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 Privacy Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law as well as your rights.  Your “protected health information” means any written and oral health information about you, including 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.

I.                   Uses and Disclosures of Protected Health Information

TIS may use or disclose your protected health information for the following purposes without your authorization:

A.                Treatment.  We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with a third party for treatment purposes.  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.  We may also disclose protected health information to physicians who may be treating you or consulting with TIS with respect to your care.

B.                 Payment.  Your protected health information will be used and disclosed to submit claims and obtain payment for the services that we provide.  For example, we may need to disclose information to your health insurance company to get prior approval for the surgery that is scheduled or to determine whether you are eligible for benefits or whether a particular service is covered under your health plan.  We may also need to disclose your protected health information to your health insurance company to demonstrate the medical necessity of the services or for utilization review.  We may also disclose protected health information to another provider involved in your care for the other provider’s payment activities.

C.                Health Care Operations.  We may use or disclose your protected health information, as necessary, for our own health care operations.  Health care operations include such activities as: quality assessment and improvement activities, employee review activities, training programs, accreditation, certification, licensing or credentialing activities, review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs, and business management and general administrative activities.  We may also disclose information to another provider or health plan for their health care operations.

D.                Other Uses and Disclosures.  As part of treatment, payment and health care operations, we may also use or disclose your protected health information for the following purposes: to remind you of your surgery date, to inform you of potential treatment alternatives or options, or to inform you of health-related benefits or services that may be of interest to you.

E.                 Research.  Your protected health information may be used or disclosed without your consent or authorization if an Institutional Review Board or Privacy Board approves a waiver of authorization for disclosure and other requirements of state law are satisfied.

F.                 When Legally Required, For Law Enforcement or Judicial or Administrative Proceedings.  We will disclose your protected health information when we are required to do so by any federal, state or local law.  For example, we may notify government authorities in instances of abuse, neglect or domestic violence.  We may also disclose your protected health information for law enforcement purposes, such as reporting certain types of wounds or injuries, pursuant to court order, subpoena, or similar process, identifying a suspect, fugitive, material witness or missing person, or when you are the victim of a crime.  We may also disclose your protected health information when ordered in the course of any judicial or administrative proceeding or any other government functions.

G.                When There Are Risks to Public Health.  We may disclose your protected health information for public activities and purposes, such as to prevent, control, or report disease, injury or disability as permitted by law, to report vital events such as birth or death as permitted or required by law, to conduct public health surveillance, investigations and interventions as permitted or required by law, to collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs or replacements to the FDA, or to notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.

H.                To Conduct Health Oversight Activities.  We may disclose your protected health information to a health oversight agency for activities including audits; investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law.

I.                   To Coroners, Funeral Directors, and for Organ Donation.  We may disclose protected health information to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner, medical examiner or funeral director to perform other duties authorized by law.  Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

J.                  In the Event of a Serious Threat to Health or Safety.  We may use or disclose your protected health information if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

K.                For Worker’s Compensation.  TIS may release your health information to comply with worker’s compensation laws or similar programs.

II.                Uses and Disclosures Permitted with Opportunity to Object

We may disclose your protected health information to a family member or a close personal friend if it is directly relevant to the person’s involvement in your surgery or payment related to your surgery.  We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.  You may object to these disclosures.

III.             Uses and Disclosures which you Authorize

Other than as stated above, we will not disclose your health information other than with your written authorization.  You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.

In addition, federal and Texas law require special privacy protections for certain “highly confidential information” about you, including the subset of your protected health information that is: (1) maintained in pyschotherapy notes; (2) about mental health and/or mental retardation services; (3) about alcohol and drug abuse prevention, treatment, and referral; (4) about HIV/AIDS or other sexually transmitted disease testing, diagnosis or treatment; (5) about child abuse and neglect; or (6) about sexual assault.  In order for your highly confidential information to be disclosed for a purpose other than those permitted by law, your written authorization must be obtained.

IV.             Your Rights

You have the following rights regarding your protected health information:

A.                The right to inspect and copy your protected health information.  In most cases, you may inspect and obtain a copy of your protected health information for as long as we maintain the protected health information.  In certain circumstances, we may deny your request to inspect or copy your protected health information.  You may have the right to request a review of this decision.  To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on the last page of this Privacy Notice.  If you request a copy of your information, we may charge you a reasonable fee for the costs of copying, mailing or other costs incurred by us in complying with your request.  If you agree, we may also provide you with a summary of your protected health information.

B.                 The right to request a restriction on uses and disclosures of your protected health information.  You have the right to ask us not to use or disclose certain parts of your protected health information and to whom you want the restriction to apply.  TIS is not required to agree to your request.  We will notify you if we deny your request to a restriction.  If TIS agrees to the requested restriction, we may not use or disclose your protected health information in violation of that restriction except in emergency situations.  You may not limit the uses and disclosures that we are legally required to make.  You may request a restriction by contacting the Privacy Officer.

C.                The right to request how you receive information from us.  You have the right to request that we send information to you in certain ways.  For example, you have the right to ask that we send information to you at an alternate address (work rather than home) or by alternate means (email instead of regular mail).  We will accommodate reasonable requests.  We will not require you to provide an explanation for your request.  Requests must be made in writing to our Privacy Officer.

D.                The right to request amendments to your protected health information.  You may request an amendment of your protected health information for as long as we maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.  Requests for amendment must be in writing and must be directed to our Privacy Officer.  In this written request, you must also provide a reason to support the requested amendments.

E.                 The right to receive an accounting.  You have the right to request an accounting of certain disclosures of your protected health information made by TIS for purposes other than treatment, payment or health care operations.  We will not account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, disclosures to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization as permitted by law.  The request must be made in writing to our Privacy Officer and should specify the time period sought for the accounting.  We are not required to provide an accounting for disclosures that took place prior to April 14, 2003.  Accounting requests may not be made for periods of time in excess of six years.  We will respond within sixty (60) days of your request.  We will provide the first accounting you request during any 12-month period without charge, but may charge for subsequent requests.

F.                 The right to obtain a paper copy of this notice.  Upon request, we will provide a separate paper copy of this Notice even if you have already received a copy of the Notice or have agreed to accept this Notice electronically.

V.                Our Duties

TIS is required by law to maintain the privacy of your protected health information and to provide you with this Privacy Notice explaining our legal duties and privacy practices.  We are required to abide by the terms of this Notice as may be amended from time to time.  We reserve the right to change the terms of this Notice and our privacy practices at any time.  If TIS changes its Notice, we will post a copy of the revised Notice and provide you a copy of the revised Notice upon request.

VI.             Complaints

You have the right to make complaints to TIS and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated.  You may complain to TIS by contacting the Privacy Officer verbally or in writing, using the contact information below.  We encourage you to express any concerns you may have regarding the privacy of your information.  You will not be retaliated against in any way for filing a complaint.

VII.          Contact Person

The contact person for all issues regarding patient privacy is the Privacy Officer.  Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer.  If you feel that your privacy rights have been violated by TIS you may submit a complaint to our Privacy Officer by sending it to:

Texas Institute for Surgery at Presbyterian Hospital of Dallas
7115 Greenville Ave.,  #100
Dallas, Texas 75231
ATTN: Privacy Officer

The Privacy Officer can be reached by telephone at 214-647-5312.

VIII.       Effective Date

This Privacy Notice is effective 10/2004 and revised on 5/2008.