As required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU MAY GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Evansville Surgical Associates is dedicated to protecting your medical information.  We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information.  Evansville Surgical Associates  is required by law to abide by the terms of this Notice.

HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED

How ESA is Required to Use or Disclose Your Medical Information

Required by Law:  ESA may disclose your medical information when required to do so by federal, state, or local law.
Public Health Activities:  We may use or disclose your medical information for public health activities, including the reporting of disease, injury, vital events and the conduct of the public health surveillance, investigation and/or intervention, including, but not limited to, the reporting of abuse and neglect, reporting possible exposure to infectious disease, and to report births and deaths.
Health Oversight Activities:  We may disclose your medical information to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions, administrative and/or legal proceedings.
FDA Reports:  We may disclose information about you to a person or company required by the Food and Drug Administration to report adverse product reactions, defects, or problems; track products; engage in product recalls; make repairs or replacements; or conduct post-marketing surveillance.
Law Enforcement:  We may disclose your medical information for law enforcement purposes or other specialized governmental functions. Public Safety:  We may use or disclose your medical information to prevent or lessen a serious threat to the health or safety of you, another person or to the public.
Disclosure to Department of Health and Human Services:  We may disclose medical information when required by the United States Department of Health and Human Services as part of an investigation or determination of our compliance with relevant laws.

How ESA Is Permitted to Use or Disclose Your Medical Information

For Treatment:  We will use your medical information as part of rendering patient care.  For example, your medical information may be used by the doctor or nurse treating you, or it may be disclosed to another health care provider involved in providing you care.
For Payment:  We will use and disclose your medical information as necessary to obtain payment for services provided to you by ESA or other health care providers involved in providing you care.  For example, we may disclose information about you to your insurance company to obtain payment.
For Health Care Operations:  We will use and disclose your medical information to conduct various administrative functions necessary to ESA’s operations and for certain administrative operations of other entities with which you have a relationship.  For example, we may use or disclose your information as part of our quality of care review process.
Appointment Reminders and Other Notifications:  ESA may use and disclose your medical information as necessary to contact you at your home phone number or address as a reminder that you have an appointment, as a reminder that you should schedule an appointment, or to notify you of test results.
Treatment Alternatives, Benefits and Services:  ESA may disclose your health information to tell you about or recommend possible treatment options or alternatives, health-related benefits or other services that may be of interest to you.
Family, Friends and Other Individuals Involved in Your Care or Payment for Your Care:  Unless you object, ESA may discuss your health care with members of your family, close friends or other individuals you identify who may be involved in your care or the payment for your care when such a disclosure is relevant to their involvement in your care or when necessary to notify them of your general care or death.
Research:  ESA may use or disclose your medical information for research purposes where an Institutional Review Board or similar body referred to as a Privacy Board determines that your privacy interests will be adequately protected in the study.  A/WDI may also use and disclose your health information to prepare or analyze a research protocol and for other research purposes.
Business Associates:  From time to time it is necessary for ESA to disclose medical information to a third party with which it contracts to provide services to or on behalf of ESA.  We may disclose your health information to such a “business associate.”  To protect your health information, we require our business associates to appropriately safeguard the health information of our patients.

Special Circumstances under Which ESA May Use or Disclose Your Medical Information

Coroners, Medical Examiners and Funeral Directors:  We may disclose your medical information to a coroner, medical examiner or a funeral director as necessary for them to carry out their duties.
Organ Donation:  If you are an organ donor, we may disclose your medical information to an organ donation and procurement organization.
Workers’ Compensation and Other Employee Benefit Programs:  ESA may release your medical information to workers’ compensation or similar programs.
Military:  If you are a member of the Armed Forces, ESA may release your medical information as required by military command authorities.  ESA also may release medical information about foreign military personnel to the appropriate foreign military authority.
Legal Proceedings:  We may disclose your medical information in the course of certain judicial or administrative proceedings, pursuant to lawful discovery requests, at the direction of a court order or pursuant to some other legal process.
Inmates:  If you are an inmate, ESA may release your medical information to a correctional institution where you are incarcerated or to law enforcement officials.
National Security and Intelligence:  ESA may disclose your medical information for national security and intelligence activities and for the provision of protective services to the President of the United States and other officials or foreign heads of state.
Workers’ Compensation:  We may disclose your medical information as authorized by laws relating to workers’ compensation or similar programs.

AUTHORIZATIONS

We will not use or disclose your medical information for any purpose other than those listed above without your written authorization.  Once given, you may revoke your authorization in writing at any time. To request a Revocation of Authorization form, you may contact:  Evansville Surgical Associates, Evansville, IN 47710, Attn: Compliance Manager.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights with respect to your medical information:

Restrictions on Use and Disclosure:  You may ask us to restrict certain uses and disclosures of your medical information.  We are not required to agree to your request, but if we do, we will honor it.
Right to Request Alternative Delivery of Information:  You have the right to request that you receive communications containing your medical information from ESA by alternative means or at alterative locations.  For example, you may ask that we only contact you at home or by mail.  ESA is not required to accept any such requests that are unreasonable.
Right to Inspection and Copy of Certain Medical Information:  Generally, you may inspect and have certain medical information about you copied.  The right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records.  Under some circumstances, ESA may provide you a summary of your medical information in lieu of providing the actual documentation in your file. By acknowledging this request, you agree to the provision of this summary and to pay for any reasonable costs associated with its preparation.  Under some circumstances, ESA may deny your request to access your medical information.  Under some circumstances, if ESA denies your request to inspect your records, you may request in writing that the denial be reviewed.
Right to Amend Certain Medical Information:  You may ask us to amend your medical information.  We may deny your request for certain, specific reasons.  If we deny your request, we will provide you with a written explanation for the denial and information regarding further rights you may have at that point.
Right to Request an Accounting:  You have the right to receive an accounting of certain disclosures of your medical information.  Your request must state a time period that cannot be longer than six years and cannot include dates prior to April 14, 2003.  The first accounting requested in any 12-month period will be free.  You will be charged a fee for any additional requests in any 12-month period.
Right to a Paper Copy:  You may request a paper copy of this Notice of Privacy Practices for Protected Health Information.
Right to File a Complaint:  You have the right to complain to us and/or with the United States Department of Health and Human Services if you believe that we have violated your privacy rights or those of others.  If you choose to file a complaint, you will not be retaliated against in any way.

To Exercise Any of Your Rights, Please Contact ESA in Writing at:  Evansville Surgical Associates, Attn: Compliance Manager, 520 Mary Street, Suite 520, Evansville, IN 47710, (812) 424-8231.

If you would like further information regarding your rights or regarding the uses and disclosures of your medical information, or you would like to file a complaint directly with the government, please contact:  United States Department of Health and Human Services, 200 Independence Avenue S.W., Washington, D.C. 20201.

Publication Date: THIS NOTICE IS EFFECTIVE AS OF APRIL 14, 2003.

REVISION OF NOTICE OF PRIVACY PRACTICES

We reserve the right to change the terms of this Notice, making any revision applicable to all the protected health information we maintain.  ESA reserves the right to make the revised notice effective for medical information ESA has about you as well as any information ESA receives in the future.  In the event this authorization is revised, a copy of the revised version will be supplied to you upon your first visit after the effective date of the new version.  A copy of the new version will also be posted in a public area of each of ESA’s locations, on ESA’s website, if any, and in hardcopy form at any of ESA’s locations.  In addition, you may request a copy of the revised Notice at any time.