MID-ATLANTIC SURGICAL ASSOCIATES, P.C.
HIPAA NOTICE OF PRIVACY PRACTICES
Effective Date: February 16, 2011
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 is provided to you pursuant to the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations ("HIPAA"). It is designed to tell you how we may, under federal law, use or disclose your Health Information.
We May Use or Disclose Your Health Information for Purposes of Treatment, Payment or Healthcare Operations without Obtaining Your Prior Authorization and Here is One Example of Each:
We may provide your Health Information to other health care professionals - including doctors, nurses, and technicians - for purposes of providing you with care.
Our billing department may access your information - and send relevant parts - to other insurance companies to allow us to be paid for the services we render to you.
We may access or send your information to our attorneys or accountants in the event we need the information in order to address one of our own business functions.
We May Also Use or Disclose Your Health Information Under the Following Circumstances without Obtaining Your Prior Authorization:
To Notify and/or Communicate with Your Family.
Unless you tell us you object, we may use or disclose your Health Information in order to notify your family or assist in notifying your family, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in any communications with your family and others.
As Required by Law.
We may use and disclose your Health Information as required by law. For example, we may disclose your Health Information: for judicial and administrative proceedings pursuant to legal authority; to report information related to victims of abuse, neglect or domestic violence; or to assist law enforcement officials in their law enforcement duties.
For Public Health Purposes.
We may use or disclose your Health Information to provide information to state or federal public health authorities, as required by law to prevent or control disease, injury, or disability; to report child abuse or neglect; report domestic violence; report to the Food and Drug Administration problems with products and reactions to medications; and report disease or infectious exposure.
For Health Oversight Activities.
We may use or disclose your Health Information to health oversight agencies during the course of audits, investigations, certification and other proceedings.
For Purposes of Organ Donation.
We may use or disclose your Health Information for purposes of communicating to organizations involved in procuring, banking or transplanting organs and tissues.
For Public Safety.
We may use or disclose your Health Information in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
To Aid Specialized Government Functions.
If necessary, we may use or disclose your Health Information for military or national security purposes.
For Worker's Compensation.
We may use or disclose your Health Information as necessary to comply with worker's compensation laws.
To Correctional Institutions or Law Enforcement Officials.
If You are an Inmate.
To Coroners or Funeral Directors.
We may use or disclose your Health Information for purposes of communicating with coroners, medical examiners and funeral directors.
For All Other Circumstances.
We May Only Use or Disclose Your Health Information After You Have Signed an Authorization. If you authorize us to use or disclose your Health Information for another purpose, you may revoke your authorization in writing at any time, except to the extent that we have already taken action in reliance upon the authorization.
Authorization for Marketing Purposes.
We will obtain your written authorization prior to using or disclosing your Health Information for marketing purposes. However, we are permitted to provide you with marketing materials in a face-to-face encounter, without obtaining a marketing authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining a marketing authorization. In addition, as long as we are not paid to do so, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings. We may use or disclose Health Information to identify health-related services and products that may be beneficial to your health and then contact you about the services and products.
Incidental Uses and Disclosures of Information May Occur.
An incidental use or disclosure is a secondary use or disclosure that cannot be prevented, is limited in nature, and that occurs as a by-product of an otherwise permitted use or disclosure. However, such incidental uses or disclosures are permitted only to the extent that we have applied safeguards and do not disclose any more of your Health Information than is necessary to accomplish the permitted use or disclosure. For example, a conversation about a patient within the office that might be overhead by persons not involved in the patient’s care is an incidental disclosure and it is not likely to constitute a HIPAA violation.
You Should Be Advised that We May Also Use or Disclose Your Health Information for the Following Purposes:
We may use your Health Information in order to contact you to provide appointment reminders or to give information about other treatments or health-related benefits and services that may be of interest to you. Please let us know if you do not wish to have us contact you for these purposes, or if you would rather we contact you at a different telephone number or address.
Change of Ownership.
In the event that our Practice is sold or merged with another organization, your Health Information/record will become the property of the new owner.
You have the right to request restrictions on the uses and disclosures of your Health Information. However, we are not required to comply with your request. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. Under certain circumstances, we may terminate an agreement to a restriction. Notwithstanding the foregoing, effective for services provided to you after February 16, 2010, you have the right to ask us to restrict the disclosure of your Health Information to your health plan for a service we provide to you where you have directly paid us (out of pocket, in full) for that service, in which case we are required to honor your request.
You have the right to receive your Health Information through confidential means through a reasonable alternative means or at an alternative location.
In most cases, you have the right to inspect and copy your Health Information, but you must make the request in writing. If we do not have your Health Information but know who does, we will tell you how to get it. We will respond to your request within thirty (30) days after our receipt of your written request. If you request copies of your Health Information, we may charge you a reasonable cost-based fee, as permitted by applicable New Jersey law, to cover copying, postage and/or preparation of a summary. If we maintain an electronic health record for you, you may request access to your Health Information in electronic format. Instead of providing the Health Information you requested, we may provide you with a summary or explanation of the Health Information as long as you agree to that and to the cost in advance. In certain situations, we may deny your request. In such case, we will tell you, in writing, the reasons for the denial and explain your right to have the denial reviewed.
**Please note, if you are the parent or legal guardian of a minor, certain portions of the minor’s medical record may not be accessible to you. For example, records relating care and treatment to which the minor is permitted to consent himself/herself (without your consent), such as care received by a married minor, may be restricted unless the minor patient provides an authorization for such disclosure. **
You have a right to request, in writing, that we amend your Health Information that you believe is incorrect or incomplete. We may deny your request if the Health Information is (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file one, you have the right to have your request and our denial attached to all future disclosures of your Health Information. If we approve your request, we will make the change to your Health Information, tell you that we have done so, and tell others that need to know about the change to your Health Information.
You have a right to receive an accounting of disclosures of your Health Information made by us, except that we do not have to account for disclosures: authorized by you; made for treatment, payment, health care operations; provided to you; provided in response to an Authorization; made in order to notify and communicate with family; and/or for certain government functions, to name a few. You may request an accounting of disclosures made in the last six (6) years or a shorter time. The list will include the date of the disclosure, to whom the Health Information was disclosed (including their address, if known), a description of the Health Information disclosed and the reason for the disclosure. We will provide one (1) list during any 12-month period without charge. Subsequent requests may be subject to a reasonable cost-based fee.
You have a right to a paper copy of this Notice of Privacy Practices. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer.
We are required by law to maintain the privacy of your Health Information and to provide you with a copy of this Notice.
We are also required to abide by the terms of this Notice.
We reserve the right to amend this Notice at any time in the future and to make the new Notice provisions applicable to all your Health Information - even if it was created prior to the change in the Notice. If such amendment is made, we will immediately display the revised Notice at our office and on our website. We will provide you with another copy of this Notice at any time, upon request.
You may make complaints to our Privacy Officer or to the Secretary of the Department of Health and Human Services ("DHHS") if you believe your rights have been violated.
We promise not to retaliate against you for any complaint you make about our privacy practices.
You may contact us about our privacy practices by calling the Privacy Officer at:
Mid-Atlantic Surgical Associates, P.C.
100 Madison Avenue
Morristown, NJ 07960
You may contact the DHHS at:
200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll Free: 1-877-696-6775
Notice of Privacy Practices Acknowlegement Form
Click here to open a PDF of the Notice of Privacy Practices Acknowlegement Form
This Notice of Privacy Practices is also available on our web page as