Notice of Provider Privacy Practices



Evergreen Surgical, S.C. must maintain the privacy of your personal health information and give you this notice that describes our legal duties and privacy practices concerning your personal health information.  In general, when we release your health information, we must release only the information we need to achieve the purpose of the use or disclosure.  However, all of your personal health information that you designate will be available for release if you sign an authorization form, if you request the information for yourself, to a provider regarding your treatment, or due to a legal requirement.  We must follow the privacy practices described in this notice.

However, we reserve the right to change the privacy practices described in this notice, in accordance with the law.  Changes to our privacy practices would apply to all health information we maintain.  If we change our privacy practices, you will receive a revised copy.

Without your written authorization, we can use your health information for the following purposes:

1.  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 example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you.  Or your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

2.  Payment.  Your protected health information will be used, as needed, to obtain payment for your health care services.  For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

3.  Health Care Operations.  We may use or disclose, as needed, your protected health information in order to support the business activities of your physician=s practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students or residents, licensing, and conducting or arranging for other business activities.  For example, we may disclose your protected health information to medical students or residents who see patients in our office.  We may also call you by name in the waiting room when your physician is ready to see you.  We may use or disclose our protected health information, as necessary, to contact you with appointment reminders or test results.

4.  As required or permitted by law.  Sometimes we must report some of your health information to legal authorities, such as law enforcement officials, court officials, or government agencies.  For example, we may have to report abuse, neglect, domestic violence or certain physical injuries, or respond to a court order.

5.  For public health activities.  We may be required to report your health information to authorities to help prevent or control disease, injury, or disability.  This may include using your medical record to report certain diseases or injuries, birth or death information, information of concern to the Food and Drug Administration, or information related to child abuse or neglect.  We may also have to report to your employer certain work-related illnesses and injuries so that your workplace can be monitored for safety.

6.  For health oversight activities.  We may disclose your health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for government benefit programs.

7.  For organ, eye or tissue donation.  We may disclose your health information to people involved with obtaining, storing or transplanting organs, eyes or tissue of cadavers for donation purposes.

8.  For research.  Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.  Such research might try to find out whether a certain treatment is effective in curing an illness.

9.  To avoid a serious threat to health or safety.  As required by law and standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to your or the public=s health or safety.

10.  For military, national security, or incarceration/law enforcement custody.  If you are involved with the military, national security or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, we may release your health information to the proper authorities so they may carry out their duties under the law. 

11.  For workers= compensation.  We may disclose your health information to the appropriate persons in order to comply with the laws related to workers= compensation or other similar programs.  These programs may provide benefits for work-related injuries or illness.

12.  To those involved with your care or payment of your care.  If people such as family members, relatives, or close personal friends are helping care for you or helping you pay for your medical bills, we may release important health information about you to those people.  The information released to these people may include our location within our facility, your general condition, or death.  You have the right to object to such disclosure, unless you are unable to function or there is an emergency.  In addition, we may release your health information to organizations authorized to handle disaster relief efforts so those who care for you can receive information about your location and health status.  We may allow you to agree or disagree orally to such release, unless there is an emergency.  It is our duty to give you enough information so you can decide whether or not to object to the release of your information to others involved with your care.

NOTE:  Except for the situations listed above, we must obtain your specific written authorization for any other release of your health information. 

If you sign an authorization form, you may withdraw your authorization at any time, as long as your withdrawal is in writing.  If you wish to withdraw your authorization, please submit your written withdrawal to our Privacy Officer/Office Manager.

Your Health Information Rights

You have several rights with regard to your health information.  If you wish to exercise any of the following rights, please contact our Privacy Officer/Office Manager.  Specifically, you have the right to:

1.  Inspect and copy your health information.  With a few exceptions, you have the right to inspect and obtain a copy of your health information.  However, this right does not apply to psychotherapy notes or information gathered for judicial proceedings, for example.  In addition, we may charge you a reasonable fee if you want a copy of your health information.

2.  Request to correct your health information.  If you believe your health information is incorrect, you may ask us to correct the information.  You may be asked to make such requests in writing and to give a reason as to why your health information should be changed.  However, if we did not create the health information that you believe is incorrect, or if we disagree with you and believe your health information is correct, we may deny your request.

3.  Request restrictions on certain uses and disclosures.  You have the right to ask for restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities.  Or, you may want to limit the health information provided to family or friends involved in your care or payment of medical bills.  You may also want to limit the health information provided to authorities involved with disaster relief efforts.  However, we are not required to agree in all circumstances to your requested restriction. 

4.  As applicable, receive confidential communication of health information.  You have the right to ask that we communicate your health information to you in different ways or places.  For example, you may wish to receive information about your health status in a private room or through a written letter sent to a private address.  You may also request that messages regarding your health information not be left on an answering machine.  We must accommodate reasonable requests.

5.  Receive a record of disclosures of your health information.  In some limited instances, you have the right to ask for a list of the disclosures of your health information we have made during the previous six years, but the request cannot include dates before April 14, 2003.  This list must include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made.  We must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request such list more than once per year.  In addition, we will not include in the list disclosures made to you, or for purposes of treatment, payment, health care operations, national security, law enforcement/corrections, and certain health oversight activities.

6.  Obtain a paper copy of this notice.  Upon your request, you may at any time receive a paper copy of this notice, even if you earlier agreed to receive this notice electronically.  Evergreen Surgical’s Patient Privacy Notice is available electronically through our website at

7.  Complain.  If you believe your privacy rights have been violated, you may file a complaint with us and with the federal Department of Health and Human Services.  We will not retaliate against you for filing such a complaint.  To file a complaint with either entity, please contact our Privacy Officer/Office Manager, who will provide you with the necessary assistance and paperwork.

Again, if you have any questions or concerns regarding your privacy rights or the information in this notice, please contact our Privacy Officer/Office Manager at 715-832-1044.

This Notice of Medical Information Privacy is Effective April 14, 2003.

Pablo Center at the Confluence