Arizona Urology Specialists ASSOCIATES, LLC
NOTICE OF PRIVACY PRACTICE
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.
If you have any questions about this notice, please contact our Privacy Officer at (865) 690-0602.
Who Must Follow This Notice
This notice describes Arizona Urology Specialists Associates, LLC’s practices and those of:
- Any healthcare professional authorized to enter information into your chart;
- All departments and units of Arizona Urology Specialists Associates, LLC;
- Any member of a volunteer group we allow to help you while you are at Arizona Urology Specialists Associates, LLC;
- All employees, staff and other surgicenter personnel;
- Any and all business associates, and/or their subcontractors, that contract with Arizona Urology Specialists Associates, LLC;
- All of these entities will follow the terms of this notice. In addition, these entities may share medical information with each other for treatment, payment or surgicenter operations purposes described in this notice.
Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal, and we are committed to protecting your medical information. In order to provide you quality care and to comply with legal requirements, we create a record of the care and services you receive at Arizona Urology Specialists Associates, LLC. This notice applies to all of the records of your care generated by Arizona Urology Specialists Associates, LLC, whether made by surgicenter personnel, your personal doctor, or other practitioners involved with your care. Any use or disclosure not described in this notice will be made only with your express authorization.
This notice will tell you about the ways in which we may use and disclose your medical information. It will also describe your rights as well as our obligations regarding the use and disclosure of medical information.
We are required by law to:
- Ensure that identifying medical information is kept private;
- Furnish you with this notice of our legal duties, privacy practices and patient rights with respect to your medical information;
- Follow the terms of this notice;
- Notify you of any breach of privacy involving your information.
How We May Use And Disclose Patient Medical Information
The following categories describe different manners in which we may use and disclose medical information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories.
- For Treatment: We may use your medical information in order to provide you with medical treatment or services. We may disclose your medical information to doctors, nurses, technicians, medical students or other personnel who are involved in your care. For example, your physician will need to know your past medical history in order to evaluate your condition and health care needs. Different departments in the surgicenter also may share information about you in order to coordinate your care; for example, providing you with prescriptions, performing lab work or conducting ultrasounds. We may also disclose your medical information about you to outside parties (such as a pharmacist) who may be involved in your medical care after you leave the surgicenter.
- For Payment: We may use and disclose your medical information so that the treatment and services you receive at Arizona Urology Specialists Associates, LLC may be billed to/ payment collected from you, an insurance company, or a third party. For example, we may need to give your health insurance provider information about surgery you received so your health plan will pay us, or reimburse you, for the surgery. We may also tell your health insurance about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment.
- For Health Care Operations: We may use and disclose your medical information for Arizona Urology Specialists Associates, LLC operations. These uses and disclosures are necessary to run the surgicenter and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services, or to evaluate the performance of our staff in caring for you. We may also combine medical information about many surgicenter patients to decide what additional services the surgicenter should offer, what services are not needed, and whether certain new services are effective. We may also disclose information to doctors, nurses, technicians, medical students and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other institutions to compare our level of service and to improve the care and services we offer. We may remove information that identifies you from this type of medical information so that others may use it to study health care and health care delivery while maintaining your personal anonymity.
- Research: Under certain circumstances, we may use or disclose your medical information for research purposes. For example, a research project could involve comparing the results of all patients who receive one medication to those who receive another medication for the same condition. Participation in any research conducted at Arizona Urology Specialists Associates, LLC occurs on a volunteer basis, and only with your explicit and informed consent. All research projects are subject to a special approval process. In the case of any obligatory State or Federally mandated statistics reporting, identifying patient information is removed prior to reporting.
- Marketing/Fundraising: Any information used at Arizona Urology Specialists Associates, LLC for marketing or statistical purposes involves non-identifying information only. Arizona Urology Specialists Associates, LLC will never contact you for fundraising purposes.
- As Required By Law: We are obligated to disclose your medical information when we are required to do so as mandated by Federal, State or Local law.
If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
We may contract with business associates to perform activities on your behalf for purposes such as payment and health care operations. Our business associates, and any subcontractors they may employ, are also under contract to safeguard your medical information.
Public Health Risks (Health and Safety of You and Others)
We may disclose your medical information for public health activities. We may use and disclose your medical information to agencies when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. These activities generally include the following:
- to prevent or control disease, injury or disability;
- to report child abuse or neglect;
- to report reactions to medications or problems with products;
- to notify patients of recalls of products they may be using;
- to notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition;
- to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure when required or authorized by law.
Health Oversight Activities
We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities may include audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose your medical information in response to a court or administrative order. We may also disclose your medical information in response to a subpoena, discovery request, or other lawful process by another party involved in the dispute.
We may release medical information if asked to do so by a law enforcement official:
- in response to a court order, subpoena, warrant, summons or similar process;
- to identify or locate a suspect, fugitive, material witness or missing person;
- if the patient has been a victim of a crime and we are unable to obtain the person’s agreement;
- if a death has occurred that we believe may be the result of criminal conduct;
- about criminal conduct at Arizona Urology Specialists Associates, LLC;
- in emergency circumstances to report a crime; the location of a crime; or the identity, description or location of a person who committed the crime.
National Security and Intelligence Activities
We may release your medical information to authorized federal officials for intelligence, counterintelligence and other national security activities as required by law.
Protective Services for the President and Others
We may disclose your medical information to authorized federal officials sot they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your medical information to the correctional institution or law enforcement official. This release would be necessary:
- for the institution to provide you with health care;
- to protect your health and safety or the health and safety of others;
- for the safety and security of the correctional institution.
Your Rights Regarding Your Medical Information
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy
You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
To inspect and copy medical information that may be used to make decisions about you, contact the Medical Records Department at (865) 690-0602. If you request a copy of the information, we may charge a fee for the cost of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Arizona Urology Specialists Associates, LLC will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Arizona Urology Specialists Associates, LLC. To request an amendment, you must submit a written request to our Medical Records Department. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- is not part of the medical information kept by or for Arizona Urology Specialists Associates, LLC;
- is not part of the information which you would be permitted to inspect and copy;
- is accurate and complete.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we have made of medical information about you to others except for purposes of treatment, payment or operations identified above.
To request this list or “accounting of disclosures,” you must submit your request in writing to the Medical Record Department. Your request must state a time period which may not be longer than six (6) years prior to the date of the request. Your request should indicate in what form you want the list, for example, electronically or on paper. The first list you request within a 12-month period will be free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or for the payment for your care, such as a family member or friend. For example, you can ask that we not use or disclose information about a surgery you had.
Please note that it is NOT the practice of Arizona Urology Specialists Associates, PLLC to disclose information to friends or family members without your prior consent, but we must, by law, let you know how you can request restrictions. We automatically assume that your healthcare records are confidential unless you inform us otherwise.
We are not required to agree to your request. If we do agree, however, we will comply with your request unless the information you have asked to be withheld is required to provide you with emergency treatment. To request restrictions, you must make your request in writing to the Privacy Officer. Please include:
- the information you want to limit;
- whether you want to limit our use, disclosure or both; and
- to whom you want the limits to apply. For example, restricting disclosures to your spouse, or requesting that we only contact you via your work telephone.
To request confidential communications, you can let us know verbally. We will not ask you the reason for your request, and will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this privacy notice. You may ask us to give you a copy of this privacy notice at any time by requesting a copy from any member of our staff.
Changes To This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have on file, as well as any information we may receive in the future. We will post a copy of the current notice at Arizona Urology Specialists Associates, LLC. The notice will contain, on the first page, the effective date. In addition, each time you are admitted to Arizona Urology Specialists Associates, LLC for treatment or health care services, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may contact or submit your complaint in writing to the Privacy Officer in the Medical Records Department at Arizona Urology Specialists Associates, LLC. If we cannot resolve your concern, you also have the right to file a written complaint with the Secretary of the Department of Health and Human Services.
The quality of your care will not be jeopardized, nor will you be penalized for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your medical information for the reasons covered by your written authorization. We are unable to rescind disclosures we have already made with your permission. Please note that we are required to retain our records of the care that we have provided you.
You have the right to:
- considerate and respectful care, and to be made comfortable. You have the right to expect compassionate care, regardless of your cultural, psychosocial, spiritual and personal values, beliefs and preferences.
- have a family member, or other representative of your choosing, and your own physician notified promptly upon your admission to Arizona Urology Specialists Associates, LLC.
- know the name of the physician and/or CRNA who has primary responsibility for coordinating your care.
- receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcome of care in terms that you can understand.
- make decisions regarding medical care, and receive as much information about any proposed treatment or procedure you may need in order to give informed consent or refuse a course of treatment. This information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment and the name of the person who will perform the procedure.
- exercise your rights without being subjected to discrimination or reprisal.
- execute an advanced directive in accordance with Tennessee State Health and Safety Laws. The advance directive should be discussed with your physician during your initial appointment. Official State Advance Directive forms are available if requested.
- request or refuse treatment, to the extent permitted by law. However, you do not have the right to demand inappropriate or medically unnecessary treatment.
- reasonable responses to any reasonable requests made for services.
- appropriate assessment and management of your pain, information about your pain, pain relief measures and participation in pain management decisions.
- have your personal privacy respected. Case discussion, consultation, examination and treatment are confidential and should be discussed as discreetly as possible. You have the right to be informed of the reason for the presence of any individual. Privacy curtains will be used in semi-private rooms.
- confidential treatment of all communications and records pertaining to your care and stay at Arizona Urology Specialists Associates, LLC. You will receive a “Notice of Privacy Policies” that explains your privacy rights in detail.
- receive care in a safe setting; free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment.
- reasonable continuity of care, and to know in advance the time and location of appointments as soon as they are scheduled.
- be informed by the physician, or a delegate of the physician, of continuing health care requirements and options following discharge from Arizona Urology Specialists Associates, LLC.
- designate visitors of your choosing unless:
- Arizona Urology Specialists Associates, LLC has reasonably determined that the presence of a particular visitor would endanger the health or safety of a patient, a member of the staff or would significantly disrupt the operations of the facility.
- you have told Arizona Urology Specialists Associates, LLC that you no longer want a particular person to be in the facility.
- examine and receive an explanation of any bill from Arizona Urology Specialists Associates, LLC, regardless of the source of payment.
- exercise these rights without regard to sex, race, color, religion, ancestry, national origin, age, disability, medical condition, economic status, sexual orientation, educational background, economic status or source of payment for care.
- file a grievance. If you want to file a grievance with Arizona Urology Specialists Associates, LLC, you may do so by calling or writing:
Arizona Urology Specialists Associates, LLC
77 E. Thomas Rd. | Suite 230 | Phoenix, AZ 85012
Phone: (602) 222-1900
The grievance will be reviewed and you will be provided with a written response within 30 days. The written response will contain the name of the person to contact at Arizona Urology Specialists Associates, LLC, steps taken to investigate the grievance, the results of the grievance process and the date of completion of the grievance process. Concerns regarding the quality of care will also be referred to appropriate committee.
- file a complaint with the State Department of Health Services regardless of whether you use the grievance process. You can contact the State Department of Health Services at:
AZ Department of Health Services
150 North 18th Avenue, Phoenix, Arizona 85007
Office of the Medicare Beneficiary Ombudsman
Acting On a Patient’s Behalf
If the patient is unable to act on their own, they continue to have all the rights set forth above, and in addition:
- If a patient is adjudged incompetent under applicable State Health and Safety Laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under State Law to act on the patient’s behalf.
- If a State Court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with State Law may exercise the patient’s rights to the extent allowed by State Law.
Appointments & Information
*If this is an emergency, please call 911 immediately.
Please provide your email address and phone number and a Arizona Urology Specialists representative will contact you shortly to assist with your question or issue.
Monday–Friday, 8:30 a.m. to 4:30 p.m.