HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED:

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, by the business office to process your payment for the services rendered and by administrative personnel reviewing the quality of the care you receive.

We may also use and/or disclose your information in accordance with federal and state laws for the following purposes:

Appointment Reminders.

• We may contact you to provide appointment reminders.

Treatment Information.

• We may contact you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.

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.

Facility Directory.

• Unless you object, we will include your name, location in Ball Memorial Hospital, your condition described in general terms and your religious affiliation in our directory of individuals.  The directory information, except for your religious affiliation, will be released to people who ask for you by name.  Your religious affiliation may be given to members of the clergy, even if they do not ask for you by name, unless you object.

Family and Friends.

• Unless you object, we may disclose your medical information to family members, other relatives or close personal friends when the medical information is directly relevant to that person’s involvement with your care.

Notification.

• Unless you object, we may use or disclose your medical information to notify a family member, a personal representative or another person responsible for your care of your location, general condition or death.

Disaster Relief.

• We may disclose your medical information to a public or private entity, such as the American Red Cross, for the purpose of coordinating with that entity to assist in disaster relief efforts.

Health Oversight 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 public health surveillance, investigation and/or intervention.  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.

Abuse or Neglect.

• We may disclose your medical information when it concerns abuse, neglect or violence to you in accordance with federal and state law.

Legal Proceedings.

• We may disclose your medical information in the course of certain judicial or administrative proceedings.

Law Enforcement.

• We may disclose your medical information for law enforcement purposes or other specialized governmental functions.

Coroners, Medical Examiners and Funeral Directors.

• We may disclose your medical information to a coroner, medical examiner or a funeral director.

Organ Donation.

• If you are an organ donor, we may disclose your medical information to an organ donation and procurement organization.

Research.

• We may use or disclose your medical information for certain research purposes if an Institutional Review Board or a privacy board has altered or waived individual authorization, the review is preparatory to research or the research is on only decedent’s information.

Public Safety.

• We may use or disclose your medical information to prevent or lessen a serious threat to the health or safety of another person or to the public.

Workers’ Compensation.

• We may disclose your medical information as authorized by laws relating to workers’ compensation or similar programs

Business Associates.

• We may disclose your health information to a business associate with whom we contract to provide services on our behalf.  To protect your health information, we require our business associates to appropriately safeguard the health information of our patients.

AUTHORIZATIONS:

We will not use or disclose your medical information for any other purpose 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:

Muncie Surgical Associates, Inc - 2525 University Ave Suite 403 - Muncie, In  47303  765/289-6381

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:

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

• 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.
• You have the right to receive communications from us in a confidential manner.
• Generally, you may inspect and copy your medical information.  This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records.
• 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.                                      
• You have the right to receive an accounting of the disclosures of your medical information made by Muncie Surgical Associates during the last six years (or following April 14, 2003), except for disclosures for treatment, payment or healthcare operations, disclosures which you authorized and certain other specific disclosure types.
• You may request a paper copy of this Notice of Privacy Practices for Protected Health Information.
• You have the right to complain to us and/or to the United States Department of Health and Human Services if you believe that we have violated your privacy rights.  If you choose to file a complaint, you will not be retaliated against in any way.  To complain to us, please contact:

Muncie Surgical Associates, Inc  2525 University Ave Suite 403   Muncie, In  47303  765/289-6381

If you would like further information regarding your rights or regarding the uses and disclosures of your medical information, you may contact:

Muncie Surgical Associates, Inc  2525 University Ave Suite 403   Muncie, In  47303  765/289-6381

THIS NOTICE IS EFFECTIVE AS OF April 16, 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.  If we revise the terms of this Notice, we will post a revised notice at Muncie Surgical Associates and will make paper copies of the revised Notice of Privacy Practices available upon request.

ACKNOWLEDGMENT:

 I hereby acknowledge that I have received and had an opportunity to ask questions concerning:  Muncie Surgical Associates’ Notice of Privacy Practices.
 

                                                      _____
Patient or Patient’s Representative

                                                      _____
Date

                                                      _____
Representative’s Relationship to Patient

*The Proposed rule issued 3/02 eliminated the consent requirement for uses and disclosures for treatment, payment and health care operations and replaced it with a requirement that health care providers with a direct treatment relationship with the patient make a good faith effort to obtain an acknowledgment that the patient received the provider’s Notice of Privacy Practice