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

PLEASE READ IT CAREFULLY.

Who We Are and Our Legal Obligations To You

You are coming to High Pointe Surgery Center to receive medical care. Several different medical providers work together to provide you care at this facility, and, for this reason, the following providers are issuing this Notice of Privacy Practice jointly: High Pointe Surgery Center, the members of the board of directors of High Pointe Surgery Center, various medical directors of High Pointe Surgery Center, Metropolitan Anesthesia Network, Nurse Anesthesia Providers, P.A., and, in some cases, the medical staff of High Pointe Surgery Center. High Pointe Surgery Center is the ambulatory surgery center where you are receiving care. Its board of directors consists of (5) persons who manage and control the operations of this facility. Its medical directors are physicians who assist in the management of the facility. Its medical staff is the physicians who treat patients at the facility. Metropolitan Anesthesia Network is the medical practice that provides anesthesiology services to this facility. Nurse Anesthesia Providers, P.A. is the practice that provides certified nurse anesthetist services to this facility.

We are all separate legal entities, and we are coming together only for the purpose of issuing this Notice of Privacy Practices jointly. Your treating physician is not typically a part of this joint issuance. Your physician will ordinarily provide you with the Notice of Privacy Practices of the physician’s practice, but, in a few situations, our physician will be able to provide you with this independent Notice of Privacy Practices and will operate pursuant to this jointly issued Notice of Privacy Practices.

The law requires us to protect the privacy of your health information and to provide you with notice of its legal duties and privacy practices with the respect to this health information. This Notice of Privacy Practices outlines our legal obligations regarding your health information. We are required to comply with the terms of this Notice of Privacy Practices, effective April 14, 2003. We reserve the right to change the terms of this Notice of Privacy Practices and to make the new terms effective for all health information we possess. We will communicate any changes by providing you with a new copy of the Notice of Privacy Practices the next time you receive treatment at our facility after any such change.

How We May Use or Disclose Your Health Information

We collect health information from you and store it in a chart or on our computer system. This is your medical record. Although this record belongs to High Pointe Surgery Center, the information in the record belongs to you. The law allows us to use or disclose your health information for the following purposes:

1. For Treatment. We may use your health information to provide you with medical treatment of services. For example, if you are receiving surgery at our facility, a surgeon may review your medical record and release medical information if it is necessary to provide you treatment, such as sending information to a laboratory to run tests on your behalf.
2. For Payment. We may use and disclose your health information for purposes of receiving payment for treatment and services that you receive. For example, we may send a bill for your services to your health insurance company, and this bill may contain certain information such as your name and the service we provided to you.
3. For Health Care Operations. We may use and disclose your health information for the operation of our facility. For example, we may disclose information to our medical staff or employees for training purposes, to evaluate performances, to assess the quality of care provided in our facility, and to determine how to improve the health care we provide.
4. Exchange With Each Other. We, the providers issuing this joint notice, may share your health information with each other for the purpose of carrying out your treatment, the payment for your medical services, and our joint health care operations.
5. Follow Up Contact. We may use your health information to check on your recovery status after surgery to provide you with information regarding other treatment or treatment options.
6. Directories. Unless you inform us that you do not want us to do this, we will disclose your location and general condition to persons who call us and request you by name.
7. Communication with Family and Friends. We will disclose your health information to your family members and friends if you are present and conscious and you allow such a disclosure or it is reasonable to assume from the circumstances that you allow the disclosure. If you are not present or you are unconscious, our health care practitioners will exercise professional judgement to determine whether a diclosure to your familly, personal representative, or other persons responsible for your care is in your best interests. The practitioner will only disclose information directly relevant to the recipient’s involvement in your health care or payment for your health care.
8. Notification. We may also disclose your health information to notify or assist in notifying a family member, your personal representative, or other person responsible for your care about your location, general condition, or death.
9. Public Health Agencies. We may use or disclose your health information for public health activities such as assisting public health authorities in preventing or tracking disease and maintaining customer records of medical supplies in the event of product recall. We are required to report initial diagnosis of sexually transmitted diseases and communicable diseases to state public health agencies.
10. Health and Safety and Law Enforcement. We are required to disclose information to law enforcement if we suspect child abuse or neglect. In the exercise of our professional judgement, we may report information in the case of domestic abuse. Your health information may also be disclosed to avert a serious threat to the health or safety of you or any other person. Finally, we may disclose health information to assist law enforcement officials in their duties.
11. Required by Law. We will disclose health information if we are required to by law, such as pursuant to a judicial or administrative subpoena. We may also be required to disclose information of specialized government functions such as protection of public officials or reporting to various branches of the armed services.
12. Decedents. Health information may be disclosed to funeral directors or coroners to enable such persons to perform their duties. Your health information also may be used or disclosed for cadaver organ, eye, or tissue donation purposes.
13. Worker’s Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Worker’s Compensation.
14. Other Uses. Other uses and disclosures will be made with your written authorization and you may revoke the authorization except to the extent we have taken action in reliance upon the authorization.

Your Rights Regarding Your Health Information

You have certain rights with respect to your health information. They are listed below. If you would like to exercise any of these rights or if you have questions regarding your rights, please contact:

Privacy Officer
Privacy Officer
High Pointe Surgery Center
8650 Hudson Boulevard
Suite 235
Lake Elmo, MN 55042
Phone: 651.702.7431
Fax: 651.702.7414

You have the right to request that we limit our uses and disclosures of your health information, as you specify. We may not agree to your request.

You have the right to request that we communicate with you through alternative means or locations, and we will respect any reasonable requests.

You have the right to review and obtain a copy of your health information. We have the right to charge you a fee for the cost of providing you with such a copy.

You have the right to request that we amend your health information. We will review your request but not necessarily make the amendments you request.

You have the right to obtain an accounting of disclosures that we have made of your health information except disclosures for treatment, payment, health care operations, disclosures authorized by you, and disclosures for certain government functions.

You have the right to revoke any authorization you made for the use or disclosure of your health information except to the extent we have already relied on the authorization.

You have the right to receive a paper copy of this notice.

Complaints

You may complain to us if you think we have violated your privacy rights. We will listen to your complaint and do our best to address it. You will not be retaliated against for bringing a complaint. Please direct complaints to:

Privacy Officer
Privacy Officer
High Pointe Surgery Center
8650 Hudson Boulevard
Suite 235
Lake Elmo, MN 55042
Phone: 651.702.7431
Fax: 651.702.7414

You can also file a complaint with the government office that enforces your privacy rights: Department of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Bldg., 200 Independence Avenue, S.W., Room 509F HHH Building, Washington, DC 20201. You may also addresss your complaint to one of the regional offices for Civil Rights, a list of which can be found online.