.

Our Responsibilities

This office is required to:

Maintain the privacy of your health information as required by law;

Provide you with a Notice as to our duties and privacy practices as to the information we collect and maintain about you;

Abide by the terms of this Notice;

Notify you if we cannot accommodate a requested restriction or request; and

Accommodate your reasonable requests regarding methods to communicate health information with you.

Accommodate your request for an accounting of disclosures.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our Notice or by visiting our office and picking up a copy.

To Request Information or File a Complaint:

If you have questions, would like additional information, or want to report a problem regarding the handling of your health information, you may contact our Privacy Officer at the following address:

University Surgical Associates
ATTENTION: PRIVACY OFFICER
Suite 300
979 East Third Street
Chattanooga, TN  37403

Phone:  423-757-0826

Additionally, if you believe your privacy rights have been violated, you may file a complaint with the Secretary of Health and Human Services. You will not be retaliated against in any way for filing a complaint.

Following is a List of Other Uses and Disclosures 

Allowed by the Privacy Rule:  Patient Contact

As a part of treatment, payment and health care operations, we may also disclose your protected health information for the following purposes:

To remind you of an appointment.

To inform you of potential treatment alternatives or options.

To inform you of health-related benefits or services that may be of interest to you.

To inform you as a part of a fundraising effort.

Notification – Opportunity to Agree or Object

Unless you object, we may use or disclose your health information to notify or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family – Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object, or in an emergency.

Opportunity to Agree or Object NOT Required

Federal privacy rules allow us to use or disclose your protected health information without your permission or authorization for a number of reasons including the following:

PUBLIC HEALTH ACTIVITIES

Controlling Disease – As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Child Abuse & Neglect – We may disclose protected health information to public authorities as allowed by law to report child abuse or neglect.

Food and Drug Administration (FDA) – We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements

VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE
We can disclose protected health information to government authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment; the physician believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.

OVERSIGHT AGENCIES
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities to include audits, civil, administrative or criminal investigations: inspections; licensures or disciplinary actions, and for similar reasons related to the administration of health care.

JUDICIAL/ADMINISTRATIVE PROCEEDINGS
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order or administrative tribunal, provided that only the protected health information released is expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process.

LAW ENFORCEMENT
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, including laws that require reporting of certain types of wounds or other physical injury.

CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

ORGAN PROCUREMENT ORGANIZATIONS
Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.

RESEARCH
We may disclose information to researchers when their research has been approved by an Institutional Review Board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

THREAT TO HEALTH AND SAFETY
To avert serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

FOR SPECIALIZED GOVERNMENT FUNCTIONS
We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

CORRECTIONAL INSTITUTIONS
If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.

MEDICAL RESIDENTS AND MEDICAL STUDENTS
May observe or participate in your treatment or use your PHI to assist in their training.  You have the right to refuse to be examined, observed, or treated by medical residents or medical students.

FOREIGN LANGUAGE VERSION
If you have difficulty reading or understanding English, you may request a copy of this Notice in Spanish.

Your Written Authorization is Required for Other Uses and Disclosures
Uses and disclosures for marketing purposes can only be made with your written authorization. Other uses and disclosures of PHI not covered in 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. Disclosures that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

Website:
We maintain a website that provides information about our entity and you may access our Privacy Notice at the following address: www.universitysurgical.com