NOTICE OF PRIVACY PRACTICES

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This page explains how we may use and share your Protected Health Information (PHI) to provide treatment, handle payment, and run our operations, as permitted or required by law. It also outlines your rights and our responsibilities. “PHI” includes information that identifies you and relates to your past, present, or future health and care. Please review carefully.

Your Rights

This section explains your rights and how we acknowledge them.

Request a copy of your medical record (paper or electronic)

  • On request, we will provide a Request to Inspect or Copy Patient Information form (includes our privacy official’s contact information).

  • We’ll provide a copy or a summary of your health information, usually within 60 days. We may charge a reasonable, compliant fee for labor, postage, and supplies. We will not charge a fee if the copy is needed to file a claim under the Social Security Act or another state/federal needs-based program.

Receive a paper copy of this Notice

  • You may ask for a paper copy of this Notice at any time, even if you agreed to receive it electronically.

Request a correction (amendment) to your record

  • On request, we will provide a Request to Amend Patient Record form.

  • If your request isn’t in writing or doesn’t include a reason, we may deny it. We will respond in writing within 60 days.

Request confidential or alternative communications

  • You may ask us to contact you in a specific way or at a specific place (for example, at work or by email).

  • Requests must be in writing to our privacy office. We will provide a Request for Alternative Communications form.

Ask us to limit the information we share

  • You may list individuals involved in your care to whom we may disclose PHI. We’ll provide a PHI Use and Disclosure Authorization form upon request.

  • If you pay for a service out-of-pocket in full, you can ask us not to share that information with your health plan for payment or operations. Submit this in writing to our privacy office; we’ll provide a Request to Restrict Disclosure to Health Plan form.

Receive an accounting of disclosures

  • You may request a list of certain disclosures we’ve made of your PHI. (We are not required to list disclosures made for treatment, payment, and health care operations.)

  • Submit your request in writing; we’ll provide a Request for Accounting of Disclosure of PHI form. Your first request in any 12-month period is free. Reasonable fees may apply for additional requests in the same period.

Right to receive notice of a breach

  • If a breach involves your unsecured PHI, we will notify you by first-class mail or by email (if you prefer email) as soon as possible and no later than 60 days after discovery.

File a complaint if you believe your privacy rights were violated

  • You may file a complaint with our privacy officer. We will provide a Complaint Form (includes our privacy official’s name and contact information).

  • Complaints must be in writing and submitted within 180 days of when you knew or should have known about the issue.

  • You may also file with the U.S. Department of Health and Human Services, Office for Civil Rights: 200 Independence Avenue SW, Washington, DC 20201; 1-877-696-6775; or online at hhs.gov/ocr/privacy/hipaa/complaints/.

  • We will not retaliate against you for filing a complaint.

Your Choices

This section addresses choices you can make about how we share information.

You have the choice to tell us to:

  • Share information with your family and friends involved in your care.

  • Share your health information with disaster-relief organizations to coordinate care.
    If you cannot communicate (for example, you are unconscious), we may share information if we believe it is in your best interest.

We will never share your information without your written authorization for:

  • Marketing purposes. We need your written permission before using or disclosing your information for marketing. We may still contact you about health-related benefits or services that could interest you.

  • Sale of information. We will not sell patient lists or your health information to a third party without your written authorization.

Our Uses and Disclosures

This section explains how we typically use and share your information.

Health Care Treatment, Payment, and Operations

  • Plan and coordinate your care and treatment (including preauthorization and pre-certification).

  • Communicate with other providers (e.g., referring physicians).

  • Bill and coordinate payment with your health plan administrator.

  • Conduct quality and outcome assessments to improve our services.

  • Work with contracted business associates (e.g., answering services, transcription, record storage, consultants, legal counsel) under required privacy safeguards.

  • Communicate with you via newsletters, mailings, or other means about treatment options, health information, disease management, wellness programs, or community initiatives in which we participate.

Public Health and Safety

  • Manage product recalls.

  • Report suspected abuse, neglect, or domestic violence as required by law.

Compliance with the Law

  • Cooperate with Department of Health and Human Services investigations related to federal privacy laws.

  • Address workers’ compensation, law enforcement, and other government requests.

  • Respond to legal actions (court orders, subpoenas, warrants, summons, or similar processes) as authorized by law.

  • If you are deceased, disclose information to the executor/administrator of your estate to the extent that person is acting as your personal representative.

Our Responsibilities

  • If you have a personal representative (e.g., legal guardian), we will treat that person as you for purposes of PHI disclosures.

  • If a breach involves your unsecured PHI, we will notify you by mail or email (if you prefer email) as soon as possible and no later than 60 days after discovery.

  • We will provide notices like this Notice of Privacy Practices and follow the terms of our most current Notice.

  • We will notify you if we are unable to agree to a requested restriction.

Changes to This Notice

We may change our privacy practices and the terms of this Notice at any time. Changes will apply to all PHI we maintain. If our practices change, a revised Notice of Privacy Practices will be available upon request. We will not use or disclose your information without your authorization except as described in the most current Notice.

Contact Person:

Attn: Privacy Officer

Mountain View Surgical Specialists

5060 S Syracuse Street Denver, CO 80237

 The Privacy Officer can be contacted by telephone at 720-749-5599.

This notice is effective March 4, 2024.

HIPAA – Appendix

© 2023 Progressive Surgical Solutions, a division of VMG Health