This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how our organization protects and uses your personal health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. Your “protected health information” means any written and oral health information about you, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.
     We may change this notice at any time. A current Notice and Privacy Practices will be displayed in our facility. A notice will be provided to you in paper copy and made available on our website. The Notice will be effective for all protected health information kept at that time. You will be asked to sign an acknowledgement form stating you received this notice.

Uses and Disclosures of Protected Health Information based on your Written Authorization
     Uses and disclosures of your protected health information for purposes other than treatment, payment and operations will be made only with your written authorization. You may revoke this authorization at any time, in writing. If you chose to revoke your authorization, the revocation will only apply to information not previously released.

Uses and Disclosures of Protected Health Information Without Prior Authorization
     Hamden Surgery Center may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations.
     Your protected health information may be used to provide, coordinate or manage your health care and any related services. Your protected health information may be used and disclosed by physicians and other members of the healthcare team (for example, we may disclose your protected health information to a pharmacy to fill a prescription or to a laboratory to order a blood test).
     Your protected health information may also be used and disclosed to pay your health care bills (for example, we may disclose your protected health information to your health insurance company to get prior approval for the surgery or to determine whether you are eligible for benefits).
     Information may also be used to support healthcare operations (for example, as required for licensing or accreditation activities, maintaining compliance programs, etc.).
     Disclosures of your protected health information for the purposes described in this Privacy Notice may be made in writing, orally, or by facsimile.
Subject to certain requirements, we may give out health information about you without your authorization for public health purposes, abuse or neglect reporting, audits or inspections, research studies, required notifications of death, Workers’ Compensation, the Food and Drug Administration, health oversight, judicial and administrative proceedings, law enforcement, specialized government functions, state surveyors, licensing, accrediting, quality oversight agencies and emergencies.
     Unless you disagree, we may contact you to remind you of your surgery date, to inform you of potential treatment alternatives or options, to inform you of health-related benefits or services that may be of interest to you, or to contract you to raise funds for the facility or an institutional foundation related to the facility.
     Unless you disagree, we may disclose medical information about you to a friend or family member, who is involved in your medical care.
     These examples of potential disclosures of health information are not intended to cover all the ways Hamden Surgery Center may use your protected health information. Additional disclosures may be appropriate without requiring your prior authorization.

Uses and Disclosures of Protected Health Information to Business Associates
    Hamden Surgery Center will share your protected health information with third party business associates that perform various activities for the organization. Whenever an arrangement with Hamden Surgery Center and a business associate involves the use of your protected health information, we will have a written contract to protect the privacy of your health information. This contract will include documentation regarding privacy protections.

Your Rights Regarding Medical Information About You
     You have a right to request a copy or view the medical information that we use to make decisions about your care. If a request is denied, you have a right to appeal that decision. You may be charged a reasonable fee for copies.
     You have a right to a list of those instances that we disclosed medical information about you in accordance with applicable state, federal and local law. Disclosures for treatment, payment or healthcare operations and those disclosures you have authorized are not included in this listing. You may be charged a reasonable fee for this information.
     You have the right to request that your medical information be communicated to you in a confidential manner by providing our staff with an alternate address and other contact information. We may condition this accommodation by asking you for information as to how payment will be handled. This request must be communicated during each visit to the Hamden Surgery Center.
     You may request, in writing, that we not use or disclose medical information about you to persons involved in your care except when required by law, or in an emergency.
     You may request restrictions on the use and disclosure of your personal health information for treatment, payment and healthcare operations. We do not have to agree to your request for restrictions. If Hamden Surgery Center agrees to a reasonable restriction, we will comply with your request.

How to File a Complaint
     If you believe that your privacy rights have been violated, you have the right to complain to the Hamden Surgery Center. All written communication regarding a complaint of your privacy rights should be directed to:

Hamden Surgery Center
Attn: Privacy Officer
2080 Whitney Avenue
Hamden, CT 06518
(203) 288-2555

     There will be no penalty or retaliation against any individual for filing a complaint.

     If you wish to file a complaint with the Secretary of the Department of Health and Human Services, Office of Civil Rights you may send a letter to:

200 Independence Avenue
SW Humphrey Building
Mail Stop Room 506F
Washington, DC 20201

Effective April 1, 2003