Notice of Privacy Practices at Austin Surgical Hospital
 Effective: April 14, 2003

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.

All questions concerning this Notice should be directed to [Privacy Officer], Austin Surgical Hospital

II. WHO WILL FOLLOW THIS NOTICE
This Notice describes the privacy practices of the following groups of individuals and entities: Members of the Austin Surgical Hospital Medical Staff includes, but is not limited to, the following types of health care providers who may provide care or treatment to you at the Austin Surgical Hospital: Anesthesiologists, Family Practitioners, Surgeons, Oncologists, Dentists, Psychiatrists, Therapists, Counselors, Psychologists, etc.

III. OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION
Austin Surgical Hospital understands that your medical information is personal, and we are committed to protecting this information. Austin Surgical Hospital creates a record concerning all of the care, services, and treatment you receive within a Austin Surgical Hospital. Austin Surgical Hospital needs this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all records of the care, services, and treatment you receive within a Austin Surgical Hospital. This Notice does not apply to records of any care, services, or treatment you may receive outside of Austin Surgical Hospital Facilities. To the extent you receive care or treatment outside of Austin Surgical Hospital Facilities, such as in a private doctor’s office, you should inquire with those health care providers to determine their policies and notices pertaining to the use and disclosure of your medical information.

This Notice will tell you about the ways in which Austin Surgical Hospital may use and disclose your medical information. It also describes your rights and certain obligations that Austin Surgical Hospital has regarding the use and disclosure of your medical information.

Austin Surgical Hospital is required by law to:
IV. HOW AUSTIN SURGICAL HOSPITAL MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION WITHOUT YOUR AUTHORIZATION
The following categories describe different ways that Austin Surgical Hospital may use and disclose your medical information without first obtaining your written authorization. For each category of uses or disclosures, it is explained what is meant and some examples are given. Not every use and disclosure in a category will be listed. However, all of the ways that Austin Surgical Hospital is permitted to use and disclose information without your written authorization will fall within one of these categories.

    Treatment – Austin Surgical Hospital may use and disclose your medical information in order to provide you with medical treatment or services. This includes disclosures of your medical information to doctors, nurses, technicians, medical students, or other personnel who are involved in your care. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that appropriate meals can be arranged. Austin Surgical Hospital may also share internally your medical information in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. Also, Austin Surgical Hospital may use and disclose your medical information to contact you as a reminder that you have an appointment for treatment or medical care, and to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

    Payment – Austin Surgical Hospital may use and disclose your medical information so that the treatment and services you receive may be billed to, and payment may be collected from, you, an insurance company, or a third party. For example, Austin Surgical Hospital may need to give your health plan information about surgery you received so your health plan will reimburse us for the surgery. Austin Surgical Hospital may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

  Health Care Operations – Austin Surgical Hospital may use and disclose your medical information for health care operations. These uses and disclosures are necessary to run the everyday operations of Austin Surgical Hospital and to ensure that all of our patients receive quality care. For example, your medical information may be used to review treatment and services and to evaluate the performance of staff in caring for you. Your medical information may also be combined with the medical information of many patients in order to decide what additional services should be offered, what services are not needed, and whether certain new treatments are effective. Your medical information may also be combined with the medical information of other hospitals to compare how Austin Surgical Hospital is doing and to see where we can make improvements in the care and services we offer. Austin Surgical Hospital may remove information that identifies you from this set of medical information so others may use it to study health care delivery without learning who the specific patients are.

  Facility Directory – Austin Surgical Hospital may include certain limited information about you in a facility directory while you are a patient at Austin Surgical Hospital. This information is limited to your name, room location, and your general condition (e.g., fair, stable, etc.). The directory information may be disclosed to anyone who asks for you at Austin Surgical Hospital using your name. This is so your family, friends, and clergy can visit you while you are a patient and generally know how you are doing. You have the right to prohibit your information from being disclosed in this manner by completing a Request for “No Information” Status form at the Austin Surgical Hospital where you are a patient.

  Involvement in Your Care and Notification Purposes – Austin Surgical Hospital may disclose your medical information to a family member, other relative, or any other person identified by you, when this person is involved in your care and the information is necessary for the person’s participation in your care. For example, we may communicate with your family regarding the status of medical procedures performed, recovery prognosis, etc. Also, we may need to locate a family member or other person responsible for your care and notify this person about the status of your condition and location at Austin Surgical Hospital. You have the right to prohibit your information from being disclosed in this manner by completing a Request for “No Information” Status form at the Austin Surgical Hospital where you are a patient.

  When You Are Unable to Consent – In the event you become physically or mentally unable to communicate, Austin Surgical Hospital may obtain consent for your care from a member of your family, such as your spouse or a parent. Austin Surgical Hospital may also disclose your medical information to this family member who is authorized by law to consent to your medical treatment and to receive your medical information.

  Research – Under certain circumstances, Austin Surgical Hospital may disclose your medical information for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before Austin Surgical Hospital will disclose your medical information for research, the project will have been approved through this research approval process. Austin Surgical Hospital may, however, disclose your medical information to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave Austin Surgical Hospital.

  As Required or Authorized by Law – Austin Surgical Hospital will disclose your medical information when required or authorized by federal, state, or local law. For example, Texas law requires Austin Surgical Hospital to disclose your medical information to a child fatality review team who is investigating the death of a child.

  For Law Enforcement Purposes – Austin Surgical Hospital may disclose your medical information to a law enforcement official who presents a valid warrant or subpoena requesting access to the information. Austin Surgical Hospital may also disclose information about you in the following circumstances to appropriate law enforcement officials without a subpoena or warrant: (1) in response to a law enforcement official’s request for information for the purpose of locating a suspect, fugitive, material witness, or missing person; (2) in response to a law enforcement official’s request for information relating to a person who is or is suspected to be a victim of a crime, if that person agrees to the disclosure, or in limited circumstances where the person cannot agree; (3) for the purpose of alerting law enforcement of the death of an individual where we suspect the death may have been the result of a crime; (4) when we believe in good faith that a crime has been committed in or within the vicinity of a Austin Surgical Hospital; and (5) when we are providing emergency treatment, and we believe that disclosure is necessary to alert law enforcement to the commission or nature of a crime, the location of the crime or victims of such crime, and/or the identity, description, and location of the perpetrator of such crime.

  To Avert a Serious Threat to Health or Safety – Austin Surgical Hospital may, when consistent with law and standards of ethical conduct, use and disclose your medical information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to a federal, state, or local government agency or authority that is able to assist in dealing with the threat.

  Organ and Tissue Donation – If you are an organ donor, A ustin Surgical Hospital may release your medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donor bank, as necessary to facilitate organ or tissue donation and transplantation.

  Workers’ Compensation – Austin Surgical Hospital may disclose your medical information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

  Public Health Activities – Austin Surgical Hospital may disclose your medical information for public health activities. These activities generally include the following:


  Victims of Abuse, Neglect, or Domestic Violence – If you agree, or as required or authorized by law, Austin Surgical Hospital may disclose your medical information to notify the appropriate government authority that we believe you have been the victim of abuse, neglect, or domestic violence.

  Health Oversight Activities – Austin Surgical Hospital may disclose your medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

  Lawsuits and Disputes – If you are involved in a lawsuit or dispute, Austin Surgical Hospital may disclose your medical information in response to a court order. Austin Surgical Hospital may also disclose your medical information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

  Coroners, Medical Examiners, and Funeral Directors – Austin Surgical Hospital may disclose medical information about a patient to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. Austin Surgical Hospital may also disclose the medical information of patients to funeral directors as necessary to carry out their duties.

  Business Associates – Austin Surgical Hospital may disclose your medical information to our Business Associates. Business Associates are persons or entities who perform certain vital functions or services on behalf of Austin Surgical Hospital. All Business Associates are required to protect the privacy and security of any medical information received from Austin Surgical Hospital.

  Marketing – Austin Surgical Hospital may use your medical information to make marketing communications to you, and disclose your medical information to other entities so that they may make marketing communications to you. However, only marketing communications that are made in a face-to-face conversation with you or that involve only a promotional gift of nominal value may be made without your authorization. All other marketing communications will not be made to you without your authorization.

V. YOUR PRIVACY RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding your medical information maintained by Austin Surgical Hospital:

Right to Inspect and Copy – You have the right to inspect and obtain a copy of your medical information that may be used to make decisions about your care. This usually includes medical and billing records, but does not include psychotherapy notes.

If you request a copy of the information, a fee for the costs incurred in copying and mailing the materials may be charged to you.

Your request to inspect and obtain a copy may be denied in certain limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Austin Surgical Hospital will review your request and denial. The person conducting the review will not be the same person who denied your request. Austin Surgical Hospital will comply with the outcome of the review. Under some circumstances, you will not be entitled to have a denial of access reviewed. For example, to the extent your request for access to psychotherapy notes is denied, you would not be entitled to have this denial of access reviewed.

Right to Request an Amendment – If you feel that the medical information Austin Surgical Hospital has about you is incorrect or incomplete, you may ask that the information be amended. You have the right to request an amendment for so long as the information is kept by or for Austin Surgical Hospital.

Your request for an amendment must be in writing and must provide a reason in support of the request. Your request may be denied if you request an amendment to information that:


Right to Accounting of Disclosures – You have the right to request an accounting of certain disclosures of your medical information made by Austin Surgical Hospital. This is a list of some of the non-routine disclosures of your medical information made by Austin Surgical Hospital.

Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first accounting you request within a twelve (12) month period will be free of charge. For additional accountings, you may be charged for the costs of providing the accounting. You will be notified of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions – You have the right to request a restriction or limitation on the medical information Austin Surgical Hospital may use or disclose about you for treatment, payment, or health care operations. Austin Surgical Hospital is not required to agree to your request. If AUSTIN SURGICAL HOSPITAL agrees, then we will be bound by your request, unless the information is needed to provide treatment to you in an emergency.

Right to Request Confidential Communications – You have the right to request that Austin Surgical Hospital communicate with you about medical matters in a certain way or at a certain location. For example, you may request that we only contact you at a work phone number or send bills and other correspondence to you at a specific address (such as a post office box).

You do not have to give a reason for your request; Austin Surgical Hospital will accommodate reasonable requests. Your request must, however, specify how or where you wish to be contacted.

Right to Become a “No Information” Patient – You have the right to become a “No Information” patient. If you become a “No Information” patient, then no information about you will be disclosed to anyone for directory information purposes or for involvement in your care and notification purposes, as provided in Section IV of this Notice. This means that if family or friends contact Austin Surgical Hospital and request information about you, no information will be disclosed and your presence within Austin Surgical Hospital will not be confirmed or denied. Austin Surgical Hospital staff will not communicate with any person, including family members, regarding your condition, treatment alternatives, prognosis, status of procedures performed, etc., except in circumstances where you become unable to consent to medical treatment, in which case the law permits the disclosure of information to a surrogate decision-maker to facilitate the provision of care. However, if you become a “No Information” patient, this will not prohibit Austin Surgical Hospital from disclosing information about you for treatment, payment, health care operations, and other purposes as described in Section IV of this Notice.

Right to Request a Paper Copy of This Notice – You have the right to a paper copy of this Notice at any time, even if you have agreed to receive this notice electronically. To obtain a paper copy of this Notice, please visit Austin Surgical Hospital. You may also obtain a copy of this Notice by visiting www.austinsurgicalhospital.com.

EXERCISING YOUR PRIVACY RIGHTS
To exercise your rights to inspect, copy, or request an amendment to your medical information, to obtain an accounting of disclosures, to request restrictions, to request confidential communications, and to request “No Information” status, you must either submit your request in writing to the following person, or inquire within the Austin Surgical Hospital where you are or have been a patient:

Austin Surgical Hospital
Attn: Privacy Officer
3003 Bee Caves,
Austin. Texas 78746

If you have been a patient in a facility not listed above or in a physician’s private office, you should contact that provider directly to learn how to exercise your privacy rights.

VII. CHANGES TO THIS NOTICE
Austin Surgical Hospital reserves the right to make changes to this Notice, and to make any revised Notice effective as to any of your medical information already received, as well as any medical information to be obtained in the future. The most recent Notice will be posted within Austin Surgical Hospital and also on our website, www.austinsurgicalhospital.com. The Notice will contain on the first page, in the upper left-hand corner, the effective date.

VIII. COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with Austin Surgical Hospital or with the Secretary of the Department of Human Health and Services. To file a complaint with Austin Surgical Hospital contact the Privacy Officer at Austin Surgical Hospital at 3003, Bee Caves, Austin Texas 78746. You will not be penalized for filing a complaint.

IX. OTHER USES OF MEDICAL INFORMATION WITH YOUR AUTHORIZATION
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you authorize a Austin Surgical Hospital to use or disclose your medical information in ways not covered by this Notice, you may revoke that authorization at any time by submitting a written request to the persons listed in Section VI, depending upon which Austin Surgical Hospital was authorized to use or disclose your medical information. When you revoke an authorization that Austin Surgical Hospital will no longer use or disclose medical information about you for the purposes set forth in the authorization. You understand, however, that we are unable to take back any disclosures already made with your permission, and that the law requires the retention of records relating to the care we have provided to you.