NOTICE OF PRIVACY PRACTICES

FOR ANESTHESIA SERVICE MEDICAL GROUP (“ASMG”)

Effective Date: April 14, 2003

This notice describes how health information about you may be used and disclosed and how you can access this information.  Please review it carefully.

Contact - If you have any questions about this notice, please contact our Management Company, Anesthesia Management Professionals ("AMP") at (858) 277-4767 and ask for the Legal Department Administrative Assistant.  You may also visit our web site at ASMGmd.com for updates on this Notice and to view the ASMG mission statement.

OUR PLEDGE REGARDING YOUR HEALTH INFORMATION

To our Patients and their Families: 

ASMG physicians understand that your health information is personal and confidential.  This Notice of Privacy Practices (“Notice”) describes how ASMG uses and discloses your protected health information to provide treatment, obtain payment, or for other purposes necessary for operations.  Your health information includes the reason(s) for your hospitalization/treatment, the type of care and treatment you may receive, and other information, including demographic information (e.g., your home address, age, gender, religious preferences, etc.) that may be either necessary or helpful to identify you, or to assist your ASMG physician in providing your necessary medical care.  ASMG must follow the terms of the Notice currently in effect.

CHANGES TO THIS NOTICE

We reserve the right to change this notice without written notification to you.  We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future.  We will post a copy of the current notice on our website at ASMGmd.com.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following pages describe different ways that ASMG uses your health information and discloses your health information to persons and entities outside of ASMG.  Each description is of a category of use or disclosure.  We have not listed every use or disclosure within the categories, but all permitted uses and disclosures will fall within one of the following categories:

Treatment - ASMG may use health information about you to provide you with medical treatment and services.  We may disclose health information about you to other medical professionals and personnel who are involved in taking care of you.  Unless you tell us not to do so, we may also disclose health information about you to people outside the hospital who may assist in providing your medical care after you leave the hospital, such as family members or clergy.  Also, we may request information about you from a doctor’s office, or from another hospital where you were admitted, in order to coordinate and manage your care among all the health care providers who take part in providing your care. 

Payment - ASMG may use and disclose health information about you in order to obtain authorization from your insurance company, when required, to provide you services and treatment.  ASMG may also use and disclose health information about you in order to bill for the services we provided, and to collect payment from you, an insurance company, or a third party.  For example, we may tell your health plan about a future treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Health Care Operations - We may use and disclose health information about you for health care operations, including, for example: quality assurance, peer review, and risk management activities; administrative activities, including ASMG financial and business planning and development; and customer service activities, including investigation of complaints.  These uses and disclosures are necessary to operate ASMG and make sure all of our patients receive quality care.  For example, we may use medical information to review our treatment and services and to evaluate the performance of the ASMG physicians who care for you. 

Business Associates - There are some services provided in our organization through contracts with business associates.  Examples of business associates include billing companies, management consultants, quality assurance reviewers, etc. We may disclose your health information to our business associates so that they can perform the job we’ve asked them to do.  To protect your health information, we require our business associates to sign a contract that states they will appropriately safeguard your information. 

Appointment Reminders - We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care from an ASMG physician.  We may call you and leave information on your answering machine regarding food and liquid restrictions prior to a surgery, unless you tell us not to. 

Individuals Involved in your care or payment for your care - We may disclose health information about you to a friend or family member who is involved in your medical care, unless you tell us in advance not to do so.  We may leave preoperative or postoperative instructions for you on an answering machine or voicemail at the phone number you have provided to ASMG or the facility where you will be receiving care, unless you tell us not to do so. 

WITH YOUR SPECIFIC WRITTEN “AUTHORIZATION”

If there are reasons we need to use your information that has not been described in the sentences above, we will obtain your written permission (called “authorization”).  If you authorize us to use or disclose health information about you, you may revoke that authorization in writing at any time.  If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization.  Please understand that we are unable to take back any disclosure we have already made with your permission, and that we are required to retain our records of the care that we provided to you.  Some typical disclosures that require your written authorization, or the written authorization of your representative are for disclosure of Drug and Alcohol Abuse Treatment, HIV and AIDS Test Results, and Mental Health Treatment.  

SPECIAL SITUATIONS THAT DO NOT REQUIRE YOUR INFORMATION

CONSENT OR AUTHORIZATION

We will disclose health information about you without your permission when required to do so by federal, state or local law.  The following disclosures are permitted by law without any oral or written permission from you, although this list is not intended to be all-inclusive:

Organ and Tissue Donation - If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans - If you are a member of the armed forces, we may release health information about you as required by military command authorities.

Worker’s Compensation - We may release health information about you for worker’s compensation or similar programs if you have a work related injury.  These programs provide benefits for work related injuries.

Averting a Serious Threat to Health or Safety - We may use and disclose health information about you when necessary to prevent a serious threat to your health or safety, or the health and safety of another person or the public.  These disclosures would be made only to someone able to help prevent the threat.

Public Health Activities - We may disclose health information about you for public health activities.  These generally include the following:

  • To prevent or control disease, injury or disability.
  • To report births and deaths.
  • To report child abuse or neglect.
  • To report reactions to medications, problems with products or other adverse events.
  • To notify people of recalls of products they may be using.
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
  • To notify the appropriate government authority if we believe a patient has been the victim of abuse (including elder abuse), neglect or domestic violence.  We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities - We may disclose health information to a health oversight agency for activities authorized by law.  These oversight activities include 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 a dispute, we may disclose health information about you in response to a court or administrative order.  We may disclose health information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute.  We would only disclose this information if efforts have been made to tell you about the request to allow you to obtain an order protecting the requested information.

Law Enforcement - We may disclose health information if asked to do so by law enforcement officials for the following reasons:

  • In response to a court order, subpoena, warrant, summons or similar process.
  • To identify or locate a suspect, fugitive, material witness or missing person.
  • About the victim of a crime if, under certain circumstances, we are unable to obtain the person’s agreement.
  • About a death we believe may be the result of a criminal conduct.
  • About criminal conduct at our facility.
  • In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Home Directors - We may disclose health information to a coroner or medical examiner.  This may be necessary to identify a deceased person or determine the cause of death of a person.  We may also release health information about patients at our facility to funeral home directors as necessary to carry out their duties.

National Security and Intelligence Activities - We may disclose health information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Inmates - If you are an inmate of a correctional institution or under custody of a law enforcement official, we may disclose health information about you to the correctional institution or the law enforcement official.  This is necessary for the correctional institution to provide you with health care, to protect your health and safety and the health and safety of others, or for the safety and security of the correctional institution.

YOUR HEALTH INFORMATION RIGHTS

You have the following rights regarding your information in our possession.

You have the right to:

  1. Request a restriction on certain uses and disclosures of your information.  We are not required by law to agree to your request.  If we do agree, we will comply with your request to the best of our ability unless the information is needed to provide you with emergency treatment.
  1. Obtain a copy of this Notice upon request.
  1. Inspect and request a copy of your health record for a fee.  We may deny your request under very limited circumstances.  If you are denied access to health information, you may request that the denial be reviewed by another health care professional chosen by someone on our health care team.  We will abide by the outcome of that review.
  1. Request an amendment to your health record.  If you feel that information included in your medical record is incorrect or incomplete, you may request an amendment.  We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  Also, we may deny your request if the information you want to amend was not created by an ASMG physician, is not part of the information kept by ASMG, is not part of the information which you would be permitted to inspect and copy, and if the information is accurate and complete.  Please note that even if we accept your request, we are not required to delete any information from your health record.
  1. Obtain an accounting of disclosures of your health information.  The accounting will only provide information about disclosures made for purposes other than treatment, payment or health care operations.
  1. Request communication of your health information by alternative means or locations.
  1. Revoke your authorization.  You may revoke your authorization to use or disclose health information except to the extent that action has already been taken.
  1. Complain about any aspect of our health information practices to us or to the Department of Health and Human Services of the United States.   Complaints about this Notice or how ASMG handles your health information should be directed in writing to:

General Counsel
Anesthesia Management Professionals, Inc.
P.O. Box 85303
San Diego, CA 92186-5303

If you are not satisfied with the manner in which ASMG handles a complaint, you may submit a formal complaint to the Department of Health and Human Services or one of the regional Offices for Civil Rights.


Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I have received a copy of the ASMG “Notice of Privacy Practices” which sets forth ASMG’s privacy practices and my rights regarding privacy of my PHI.

            __________________________________________________________

            Patient/Personal Representative Name (please print)

            __________________________________________________________

            Patient/Personal Representative Signature                                                   Date               

Please complete this page and hand it to your ASMG doctor or send it to:

General Counsel
Anesthesia Management Professionals, Inc.
P.O. Box 85303
San Diego, CA 92186-5303

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