Sage Bariatric
(Texas Center for Medical & Surgical Weight Loss)
NOTICE OF PRIVACY PRACTICES
Effective Date: September 23, 2013
Revised: February 1, 2020
Dear Patient:
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.
THE PURPOSE OF THIS NOTICE
Sage Bariatric, P.A. Notice of Privacy Practices: This is Sage Bariatric, P.A.’s Notice of Privacy Practices (“Notice”). It is applicable to all of our patients. Sage Bariatric is referred to in this Notice as “us,” “we,” or “our.” This Notice is required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as later modified and updated, and by other Texas and federal laws. In general, HIPAA and related statutes deal with your “Protected Health Information,” which HIPAA defines as personal information that identifies you and relates to the diagnosis and treatment of your past, present or future physical or mental health condition(s). For the sake of simplicity, this Notice uses the term “medical information” instead of “Protected Health Information.”
Further Information: We strive at all times to deliver high quality clinical services, and we are dedicated to maintaining the privacy of your medical information. We will provide you with a copy of our current Notice when you come to our office for your first appointment. We will ask you, your parent or guardian, or your personal representative, as applicable, to acknowledge in writing your receipt and review of this document. Our current Notice will also be posted prominently in our office and on our website at www.sagebariatric.com. If you desire an additional copy of this Notice or you have any further questions or concerns about your medical information, our Privacy Officer, Nadia Villarreal, is available to assist you. You may contact her by calling (210) 651-0303, by writing to Sage Bariatric, P.A., c/o Privacy Officer, 9618 Huebner Road, Suite 202, San Antonio, Texas, 78240, or by emailing us at nadia@sagebariatric.com.
OUR DUTIES
We are required by law: to maintain the privacy of your medical information (subject to the contents of this Notice); to provide you with notice of our legal duties and privacy practices with respect to your medical information; and to notify you following a breach of the privacy of your medical information (in the manner prescribed by applicable law). We are required to abide by the terms of our current Notice.
HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
We may use and disclose your medical information in a number of circumstances and for a variety of reasons, some of which require your prior authorization. There are many situations, however, in which we are legally permitted or required to use and disclose your medical information without your prior authorization. Many of these instances will occur in connection with: a) your treatment, b) payment for healthcare services that we provide to you, and/or c) our routine healthcare business operations. This Notice describes these situations. In some cases we may completely remove any personal identifiers. Specifically, we may use and disclose your medical information as follows:
Permitted Disclosures of Your Medical Information
We may use and disclose your medical information without your prior authorization in the ordinary course of our routine business operations. Such instances include the following:
Treatment: We may use your medical information to facilitate the provision of our services to you. This includes disclosing your medical information to individuals who may need that information to treat you, such as our surgeons, other physicians, physician assistants, nurses, technicians, therapists, counselors, and nutritionists, and others involved in your care, such as your primary care physician or specialists. We may also use and disclose your medical information to remind you of upcoming appointments, inform you about treatment options or alternatives, tell you about healthcare-related services, or monitor and evaluate your experience with us through follow-up communications.
Payment: We may use your medical information to bill and receive payment from your insurance company, you, or another person/entity responsible for payment of your account. We may also use it when contacting your health plan to see if it will pay for your treatment with us or for any other customary purpose related to billing and payment. You may also request to pay out-of-pocket for the services we provide to you and, in such a case, you may request that we not bill your insurer for such services.
Healthcare Operations: We may also use or disclose your medical information to conduct our normal business and professional operations. For example, we routinely review past medical and surgical procedures to assess our service and clinical performance. We might also use your medical information for internal and external review purposes. In addition, we may use your medical information to demonstrate our competencies to an accreditation body. Accreditation is important to you and to us because the process assists us in maintaining our proficiency in performing our medical services. Other operational matters that might require us to use or disclose your medical information include professional and staff training, payor credentialing, risk management activities, insurance underwriting, cost and utilization management, legal and regulatory compliance, facility licensing and certification, and financial accounting and auditing.
Emergency Treatment: We may disclose your medical information if you require emergency treatment or are unable to communicate with us.
Family and Friends: We may disclose your medical information to a family member, a friend, or any other person you identify as being involved with your care or payment for your care, unless you object.
Disclosures Required by Law: Federal, state, or local law may require us to disclose our patients’ medical information for certain legally-mandated purposes.
Public Health Activities: We may disclose your medical information to a public agency for public health and quality control/improvement purposes.
Victims of Abuse, Neglect, or Domestic Violence: We may disclose your medical information to proper authorities in accordance with applicable law if we reasonably believe it is relevant to instances of abuse, neglect, or domestic violence.
Health Oversight Activities: If you are the beneficiary of a government healthcare program, we may be required to disclose your medical information to that program or a related agency if it selects your case for medical review.
Judicial and Administrative Proceedings: If information in your medical record is relevant to a legal proceeding, we may be required to comply with a court or administrative tribunal subpoena commanding us to disclose your medical information.
Research: We may disclose your medical information for certain research purposes, but only if we have protections and protocols in place to ensure the privacy of your medical information.
Law Enforcement: We may disclose your medical information when legally required by appropriate authorities in connection with a criminal or other official investigation.
Serious Threats to Health or Safety: We may disclose your medical information if, in our professional judgment, doing so would help to avert a serious threat to the public’s or your health or safety.
Specialized Government Functions: We may use and disclose medical information of certain individuals for specific national security, military, intelligence, or protective service purposes.
Disclosures Requiring Your Authorization
Situations Requiring Written Authorization: All uses and disclosures of your medical information not generally described above in this Notice will require your prior written authorization. In those situations, we will ask for the authorization before we release your medical information. Examples of these situations include our: a) compliance with requests to provide medical information to your attorney or to life or disability insurance companies; b) use and disclosure of psychotherapy notes, if any; c) use of your testimonial or photographic images; d) use or disclosure of your medical information for other marketing purposes, including communications intended to inform you of subsidized treatment options offered by specific providers; and e) use or disclosure of your medical information in any way that constitutes its sale.
Revocation of Authorization and Its Effects: You may revoke any standing authorization to disclose your medical information by so notifying our Privacy Officer in writing at the physical or email address provided on the first page of this Notice. You revocation can only be prospective, and we will not request the return of information previously disclosed in reliance on your authorization.
YOUR RIGHTS
You have certain rights with respect to our communication of, your access to, the amendment of, and accounting for the disclosure of your medical information:
Requesting Restrictions: You may ask us to limit our use or disclosure of your medical information under certain circumstances. For example, we may disclose your medical information to an immediate family member(s), other relative(s), or close personal friend(s) who are directly involved either in your care or in the payment for your care if we reasonably determine, based upon our professional judgment, that you would not object. You may, however, request a restriction on what medical information we may disclose to someone who is directly involved either in your care or in the payment for your care. You are entitled to request other restrictions as well. We are not required to agree to your request, but if we agree to it, we will abide by your request, except as required by law, in emergencies, or when the information is necessary to treat you. All such requests must be in writing and directed to our Privacy Officer in writing at the physical or email address provided on the first page of this Notice. Your request must describe the information that you want restricted, state if the restriction is to limit our use or disclosure, and state the party(ies) to whom the restriction applies. You may revoke your restriction at any time by contacting our Privacy Officer at the physical or email address on the first page of this Notice.
Confidential Communications: In order to protect your medical information, you may ask that we communicate with you in a particular way or at a certain location. Your request must be in writing, tell us how you intend to satisfy your payment obligation (if your request potentially interferes with our obtaining third party payment), and specify an alternate way that we can contact you confidentially. You do not have to give a reason for your request. You may revoke your request at any time by contacting our Privacy Officer at the physical or email address on the first page of this Notice. We will accommodate your reasonable request, but in determining whether your request is reasonable, we will consider the administrative burden it may impose upon us.
Inspect and Copy: You may ask to review and obtain a copy of your medical information. You must make your request in writing to our Privacy Officer at the physical or email address on the first page of this Notice. We may charge a fee for copying or preparing a summary of requested medical information. We will respond within 15 days of receiving your request unless your medical information is not readily-accessible or the information is maintained in an off-site storage location. Additionally, you have the right to access your own e-health record in an electronic format and to direct us to send the e-health record directly to a third party. In connection with transfers of e-health records, we may charge for labor costs only.
Amendment: You may request, in writing, that we make a change or addition to your medical information. To make such a request you may contact our Privacy Officer using the contact information on the first page of this Notice. The law limits your right to change or add to your medical information. Specifically, we may decline to change your medical information: if we did not create the medical information; if it is not included in the medical records we maintain for you; if we believe that the medical information is accurate and complete without any changes; or if the medical information contains information you are not permitted to inspect or copy (such as psychotherapy notes). Under no circumstances will we erase or otherwise delete original documentation in your medical information.
Accounting of Disclosures: You may request a list of non-routine disclosures that we have made of your medical information during the six years prior to the date of your request. This list will not include disclosures we make to provide our medical services to you, to seek payment for our medical services, to conduct our normal business operations, or disclosures we make pursuant to your written authorization. Your first request in a 12-month period is free, but we may charge for additional lists in the same 12-month period. If your medical information is maintained in an electronic health record after December 31, 2013, we must also provide an accounting of disclosures through an e-health record to carry out treatment, payment, and healthcare operations within the three-year period prior to the date of your request. If you make such a request, we must either: provide you with an accounting of all such disclosures made by us and by all of our Business Associates; or provide you with an accounting of all such disclosures made by us and a list of our Business Associates, including their contact information, who will be responsible for providing an accounting of such disclosures upon your request.
Breach Notification: We are required to notify you if the privacy of your medical information has been breached (as defined in applicable federal regulations). Notification must occur by first class mail within sixty (60) days of the event. The notice of breach must contain: a) a brief description of what happened, including the date of the breach and the date of discovery; b) the steps you should take to protect yourself from potential harm resulting from the breach; and c) a brief description of what we are doing to investigate the breach, mitigate losses, and protect against further breaches.
Business Associates: Like most medical practices we conduct some of our business operations with the help of third party vendors and contractors known under HIPAA as “Business Associates.” In accordance with federal law, we have entered into Business Associate Agreements which provide that all of the HIPAA administrative security safeguards, physical safeguards, technical safeguards, and security policies, procedures and documentation requirements that apply to us also apply directly to each of our Business Associates.
Paper Copy of Notice: You are entitled to receive a paper copy of our Notice of Privacy Practices by contacting our Privacy Officer using the contact information on the first page of this Notice. You may also take a copy of this Notice with you. Even if you have requested this Notice electronically, you may always request a paper copy.
Changes in Our Privacy Practices: We reserve the right to change our medical records privacy practices, as permitted by applicable law. Any changes we make will apply to all medical information we then-currently maintain as well as medical information developed in the future. If we make such a change, this Notice will be amended accordingly, posted prominently in our office and on our website at www.sagebariatric.com, and made available to you, upon your request, whenever you subsequently visit our office for care.
File a Complaint: If you believe that we have violated your privacy rights, you may file a complaint directly with our Privacy Officer using the contact information on the first page of this Notice. You may also file a complaint with the Secretary of the Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue S.W., Washington, DC 20201 or calling 1-877-696-6775. You will not be penalized or retaliated against for filing a complaint.
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