Anesthesia Medical Group, P.C.
Notice of Privacy Practices and Patient’s Privacy Rights

Effective Date: April 14, 2003

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

This notice applies to Anesthesia Medical Group, P.C. (AMG), including its employees, staff and third party business associates.

Patient Health Information:

Under federal law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment and related medical information. Patient health information also includes payment, billing and insurance information.

This notice will tell you the ways that we may use and disclose any patient health information about you. Your rights regarding your health information and obligations we have regarding the use and disclosure of this information are also described.

We are required by law to:

Protect and maintain the privacy of your health information.
Give you this notice of our legal duties and privacy practices regarding health information.
Follow the terms of the notice currently in effect.
How We May Use and Disclose Your Patient Health Information:

The following are descriptions of different ways that we may use and disclose your patient health information. We are required to comply with any state laws that impose stricter standards than the uses and disclosures described in this notice.

Treatment:

We may use your patient health information to provide you with medical treatment or services. We may disclose information about you to doctors, nurses, technicians, and other medical providers or personnel who are involved in taking care of you. For example, we may share information with your surgeon concerning your medical treatment and status during surgery.

Payment:

We may use and disclose your patient health information so that the treatment and services you received from AMG may be billed to and payment may be collected from you, an insurance company or a third party.

For example, we will send your medical information to your insurance carrier to request payment for services or we may contact your insurance to verify coverage.

Health Care Operations:

We may use and disclose your patient health information to conduct our standard internal operations, including proper administration of records, to evaluate our quality of treatment, to assess the care and outcome of your case and others like it, and to arrange for legal services, when necessary. For example, we may use this information in reports to evaluate our staffing needs or requirements at the hospital.

As Required By Law:

We will disclose your patient health information when it is required to do so by federal, state or local law. These types of disclosures may include reports of gun shot wounds and disclosures to the United States Department of Health and Human Services for it to determine our compliance with privacy regulations.

Health Oversight Activities:

We may disclose information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, and inspections necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and Judicial Proceedings:

We may disclose information about you in response to a court or administrative order in response to a subpoena, discovery request, or other lawful process when certain requirements are followed.

National Security and Intelligence Activities:

We may release medical 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 the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.

Public Health Activities:

As required by law, we may disclose vital statistics, disease information, information related to recalls of dangerous products and similar information to public health authorities.

Abuse, Neglect or Domestic Violence:

As permitted or required by law, we may disclose information to appropriate agencies about individuals we believe to be victims of abuse, neglect or domestic violence.

Law Enforcement Purposes:

Subject to certain restrictions, we may disclose information required by law enforcement officials.

Deaths:

We may report information regarding deaths to coroners, medical examiners, and funeral directors.

Organ Donation:

We may use and disclose information to entities involved in procuring, banking, and transplanting organs, eyes and tissues to assist with donation or transplantation.

Serious Threat to Health and Safety:

We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Military Personnel:

If you are a member of the armed forces, we may release information as required by military command authorities.

Research:

We may use and disclose information for approved medical research in certain cases.

Workers Compensation:

We may release information about you for workers compensation or similar programs providing benefits for work-related injuries or illness as required by state law.

Communication with Family/Disaster Notification:

Unless you object, we may disclose to your family members or others involved in your care information relevant to their involvement in your care or payment for your care or information necessary to inform them of your location and condition. We may also release information to disaster relief agencies so they may assist in notifying those involved in your care of your location and general condition.

Appointment Reminders/Treatment Alternatives:

We may use your information to contact you with appointment reminders. We may also contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Other Uses and Disclosures of Medical Information:
Other uses and disclosures of patient health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose medical 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. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provide to you.

Your Rights Regarding Patient Health Information About You:

The following are your rights regarding patient health information we maintain about you.

The Right to Inspect and Copy:

In most cases, you have the right to inspect and/or request a copy of your patient health information that may be used to make decisions about you. This type of information usually includes medical and billing records.

To inspect and copy your patient health information you must submit a request in writing to Linda Engle, Privacy Official. If you request a copy of the information, we may charge you a fee for the costs of copying, mailing or other supplies associated with your request.

The Right to Amend:

If you feel that the patient health information we have concerning you is incorrect or incomplete, you have the right to ask that we amend the information.

To request an amendment of your medical information, you must submit a request in writing to Linda Engle, Privacy Official. In addition, you must provide a reason that supports your request.

Right to an Accounting of Disclosures:

You have the right to request a list of the disclosures we have made of health information about you. This list will not include disclosures made for reasons of treatment, payment or health care operations, certain other disclosures or disclosures made prior to April 14, 2003.

Your request for this list must be submitted in writing to Linda Engle, Privacy Official.

The first list you request within a 12-month period will be free. For any additional lists, there may be a charge to you for the costs of providing the list. You will be notified of the cost involved and you may choose to withdraw or modify your request prior to any costs being incurred.

Right to Request Restrictions:

You have a right to request a restriction or limitation on the health information we use or disclose about you for purposes of treatment, payment, or health operations. We are not required to agree to your request, but if we do agree, we must abide by those restrictions.

To request restrictions, you must submit a request in writing to Linda Engle, Privacy Official.

Right to Request Confidential Communications:

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to Linda Engle, Privacy Official. You do not have to give a reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice:

You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. If you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, contact Linda Engle, Privacy Official at 615-327-7893.

Changes to This Notice:

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for patient health information we already have about you as well as any information we receive in the future. The notice will contain the effective date on the first page. You can request a privacy notice at any time.

Complaints:

If you believe your privacy rights have been violated, you may file a complaint with AMG or with the Secretary of the United States Department of Health and Human Services. To file a complaint with AMG, contact the person listed below. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

Contact Person:

If you have questions, requests or complaints, please contact:

Linda Engle
Privacy Official
Anesthesia Medical Group
110 29th Ave North, Suite 201
Nashville, Tn 37203
615-327-7893