NOTICE OF PRIVACY PRACTICES

Effective April 2003                                                                                                                                                      Revised on August 7, 2013

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.

About This Notice

Surgi-Care is required by law to maintain the privacy of your protected health information.  “Protected health information” 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 health care services.  Surgi-Care is also required to provide you with a notice that describes Surgi-Care’s legal duties and privacy practices and your privacy rights with respect to your protected health information.  We will follow the privacy practices described in this notice.  If you have any questions about any part of this notice, or if you want more information about Surgi-Care’s privacy practices, please contact our Compliance Officer, Darcy DiLiddo, by calling us at 800-797-8744.

In the event our practices need to be changed to be in compliance with the law, we reserve the right to change the privacy practices described in this notice.  We will make the new notice provisions effective for all the protected health information that we maintain.  If we change our privacy practices, copies of the new notice will be made available at each of our offices, upon request, and on our website at www.surgi-careinc.com.  The new notice will also be displayed prominently in each of our offices.   

How Surgi-Care May Use or Disclose Your Health Information for Treatment, Payment, or Health Care Operations

Without specific written authorization, we may use and disclose your protected health information for treatment, payment, or health care operations as described below:

• For Treatment.  We may use or disclose yourprotected health information in the provision, coordination, or management of your health care.  Our communications to you may be by telephone, cell phone, e-mail, or by mail.  For example, we may use your information to call and remind you of an appointment or refer your care to another provider.  If another provider requests your protected health information and they are not providing care and treatment to you we will request an authorization form from you before providing your information.
  
  
• For Payment.   We may use or disclose your protected health information to obtain payment for your health care services.  For example, we may provide protected health information to your insurance carrier to determine your eligibility or coverage for an orthotic product.
  
  
• For Health Care Operations.  We may use or disclose your protected health information for health care operations.  Thisincludes the business aspects of running our practices, such as conducting quality assessment and improvement activities, conducting auditing functions, cost-management analysis related to managing our business, and customer service.  For example, we may use your protected health information to conduct an internal audit of our staff’s compliance to documentation protocols.

How Surgi-Care May Use or Disclose Your Health Information Without Your Written Authorization

By law, we may use and disclose your protected health information without written authorization and without presenting the opportunity for you to agree or object as described below:

• To Notify You of Appointments, Treatment Alternatives, and Health-Related Benefits and Services.  We may use your protected health information to remind you of an appointment or to provide you with information about treatment options or other health-related benefits and services that may be of interest to you.
  
  
• For the Treatment of Minors.  We may disclose the protected health information of minor children to their parents or guardians, unless such disclosure is prohibited by law.
  
  
• As Required by Law.  We may use and disclose your protected health information when required to do so by international, federal, state, or local law.
  
  
• For Public Health Activities.  We may use and disclose your health information for the purpose of preventing or controlling disease, injury, or disability; but only to individuals who need to know and are authorized by law to receive such information.
  
  
• To Report Abuse, Neglect, or Domestic Violence.  We may disclose your protected health information to an authorized government authority, including a social service or protective services agency, if we have reason to believe you are a victim of abuse, neglect, or domestic violence.
  
  
• For Health Oversight Activities.  We may disclose your protected health information to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations; inspections, licensure, or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight of the health care system, government benefit programs, entities subject to government regulatory programs, and entities subject to civil rights laws for which health information is necessary for determining compliance.
  
  
• For Judicial and Administrative Proceedings.  We may disclose your protected health information in the course of any judicial or administrative proceeding in response to a court order, administrative tribunal, subpoena, discovery request, or other lawful process. 
  
  
• For Law Enforcement Purposes.  We may disclose your protected health information to a law enforcement official for a law enforcement purpose.  For instance, we may disclose your protected health information in response to a law official’s request for information to identify or locate a suspect, fugitive, or material witness.
  
  
• To Coroners, Medical Examiners, or Funeral Directors.  In the event of your death, we may disclose your protected health information to a coroner or medical examiner for the purpose of identifying your body, determining the cause of your death, or other duties as authorized by law.  We may also disclose this information to a funeral director as necessary to carry out their duties.
  
  
• For Cadaveric Organ, Eye, or Tissue Donation Purposes.  We may use or disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purposes of facilitating organ, eye, or tissue donation and transplantation.
  
  
• For Research Purposes.  Under certain circumstances, and only after a special approval process, we may use or disclose your protected health information to help conduct medical research.  For example, we may use your protected health information to conduct an assessment of how well a medical device is working to cure a particular medical condition or whether a certain medical device works better than another.
  
  
• To Avert a Serious Threat to Health or Safety.  Consistent with applicable law and standards of ethical conduct, we may use or disclose your protected health information if we believe the use or disclosure will prevent a serious threat to your health or safety, or to the health or safety of others.  We will only disclose this information to someone who may be able to prevent the threat.
  
  
• Workers’ Compensation.  We may use or disclose your protected health information for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.
  
  
• Data Breach Notification Purposes.  We may use your protected health information to provide legally required notices of unauthorized access to or disclosure of your protected health information.
  
  
• Military Activity and National Security.  If you are involved with the military, national security, or intelligence activities, or if you are in law enforcement custody, we may disclose your protected health information to authorized officials so they may carry out their legal duties under the law.
  
  
• If You are an Inmate.  If you are an inmate or under the custody of a law enforcement official, we may disclose your protected health information to the correctional institution or law enforcement official if the disclosure is 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) the safety and security of the correctional institution.
  

When Surgi-Care is Required to Obtain an Authorization to Use or Disclosure Your Health Information

Other permitted and required uses and disclosures will be made only with your consent, authorization, or opportunity to object, unless required by law.  Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes.  We may not sell your protected health information without your authorization.   

You may revoke the authorization, at any time, in writing, except to the extent that your provider or the provider’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

The following are statements of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information (fees may apply).  Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or electronic format.  Under federal law, however, you may not inspect or copy or copy the following records:  Information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

You have the right to request a restriction of your protected health information.  This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or health care operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.  Your provider is not required to agree to your requested restriction except if you request that the provider not disclose protected health information to your health plan with respect to health care (e.g., items and services) for which you have paid all out of pocket expenses in full.

You have the right to receive confidential communications.  You have the right to request confidential communication from us by alternative means or at an alternative location.  You have the right to obtain a paper copy of this notice about us, upon request, even if you have agreed to accept this notice alternatively (i.e., electronically).

You have the right to request an amendment to your protected health information.  If we deny your request for 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.

You have the right to receive an accounting of certain disclosures.  You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures:  pursuant to an authorization, for purposes of treatment, payment, health care operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request.

You have the right to receive notice of a breach.  We will notify you if your unsecured protected health information has been breached.

You have the right to obtain a paper copy of this notice from us, even if you have agreed to receive the notice electronically.  We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment.  We will also make available copies of our new notice if you wish to obtain one.

You have the right to file a complaint.  You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.  We will not retaliate against you for filing a complaint.  You may file a complaint with us by calling our compliance officer at (800) 797-8744, or by mailing a written notice of your complaint to the address below:

Surgi-Care, Inc.
Attn: Compliance Officer
71 First Avenue
Waltham, MA 02451

You may also report your complaint to the Secretary of Health and Human Services by calling (877) 696-6775 or by sending a formal, written complaint to the address below:

U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C., 20201