Notice Of Patients Privacy Rights:

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our facility. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of Protected Health Information (PHI).


The Law Requires Us To:

•Keep your medical information private.

•Give you this notice describing our legal duties, privacy practices and your right regardingyour PHI.

•Follow the terms of the notice that is now in effect.

•Notify you if a breach in the security of your Protected Health Information (PHI) occurs.


We Have the Right To:

Change our privacy practices and the terms of this notice at any time, as long as they are permitted by law. This includes information previously created or received before those changes. Notification will occur if any important change is made, and will be available upon request. Use and Disclosure of Your Protected Health Information (PHI): The following section describes different ways that we use your PHI. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose PHI. We will not disclose any of your PHI for any purpose not listed below, without your specific written authorization. Any specific written authorization may be revoked at anytime by writing to us. We are required to obtain your authorization prior to disclosing PHI related to psychotherapy notes, sale of PHI or marketing.


FOR TREATMENT: We may use PHI about you to provide you with medical treatment or services. We may disclose this information about you to doctors, nurses, technicians and other people taking care of you. We may also share your PHI with other health care providers to assist them in treating you.


FOR PAYMENT: We may use PHI to obtain payment for the services we provide.


FOR HEAL TH CARE OPERATIONS: We may use and disclose your PHI for our health care operations. This might include quality improvement measures, evaluating performance of employees, staff training, accreditation, obtaining certificates and licensure that we need in order to operate. This also includes business management and administrative activities.

Additional Uses Of Information:

As part of treatment, payment and health care operations, we may also use or disclose your PHI for the following purposes:


Appointment Reminders: PHI used to contact you, a family member or other responsible person, as a reminder that you have an appointment for surgery at Transformations Surgery Center. We will use the phone number(s) given to us by your surgeon's office and may leave a message with a family member. We will limit the PHI disclosed when leaving a message. If you prefer we use a different phone number, not leave messages, or prefer we do not speak with family members, this can be requested by contacting the privacy officer, in writing, at the address below.


Notification: PHI used to notify or help notify a family member or other person responsible for your care. We will share information about your location in our facility, general condition and approximate wait time. If you are present, we will get your permission if possible, before we share this information. In case of emergency and/or if you are not able to give or refuse permission, we will share only the PHI that is directly necessary for your health care, according to our professional judgment to make decisions in your best interest.



•The right to inspect and copy your PHI, via written request to the Privacy Officer. We may deny your request, if in our professional judgment, we determine that the access requested will endanger your life or another's.

•The right to request a restriction on uses and disclosures of your PHI.

•The right to request to receive confidential communications from us by alternative means or locations.

•The right to request amendments to your PHI in writing with reasons to support such a request. In certain cases, we may deny your request for anamendment.

•The right to receive an accounting of certain disclosures for purposes of treatment, payment or health care operations. These written requests must be submitted to our Privacy Officer. Requests may not be for a period more than 6 years. We will provide the first request within any 12-month charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

•The right to request that Transformations Surgery Center not disclose your PHI to your health plan for the purposes of payment or healthcare operations, and if you are paying for your treatment out of pocket in full, then the facility must honor your requested restriction.

•The right to obtain a paper copy of this notice.

•The right to revoke your authorization of PHI release at anytime.

Downloadable Form

Notice of Patient's Privacy Rights