North Scottsdale Ambulatory Surgery Center

9439 East Ironwood Square Drive, Suite 100

Scottsdale, Arizona 85258

(480) 355-3750

NOTICE OF PRIVACY PRACTICES

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

The privacy of your personal health information is important to us and we are committed to protecting it. This Protected Health Information (PHI) includes personal information about you and your demographics as well as your medical information. We create a record of the care of services you receive at our facility in order to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share your PHI. We also describe your rights and certain duties we have regarding the use and disclosure of PHI.

NORTH SCOTTSDALE AMBULATORY SURGERY CENTER is required to follow specific rules on maintaining the confidentiality of your protected health information, how our staff uses your information, and how we disclose or share this information with other healthcare professional involved in your care and treatment. This notice describes your rights to access and control your protected health information. It also describes how we follow those rules and use and disclose your protected health information to provide your treatment, obtain payment for services you receive, manage our health care operations and for other purposes that are permitted or required by law.

If you have any questions about this Notice please contact our Privacy Officer at (480) 355-3752

Your Rights Under The Privacy Rule

Following is a statement of your rights, under the Privacy Rule, in reference to your protected health information. Please feel free to discuss any question with our staff.

You have the right to receive and we are required to provide your with a copy of this Notice of Privacy Practices - We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. If needed, new versions of this notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment.

You have the right to authorize other use and disclosure This means you have a right to authorize or deny any other use or disclosure of protected health information not specified in this notice. You may revoke an authorization, at any time, in writing, except to the extent that your physician or our office has taken in action in reliance on the use or disclosure indicated in the authorization.

You have the right to designate a personal representative This means you may designate a person with the delegated authority to consent to, or authorize the use of disclosure of protected health information.

You have the right to inspect and copy your protected health information This means you may inspect and obtain a copy of protected health information about you that is contained in your patient record via written request.

You have the right to request a restriction of your protected health information This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare 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. In certain cases, we may deny your request for a restriction.

You may have the right to have us amend your protected health information This means you may request an amendment of your protected healthcare information for as long as we maintain this information. In certain cases, we may deny your request for an amendment.

You have the right to request disclosure accountability This means you may request a listing of your protected health information disclosures we have made to entities or persons outside of our office.

You have the right to request to receive confidential communications from us by alternative means or locations.

Complaints

You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Office of your complaint.

How We May Use or Disclose Protected Health Information

Following are examples of use and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

For Treatment We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that is involved in your care and treatment. For example, we would disclose your protected health information, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose protected health information to other physicians who may be involved in your care and treatment.

We may also call you by name in the waiting room and throughout your stay at the center in order to coordinate your care with your physician and other staff members.

For Payment Your protected health information will be used, as needed, to obtain payment for our health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for 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 utilization review activities.

For Healthcare Operations We may use or disclose, as needed, your protected health information in order to support the business activities of our practices. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, and auditing functions. It also includes education, provider credentialing, certification, underwriting, rating, or other insurance related activities. Additionally it includes business administrative activities such as customer service, compliance with privacy requirements, internal grievance procedures, due diligence in connection with the sale or transfer of assets, and creating de-identified information.

Other Permitted and Required Users and Disclosures

Unless you object, we may also use and disclose your protected health information in the following instances:

For Appointment Reminders: We may use your personal health information to contact you, a family member or other responsible person to remind you of your appointment at North Scottsdale Ambulatory Surgery Center and to provide information regarding payment that may be due at the time of service. We will use the phone number(s) given to us by your physician and will limit the information disclosed when leaving a message. If you prefer we use a different phone number, not leave messages, or prefer that we do not speak with anyone other than you, please contact the privacy offer in writing at the address provided in this notice.

To Notify Others Involved in Your Care: We may use your personal health information to notify a family member or other person responsible for your care. We will share information about your location at our facility, your general condition and approximate wait time. If you are present, we will get your permission if possible, before we share this information. In case of emergency and/or if you are not able to give or refuse permission, we will share only the information that is directly necessary for your health care, according to our professional judgment to make decisions in your best interest.

As Required by Law We may use or disclose your protected health information to the extent that the use or disclosure is required by law.

For Public Health We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.

For Communicable Diseases We may disclose your protected health information, if authorized by law, to a person who may have been exposed to communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

For Health Oversight We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.

In Cases of Abuse or Neglect We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the government entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

To The Food and Drug Administration We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

For Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceedings, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

To Law Enforcement: We may also disclose protected health information, so long as applicable legal requirement are met, for law enforcement purposes.

To Coroners, Funeral Directors, and Organ Donation We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

In Cases of Criminal Activity Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

For Military Activity and National Security - When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.

For Workers Compensation - Your protected health information may be disclosed by us as authorized to comply with workers compensation laws and other similar legally-established programs.

When an Inmate We may use or disclose your protected health information if you are an inmate of a correction facility and your physician created or received your protected health information in the course of providing care to you.

Required Uses and Disclosures Under the law, we must make disclosures about you and when require by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the Privacy Rule.

For Research in Limited Circumstances: We may use your information for research purposes in limited circumstances where the research has been approved by the Governing Body and protocols have been established to ensure the privacy of your information.