NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES

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.

Advanced Urology (AU) is required by law to maintain the privacy of your health information and is strongly committed to maintaining your privacy. Additionally, Advanced Urology is required to provide you with a notice of its legal duties and privacy practices. AU will not use or disclose your health information except as described in this Notice. This Notice applies to all of the health information generated by Advanced Urology, as well as information we receive from others, including health care providers and health plans.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION TREATMENT:

Advanced Urology may use and disclose your health information to provide and coordinate your healthcare treatment. We may disclose all or part of your health information to your attending physician, consulting physicians, nurses, technicians, or other health care providers who have a legitimate need for such information in your care and treatment. AU may also use or disclose your health information to tell you about or recommend treatment alternatives that may interest or benefit you, or to remind you about an appointment.

PAYMENT: Advanced Urology may use and disclose health information about you for payment purposes, including determining coverage, billing, claims management, medical data processing, and reimbursement. The information may be released to an insurance company, third party or other entity (or their authorized representatives) involved in the payment of your medical bill, and may include copies or excerpts of your medical record that are necessary for payment of your account. For example, a bill sent to a third party payer may include information that identifies you, your diagnosis, and the procedures and supplies used.

ROUTINE HEALTHCARE OPERATIONS:

Advanced Urology may use and disclose your health information for routine healthcare operations, including but not limited to quality assurance, medical review, internal auditing, licensing or credentialing activities of AU, and educational purposes. AU may engage outside companies (“business associates”) to carry out certain aspects of these healthcare operations. AU may need to disclose your health information to the business associates to enable them to perform their duties. Examples of business associates include, but are not limited to, medical transcriptionists, third-party billing companies, accountants, and lawyers. AU requires the business associate to also sign an agreement to protect the confidentiality of your health information.

USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION:

AU will obtain a written authorization from you before it uses or discloses your protected health information, unless a particular use or disclosure is expressly permitted or required by law without your authorization. We must obtain your authorization to use or disclose your protected health information for certain marketing purposes, for fundraising, or to sell your information. You have the right to revoke any authorization you have previously given by submitting a written statement of revocation to AU, however, we cannot take back any disclosures we have already made based on your authorization.

USES AND DISCLOSURES TO WHICH YOU MAY OBJECT:

AU may disclose your health information to a friend or family member who is involved in your medical care and for disaster relief purposes. If you have any objection to the use and disclosure of your health information in this manner, please tell us.

USES AND DISCLOSURES THAT ARE REQUIRED OR PERMITTED WITHOUT AUTHORIZATION REGULATORY AGENCIES:

AU may disclose your health information to government and certain private health oversight agencies, e.g., the Department of Public Health and Environment, the Joint Commission, or the Board of Medical Examiners, for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations and inspections. These activities are necessary to monitor compliance with the requirements of government programs.

LAW ENFORCEMENT/LITIGATION:

AU may disclose your health information for law enforcement purposes, judicial and arbitration proceedings, and other disputes consistent with applicable law.

PUBLIC HEALTH:

As required by law, AU may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

WORKERS’ COMPENSATION:

AU may disclose health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

MILITARY/VETERANS:

AU may disclose your health information as required by military command authorities, if you are a member of the armed forces.

CORONERS: Upon your death, AU may disclose your health information to a coroner or medical examiner for purposes of identifying you or determining a cause of death, and to funeral directors as necessary to carry out their duties.

NATIONAL SECURITY:

AU may disclose health information about you to authorized officials for intelligence, counterintelligence, and any other national security activities authorized by law.

RESEARCH:

AU may use and disclose your health information for reviews preparatory to research and, if approved, you may receive information regarding recruitment in to a study.

AS OTHERWISE REQUIRED BY LAW:

AU will disclose your health information in any situation in which such disclosure is required by law (e.g., child abuse, domestic abuse, or to prevent harm to you or other individuals).

YOUR RIGHTS RELATED TO YOUR HEALTH INFORMATION:

Although all records concerning your treatment obtained at the AU are the property of AU, you have the following rights concerning your health information.

RIGHT TO CONFIDENTIAL COMMUNICATIONS:

You have the right to receive confidential communications of your health information by alternative means or at alternative locations. For example, you may request that AU only contact you at work or by mail.

RIGHT TO INSPECT AND COPY:

You generally have the right to inspect and copy your health information in paper and electronic format, except as restricted by law. All copies are given by request only.

RIGHT TO AMEND:

You have the right to request an amendment or correction to your health information. If we agree that an amendment or correction is appropriate, we will ensure that the amendment or correction is attached to your medical record.

RIGHT TO AN ACCOUNTING:

You have the right to obtain a statement of the disclosures that have been made of your health information, except for the purposes of treatment, payment or routine operations (as detailed above), or if you have provided an authorization.

RIGHT TO REQUEST RESTRICTIONS:

You have the right to request restrictions on certain uses and disclosures of your health information. AU generally is not required to abide by your requested restrictions. However, if you pay in full out of pocket for a health care item or service, we must comply with your request to restrict the disclosure of health information related to that health care item or service to a health plan for payment or health care operations purposes.

RIGHT TO RECEIVE COPY OF THIS NOTICE:

You have the right to receive a paper copy of this Notice, upon request.

RIGHT TO REVOKE AUTHORIZATION:

You have the right to revoke your authorization to use or disclose your health information, except to the extent that action has already been taken in reliance on your consent or authorization.

RIGHT TO RECEIVE CERTAIN NOTICES:

You have a right to receive notice of certain breaches of the security of certain protected health information.

FOR MORE INFORMATION REGARDING HOW TO EXERCISE THESE RIGHTS:

If you have questions or would like more information regarding any of the rights listed above, please contact AU’s Chief Operating Officer at the address or telephone number listed below.

IF YOU BELIEVE THAT YOUR RIGHTS HAVE BEEN VIOLATED:

You may file a complaint with AU, or with the Secretary of the Department of Health and Human Services. To file a complaint with AU, please contact:

Chief Operating Officer/Practice Administrator
Advanced Urology
11960 Lioness Way, Ste 210
Parker, CO, 80134
303-695-6106

All complaints must be submitted in writing. There will be no retaliation for filing a complaint. CHANGES TO THIS NOTICE AU will abide by the terms of the Notice currently in effect. AU reserves the right to change the terms of this Notice at any time. Any new notice provisions will be effective for all protected health information that it maintains. You have the right to review this Notice at any time. AU will make its Notice, including any revisions, available at our Lone Tree/Parker and Aurora locations and on the web site AdvancedUrologyPC.com.

THE EFFECTIVE DATE:

The effective date of this notice is September 23, 2013.

We have placed this on the patient clip board in full size for easier viewing. There is also a copy in the waiting room.