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HIPAA Privacy Policy

Effective Date: April 14, 2003
Notice of Privacy Practices



The purpose of this notice (“Notice”) is to inform you of how your patient information will be handled as a result of new privacy regulations required under a federal law, the Health Insurance Portability and Accountability Act of 1996. This law protects information about you or your medical condition that identifies you as a patient (sometimes referred to as “protected health information” or “PHI”). This Notice describes the privacy practices that will be followed by Philadelphia Surgi Center, Inc. (the “Surgi Center”), and others who are permitted to use or disclose your medical information, as well as the Surgi Center’s legal obligations regarding the use or disclosure of your health information and your rights with respect to the Surgi Center’ s use and disclosure of such information. This Notice will be effective on April 14, 2003.


The Surgi Center is required by law to: (a) maintain the privacy of your PHI; (b) provide you with notice of the Surgi Center’s legal duties and privacy practices with respect to PHI; and (c) abide by the terms described inthis Notice.

1. Uses and Disclosures of Protected Health Information

A. Description of Uses and Disclosures of Protected Health Information for Treatment, Payment or Surgi Center Health Care Operations

You will be asked by Surgi Center to sign a cons ent form and an acknowledgement of receipt of this Notice. When we obtain your consent, or you acknowledge in writing your receipt of this Notice, or you fail to acknowledge receipt but we make a good faith effort to obtain a written acknowledgement (which we document along with the reasons for the failure), and in certain other circumstances, we are permitted by law to use or disclose your PHI for treatment, payment and Surgi Center health care operations. Some examples of the ways in which we may use and disclose PHI for these purposes are described below. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by the SurgiCenter once you have provided consent or acknowledged receipt of this Notice.

Treatment. We may use and disclose your PHI to provide treatment for your medical condition, coordinate or manage your health care and provide related services. Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health careservices to you. This includes the treatment for your medical condition and the coordination or management of your health care with another health care provider. For example, we may disclose your PHI, as necessary, to a home health agency that provides care to you. We may also disclose PHI to other physicians who may be treating you or otherwise assisting in the provision of care to you. For example,

your PHI may be provided to a physician to whom
you have been referred to ensure that the
physician has the necessary information to trea
t you. In addition, we
may disclose your PHI
from time-to-time to another physician or health
care provider (e.g., a sp
ecialist or laboratory)
who, at the request of your physician, become
s involved in your care by providing assistance
with your treatment.
. We may also use and disclose PHI about
you to obtain payment for the health care
services that we provide to you.
This may include certain activiti
es that your health insurance
plan may undertake before it approves or pays
for the health care services we recommend for
you such as making a determination of eligibility
or coverage for insurance benefits, reviewing
services provided to you for medical necessity,
and undertaking u
tilization review
activities. For
example, we may tell your health plan about a
treatment recommended for you in order to obtain
prior approval or to determine whether your plan
will cover the treatment.
We may need to give
your health plan information about treatment you r
eceived so your health plan will pay us or
reimburse you for that treatment. We may also
disclose PHI about you to a third party for the
payment activities of such party. For example, we
may be asked to disclose your PHI to another
provider in order to support the medical necessity
of that provider’s care to you for purposes of
payment to the provider.
Health Care Operations
. We may use and disclose your PH
I in order to support the business
activities and operations of the Su
rgi Center. These uses and disc
losures are necessary to run the
Surgi Center. For example, we may use PHI to
review our treatment and services and the
performance of our staff in caring for you. We
may also, under limited circumstances, disclose
your PHI to a third party caring for you, which is
necessary to support its health care operations.
For example, the disclosure of PHI to a third party may be necessary for such third party’s
quality assessment and improvement activities or
a review of the competence of its providers
treating you.
We may also disclose your PHI to third part
y “business associates”
that perform various
activities (e.g., billing, insurance,
accounting and medical transcrip
tion services) for or on behalf
of the Surgi Center. Whenever an arrangeme
nt between the Surgi Center and a business
associate involves the use or disclosure of your
PHI, we will have a written agreement with the
business associate that is intended to
protect the privacy of your PHI.
Treatment Alternatives
. We may use or disclose your PHI,
as necessary, to provide you with
information about treatment options or altern
atives that may be of
interest to you.
Health-Related Benefits and Services
. We may send you information about products or
services that we believe may be beneficial to you. Under certain
circumstances, we may use and
disclose your PHI for other mark
eting activities as well. For
example, your name and address
may be used to send you a newslett
er about our services we offer.
You may contact our Privacy
Department to request that these
materials not be sent to you.
Fundraising Activities
. We may use your PHI to
contact you in an effort to raise money for the
Surgi Center. We may disclose your name and
address and the dates you received services to a
foundation that is affiliated with th
e Surgi Center or a third party bus
iness associate so that either
party may contact you in raising money for the Surg
i Center. If you do not want to receive these
materials, please contact our
Advertising Department at 215
-969-1048 and request that these
fundraising materials not be sent to you.
Training Purposes
. We may use and disclose your PHI
for purposes of providing training and
education to medical school stude
nts and/or residents who treat pa
tients at the Surgi Center.

Appointment Reminders
. We may use or disclose your PHI, as necessary, to contact you as a
reminder that you have an appointment at the Surg
i Center. This may be done via an automated
calling system.
. We may use or disclose
your PHI in an emergency tr
eatment situation. Under
these circumstances, the Surgi Center will try to obtain your consent as soon as reasonably
practicable after the de
livery of treatment to you. If your
physician or another physician in the
practice is required by law to tr
eat you and the physician has a
ttempted to obtain your consent
but is unable to do so, he or she may stil
l use or disclose you
r PHI to treat you.
Communication Barriers
. We may use and disclose your
PHI if your physician or the Surgi
Center attempts to obtain consent from you but
is unable to do so due to substantial
communication barriers and the phys
ician or the Surgi Center determines, in the exercise of
professional judgment, that your consent to r
eceive treatment is clearly inferred from the
B. Pennsylvania Law Preemption.
1. Confidentiality of Medical Records
Ambulatory Surgical Facilities
. Medical records of individuals of the Surgi
Center will be treate
d as confidential. Only authori
zed personnel will have access
to such records. The written authorization of
the patient will
be presented and
then maintained in the original record as authority for release of medical
information outside of the Surgi Center.
Medical records of the Surgi Center may
not be removed from the Surgi Center
except for court purposes pur
suant to a valid subpoena
issued by a court of
competent jurisdiction requiring the producti
on of such records and copies may be
made available for authorized appropriat
e purposes, such as insurance claims and
Medical Practice Act
. Physicians are prohibited from revealing personally
identifiable facts, obtained
as a result of a physician-
patient relationship, without
the prior consent of the patient, except as
authorized or required by statute.
2. Reports of Disease or Injury or
Conduct of Public Health Surveillance
The Surgi Center may make required reports of
diseases or injuries
or for the conduct of
public health surveillance in accord
ance with applicable state law.
C. Uses and Disclosures of Protected Health
Information Requiring an Opportunity For You
to Agree or Object
We may use or disclose your PH
I without your consent or author
ization in limited circumstances
when you are informed in advance of the use
and disclosure and you ha
ve the opportunity to
agree, object, or limit the use or disclosure. Un
less you advise us of your objection to these uses,
we will assume that you agree that we may use your
PHI as described in this section. The types
of uses or disclosures that requir
e us to provide you with an opport
unity to agree or object are set
forth below. [note: as part of
the registration process, the Surgi
Center should advise the patient
of his/her rights under this section and obtain ag
reement for such use, which should then be

Clinic Directory
While you are a patient at the Su
rgi Center, we may include limited
information about you in our directory. This in
formation may include your name, location in the
Surgi Center, your general condition (e.g., fair, stab
le, etc.) and your religion. Your location and
condition may also be released
to people who ask for you by name. Your religion may be given
to a member of the clergy, such as a priest, minister
or rabbi. This is so
your family, friends and
clergy can visit you at the Surgi Center and
generally know how you are doing. If you do not
want us to list this information in our directory a
nd provide it to clergy or
others, you must tell us
that you object.
Individuals Involved in
Your Health Care
. We may disclose PHI about you to a family
member, relative, close friend or anyone you identif
y who is involved in your
medical care or to
someone who helps pay for your care. These di
sclosures will be limited to the PHI that is
directly relevant to the indi
vidual’s involvement in your ca
re or payment for your care.
Notification Identification and Loca
tion of Others and Disaster Relief
. We may use or
disclose PHI to notify, identify or
locate relatives and personal cu
stodians to inform them of your
health status, condition, or deat
h. We may disclose your PHI to a public or private entity
authorized by law to assist in disaster relief e
fforts. If you are able and available to agree or
object, we will give you the opportunity to object pr
ior to making this notification. If you are
unable or unavailable to agree or
object, our health professionals wi
ll use their best judgment in
connection with your family and others.
D. Other Permitted and Required Uses and Di
sclosures That May Be Made Without Your
Consent, Authorization or Opportunity to Object
In certain circumstances, we may use or disclose
your PHI without your cons
ent, authorization or
agreement. Some of the types of uses or disc
losures that may be made without your permission
are set forth below, but not every use or
disclosure of this type is listed.
Required By Law
. We will disclose PHI about you to the
extent that we are required to do so
by federal, state or local law.
Public Health and Health Oversight Activities
. As required by law, we may disclose to a
public health authority PHI about you for publ
ic health activities that may include:
Prevention and control of disease, injury or disability;
Providing notice to a person who ma
y be at risk for contracti
ng or spreading a disease or
condition; and
Reporting and prevention of neglect, domestic vi
olence or abuse, consistent with applicable
federal and state law.
We may disclose PHI to an agency responsible
for overseeing health care
activities authorized by
law. Health oversight activi
ties include audits, investigations, inspections, proceedings, and
licensure and disciplinary actions or other activities necessary for appropriate oversight of the
health care system, government benefit programs,
and entities subject to government regulatory
programs or civil rights laws.
FDA Reporting
. We may disclose your PHI to non-govern
ment entities subject to regulation by
the Food and Drug Administration
regarding the quality, safety
and effectiveness of FDA-
regulated products and activities, including:

Collecting or reporting of reactions to medica
tions or problems with medical devices; and
Providing notice of drug or
medical device recalls.
Legal Proceedings
We may disclose your PHI as part
of a judicial or administrative
proceeding, in response to a court or administrativ
e order. In response to a subpoena, discovery
request or other lawful process that is not acco
mpanied by a court or administrative order, we
may only produce the information if we receive sa
tisfactory assurance from the party seeking the
information that reasonable efforts have been made
to tell you about the re
quest for your PHI or
to obtain an order protecting the
information requested. If we do not receive this satisfactory
assurance, we will not disclose any PHI under these circumstances unless we make reasonable
efforts to notify you of the request for your PHI
or we seek a qualified protective order from a
court or administrative tribunal to
protect the information requested. In any case, we will only
disclose the amount and type of information that
is expressly required or authorized by the
request or order.
Law Enforcement
. We may release PHI to law en
forcement officials under limited
circumstances for purposes of: (1) responding to
a court order, subpoena, warrant, summons or
similar process, (2) identifying
or locating a suspect, fugitive
, material witness or missing
person, (3) responding to a request for information about the victim of a crime, (4) responding to
a request for information about a death we believe
may be the result of criminal conduct, (5)
responding to a request for information about cr
iminal conduct on the premises of the Surgi
Center, and (6) in emergency circumstances to report a crime.
Coroners, Medical Examiners and Funeral Directors
. We may release PHI to a coroner or
medical examiner for the purpose of identifying a deceased person, determining the cause of
death or for the coroner or medical examiner to
perform other duties authorized by law. We may
also disclose PHI about patients of the Surgi Center
to funeral directors as
necessary to carry out
their duties.
Organ and Tissue Donation
. We may release PHI to or
ganizations that handle organ
procurement or organ, eye or tissue transplantatio
n or to an organ donation bank, as necessary to
facilitate organ or tissue
donation and transplantation.
To Prevent a Serious Threat to Health or Safety
. We may disclose your PHI when necessary
to prevent or lessen a serious and imminent threat
to your health and safety or the health and
safety of the public or another person.
Military and Veterans
. If you are a member of the arme
d forces, we may release PHI about
you as required by military command authorities.
We may also releas
e PHI about foreign
military personnel to the appropriate foreign military authority.
National Security and Intelligence Activities
. We may disclose PHI about you to authorized
federal officials for intelligence, counterinte
lligence, and other national security activities
authorized by law.
Protected Services for the President and Others
. We may disclose PHI about you to
authorized federal officials so they may provi
de protection to the Pr
esident, certain other
governmental persons or foreign heads of state.
Workers’ Compensation
. We may disclose your PHI to th
e extent authorized by and to the
extent necessary to comply with laws relati
ng to workers’ compensation or other similar
programs that provide benefits for
work-related injuries or illnesses.

Correctional Institutions
. Under certain circumstances, we may use or disclose protected
information of patients who are in
mates of a correctional facility.
. In the absence of an authorization,
we may disclose PHI to researchers:
If the research has been appr
oved by an Institutional Review
Board or a Privacy Board that
has reviewed the research proposal and established protocols to
ensure the privacy of your
PHI. This might be used, for example, to
conduct records researc
h, when researchers are
unable to use de-identified information and
it is not practicable to obtain research
participants’ aut
horization; or
If we have received representations from the researcher, either in writing or orally, that the
use or disclosure of the PHI is solely to prep
are a research protocol
or for similar purposes
preparatory to research, that the researcher
will not remove any PHI from the Surgi Center
and that PHI for which access is sought is necessary for the research purpose. This
provision might be used, for example, to design
a research study or to assess the feasibility
of conducting a study; or
If we have received representations from the researcher, either in writing or orally, that the
use or disclosure being sought is solely for
research on the PHI of decedents, that the PHI
being sought is necessary for the research,
and, at the request of the Surgi Center,
documentation of the death of the individuals
about whom information is being sought.
Limited Data Set
. We may use or disclose to a third pa
rty a limited data set, which is PHI about
you which excludes certain direct id
entifiers, solely for the purposes
of research, public health or
Surgi Center health care operations.
If we use or disclose a limite
d data set to a recipient, we
will enter into a data use agreemen
t with the recipient and obtain
satisfactory assurances from the
recipient that the PHI in the limited data
set will only be used for limited purposes.
E. Uses and Disclosures of Protected He
alth Information Based upon Your Written
We may make other uses and disclosures of
your PHI not covered by this Notice. Unless
otherwise permitted or required by law, these uses
and disclosures will be made only with your
written authorization. For example, most uses an
d disclosures of PHI for
the purpose of research
will require your written permission, except as othe
rwise described in this Notice or as permitted
by law.
If you give permission to use or disclose
PHI about you, you may revoke
that permission in
writing at any time. If you revoke your permissi
on, we will no longer use or disclose PHI as had
been permitted by your written
authorization. We are, howev
er, unable to take back any
disclosures we have alrea
dy made with your permission.
Your Rights Regarding Your
Protected Health Information
You have the following rights regardi
ng the PHI we maintain about you:
Right to Request Restrictions
. You have the right to request
that we restrict the use or
disclosure of PHI about you for treatment, paymen
t or health care operations. You also have the
right to request a limit on the PH
I we disclose about you to someone who is involved in your
care or the payment for your care, like a family
member or friend. For example, you could ask
that we not use or disclose information about
a medication prescribed to you. The Surgi Center
is not, however, required to agre
e to any restriction
requested by you under this paragraph. If we

agree, we will comply with your request unle
ss the information is needed to provide you
emergency treatment, or as otherwise permitted by law.
To request restrictions, you mu
st make your request in writing. To obtain a Request for
Restrictions form contact our
Administrative Department at
215-969-1048. In your request, you
must tell us: (a) what information you want
to limit; (b) whether you want to limit our use,
disclosure or both; and (c) to whom you want th
e limits to apply – for example, disclosures to
your spouse.
Right to Inspect and Copy
. You have the right to inspect
and copy PHI that may be used to
make decisions about your care. This incl
udes medical records, but does not include
psychotherapy notes, information compiled in reas
onable anticipation of,
or use in, a civil,
criminal, or administrative action or proceeding, a
nd PHI that is subject to law that prohibits
your access to such information.
To inspect and copy PHI, you must submit your
request in writing to our Medical Records
Department at 215-969-1048. If you request a c
opy of the information, we may charge you a
reasonable fee for the costs of copying, mailing
or other costs associated with your request.
For an additional charge, you may also request a su
mmary and/or explanation of the PHI that we
use to make decisions about your care. We w
ill advise you of the then-current fee for this
optional service, and if you agree in advan
ce to this arrangement, we will provide the
information to you.
We may deny your request to inspect and copy
in certain limited circumstances. If you are
denied access to PHI, you may be able to request
a review of that decision. Depending on the
circumstances, the decision to deny access may or
may not be reviewable. If you make such a
request, we will notify you as to whether the deci
sion is reviewable. If
reviewable, another
health care professional chosen by the Surgi Center
will review your request and the denial. The
person conducting the review will not be the pers
on who denied your request. We will comply
with the outcome of the review.
Right to Request Confid
ential Communications
. You have the right
to request that we
communicate with you about medical matters in a cer
tain way or at an alternate location. For
example, you may ask that we only contact you at
the office or only by mail. If your request is
reasonable, we will accommodate it.
To request confidential communications from us
by an alternate means or at an alternative
location, you must make your request
in writing to our
Administrative Department. Your request
must specify how or where you wish to be c
ontacted. To obtain a copy of a Confidential
Communications request form, please contact
our Administrative Department at 215-969-1048.
Right to Amend
. If you believe that PHI we have about
you is incorrect or incomplete, you may
ask us to amend the information. You have the ri
ght to request an amendment for as long as the
information is kept by the Surgi Center.
To request an amendment, your request must be made in writing and submitted to our
Administrative Department. To obtain a Re
quest for Amendment Form, please contact our
Administrative Department at 215-969-1048. In a
ddition, we will require you to provide us with
a reason in support of your request.

We may deny your request for amendment if it is
not in writing. We may
also deny your request
if it does not include a reason to
support the request. In addi
tion, we may deny your request if
you ask us to amend information that:
Was not created by us, unless the person or ent
ity that created the information is no longer
available to make the amendment;
Is not part of the PHI kept by the Surgi Center;
Is not part of the information which you w
ould be permitted to inspect and copy; or
Is accurate and complete
If your request to amend your medical informa
tion is denied, you may file a statement of
disagreement with us. You also have a right to
a copy of our rebuttal statement, if we choose to
prepare one.
Right to an Accounting of Disclosures
. Subject to certain limita
tions, you have the right to
request an accounting of disclosu
res of your PHI to third parties made by the Surgi Center during
the six (6) years prior to the
date of your request. You ar
e not, however, entitled to any
Related to treatment, payment or health
care operations of the Surgi Center;
Made to you;
Incident to a use or disclosure otherwise pe
rmitted or required pursuant to a 45 C.F.R.
§164.502 (which do not provide you with an opportuni
ty to agree or object or require your
Made for the Surgi Center’s directory or to
persons involved in your
care or as otherwise
permitted under Section 1.B. above;
Pursuant to an authorization;
For national security or intelligence purposes;
To correctional institutions or law enforcement officials;
Made as part of a limited data set; or
Made prior to April 14, 2003.
To request an accounting of disclosures, you
must submit your request in writing to our
Administrative Department. Your request must st
ate a time period not longer than six (6) years,
and the time period cannot extend to dates be
fore April 14, 2003. The first list you request
within a twelve (12) month period will be free.
For additional lists, we may charge you for the
costs of providing the list.
Right to a Paper Copy of this Notice
. You have the right to r
eceive a paper copy of this
Notice. You may ask us to give you a copy of th
is Notice at any time. To obtain a paper copy of
this Notice, please contact our
Administrative Department.
An electronic copy of this Notice will be poste
d at our website when it becomes operational.



Changes to this Notice

The Surgi Center reserves the right to change

this Notice and to make the revised Notice

effective for PHI currently in our possession and fo

r any PHI we receive in the future. We will

post a copy of the current Notice at the Surgi Center

. The effective date w

ill be noted in the top

right-hand corner of the first page

of the Notice. Each time you are

registered at the Surgi Center

for treatment or health care se

rvices we will offer you a copy of

our current Notice. Unless and

until changes to the Notice are made, the Surgi Cent

er is required by law to comply with this

Notice. You will be able to tell when changes have been made to our Notice of Privacy Practices

by referring to the upper right-hand

corner of the Notice, which will

include the revision date of

that Notice.



If you believe that we have viol

ated your privacy rights,

you may file a complaint with us or the

Secretary of the Department of Health and Human

Services. To file a complaint with us, please

contact Margaret Ehrhardt of our Administrativ

e Department at (215) 959-1048. All complaints

must be submitted in writing. There will be no

retaliation against you for filing a complaint.


Questions and Requests for Further Information

If you want additional information or have any

questions about this No

tice please contact:

Margaret Ehrhardt, Privacy Officer at (215) 959-1048.

To contact our Medical Records Department, please call us at


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