Patient Resources

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost

Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
• If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, please visit www.cms.gov/nosurprises or call 1-800-985-3059.

• Receive access to equal medical treatment and accommodations regardless of race, creed, sex, national origin, religion or sources of payment for care.
• Be fully informed and have complete information, to the extent known by the physician, regarding diagnosis, evaluation, treatment, procedure and prognosis, as well as the risks, side effects, and expected outcomes associated with treatment and procedure prior to the procedure.
• To give or withhold informed consent, participate in making decisions about his/her care, treatment or services.
• Exercise his or her rights without being subjected to discrimination or reprisal.
• Voice grievances regarding treatment or care that is (or fails to be) provided.
• Personal privacy.
• Receive care in a safe setting and be treated with dignity.
• Be free from all forms of abuse, exploitation, or harassment.
• Receive the care necessary to regain or maintain his or her maximum state of health and if necessary, cope with death.
• Receive notice of their rights prior to the surgical procedure in verbal and written notice in a language and manner that ensures the patient, or the patient’s representative, or the patient’s surrogate understand all of the patient’s rights.
• Expect personnel who care for the patient to be friendly, considerate, respectful and qualified through education and experience, as well as perform the services for which they are responsible with the highest quality of services.
• Be fully informed of the scope of services available at the facility, provisions for afterhours care and related fees for services rendered.
• Be a participant in decisions regarding the intensity and scope of treatment. If the patient is unable to participate in those decisions, the patient’s rights shall be exercised by the patient’s designated representative or patient’s surrogate other legally designated person.
• Make informed decisions regarding his or her care.
• Refuse treatment to the extent permitted by law and be informed of the medical consequences of such refusal. The patient accepts responsibility for his or her actions including refusal of treatment or not following the instructions of the physician or facility.
• Approve or refuse the release of medical records to any individual outside the facility, or as required by law or third party payment contract.
• Be informed of any human experimentation or other research/educational projects affecting his or her care of treatment and can refuse participation in such experimentation or research without compromise to the patient’s usual care.
• Express grievances/complaints and suggestions at any time and to have those reviewed by the organization.
• Access to and/or copies of his/her medical records.
• Be informed as to the facility’s policy regarding advance directives/living wills.
• Be fully informed before any transfer to another facility or organization and ensure the receiving facility has accepted the patient transfer.
• Express those spiritual beliefs and cultural practices that do not harm or interfere with the planned course of medical therapy for the patient.
• Expect the facility to agree to comply with Federal Civil Rights Laws that assure it will provide interpretation for individuals who are not proficient in English.
• Have an assessment and regular assessment of pain.
• Education of patients and families, when appropriate, regarding their roles in managing pain.
• To change providers if other qualified providers are available.
• 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 laws may exercise the patient’s rights to the extent allowed by state law.

PATIENT RESPONSIBILITIES

• Be respectful and considerate of other patients and personnel and for assisting in the control of noise, eating and other distractions.
• Respecting the property of others and the facility.
• Reporting whether he or she clearly understands the planned course of treatment and what is expected of him or her.
• Keeping appointments and, when unable to do so for any reason, notifying the facility and physician.
• Providing care givers with the most accurate and complete information regarding present complaints, past illnesses and hospitalizations, medications, including over-the-counter products and dietary supplements, any allergies or sensitivities, unexpected changes in the patient’s condition, or any other patient health matters.
• Follow the treatment plan prescribed by his/her provider and participate in his/her care.
• Provide a responsible adult to transport him/her home from the facility and remain with him/her for 24 hours, if required by his/her provider.
• Observing prescribed rules of the facility during his or her stay and treatment and, if instructions are not followed, forfeit of care at the facility.
• Promptly fulfilling his or her financial obligations to the facility and accept personal financial responsibility for any charges not covered by his/her insurance.
• Identifying any patient safety concerns.

ADVANCE DIRECTIVE NOTIFICATION
All patients have the right to participate in their own health care decisions and to make Advance Directives or to execute Powers of Attorney that authorize others to make decisions on their behalf based on the patient’s expressed wishes when the patient is unable to make decisions or unable to communicate decisions. Parkwest Surgery Center respects and upholds those rights.

Our team is dedicated to delivering the highest quality care in a safe environment that places the patient at the center of our care. We respect your rights to participate in make decisions regarding your care and self determination and will carefully consider your requests.  After careful consideration and reviewing the applicable state regulation, the leadership of the facility has established a policy to initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. The majority of procedures performed at Parkwest Surgery Center are considered to be of minimal risk, hence the risk of you needing such measures are highly unlikely.  At the acute care hospital, further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, advance directive, or health care power of attorney.

You have the option of proceeding with care at our facility or having the procedure at another location that may not set the same limitations. Having been fully informed of our Statement of Limitations, you choose to proceed with your procedure at Parkwest Surgery Center.

If you wish to complete an Advance Directive, copies of the official State forms are available at our facility.

If you do not agree with this facility’s policy, we will be pleased to assist you in rescheduling your procedure.

 
PATIENT COMPLAINT OR GRIEVANCE
To report a complaint or grievance you can contact the facility Administrator by phone at (865) 531-0494 or by mail at:

Parkwest Surgery Center
9430 Parkwest Boulevard Suite 210 Knoxville, Tennessee 37923

Medicare beneficiaries may receive information regarding their options under Medicare and their rights and protections by visiting the website for the Office of the Medicare Beneficiary Ombudsman at:

https://www.cms.gov/center/special-topic/ombudsman/medicare-beneficiary-ombudsman-home
https://www.medicare.gov/claims-appeals/how-to-file-a-complaint-grievance
https://www.medicare.gov/basics/your-medicare-rights/get-help-with-your-rights-protections

DERECHOS DEL PACIENTE

• Recibir acceso a igualdad de tratamiento médico y comodidades sin importar la raza, credo, sexo, origen nacional, religión, o fuentes de pago para el cuidado.
• Estar completamente informado y tener información completa, hasta el punto conocido por el médico, sobre el diagnóstico, tratamiento, procedimiento y pronóstico, así como los riesgos y efectos secundarios asociados con el tratamiento y procedimiento antes del procedimiento.
• Ejercer sus derechos sin ser sujetado a discriminación o represalia.
• Expresar quejas sobre el tratamiento o cuidado de que sea (o no sea) proporcionada.
• La privacidad personal.
• Recibir atención en un entorno seguro.
• Estar libre de cualquier forma de abuso o acoso.
• Recibir el cuidado necesario para recuperar o mantener su estado de salud máximo y si es necesario, hacer frente a la muerte.
• Espere que el personal que cuida del paciente son amistosos, considerados, respetuosos y calificados por medio de educación y experiencia, así como realizar los servicios de los que son responsables de la más alta calidad de los servicios.
• Estar completamente informado del alcance de los servicios disponibles en el centro médico, provisiones para cuidado después de horas, y los honorarios relacionados por los servicios prestados.
• Ser un participante en las decisiones con respecto a la intensidad y alcance del tratamiento. Si el paciente no puede participar en esas decisiones, los derechos del paciente serán ejercitadas por el representante designado del paciente u otra persona legalmente designada.
• Tomar decisiones informadas con respecto a su cuidado.
• Rechazar el tratamiento en la medida permitida por la ley y ser informado de las consecuencias médicas de tal denegación. El paciente acepta la responsabilidad de sus acciones incluyendo la denegación de tratamiento o no seguir las instrucciones del médico o centro.
• Aprobar o rechazar la divulgación de informes médicos a cualquier individual fuera del centro, o de lo requerido por ley o contrato de pago de terceros.
• Estar informado de cualquier experimentación humana o de otros proyectos de investigación / educación que afectan a su cuidado del tratamiento y puede rechazar la participación en tal experimentación o investigación sin compromiso al cuidado general del paciente.
• agravios / quejas y sugerencias en cualquier momento Express.
• El acceso ay / o copias de su / sus registros médicos.
• Estar informado en cuanto a la política del centro médico con respecto a directivas / testamentos vitales antelación.
• Estar completamente informado antes de cualquier transferencia a otro centro u organización y asegurarse de la instalación receptora ha aceptado el traslado del paciente.
• Expresar las creencias espiritual y las prácticas culturales que no dañan ni interfieren con el curso previsto de terapia médica para el paciente.
• Esperar que el centro de acuerdo en conformarse con las Leyes Federales de Derechos Civiles que aseguran que proveerán interpretación para los individuos que no dominan el Inglés.
• Tener una evaluación y evaluaciones regulares de dolor.
• Educación de pacientes y familias, cuando es apropiado, con respecto a sus papeles en el manejo del dolor.
• Para cambiar personal médico si otro personal médico calificado está disponible.
• Si un paciente se adjudica incompetente bajo leyes de salud y seguridad estatal aplicable por un tribunal de jurisdicción competente, los derechos del paciente serán ejercitadas por la persona designada bajo la ley estatal de actuar en nombre del paciente.
• Si un tribunal estatal no ha adjudicado un paciente incompetente, cualquier representante legal designado por el paciente de acuerdo con leyes estatales, puede ejercitar los derechos del paciente en la medida permitida por la ley estatal.

RESPONSABILIDADES DEL PACIENTE

• Sea considerado con otros pacientes y personal y asistir con el control de ruido, comer, u otras distracciones.
• Respetar la propiedad de otros y del centro.
• Divulgar si entiende claramente el curso de tratamiento previsto y lo que se espera de él o ella.
• Mantener las citas y, cuando no pueda hacerlo por cualquier razón, notificar al centro y al médico.
• Proveer a los cuidadores la información más exacta y completa con respecto a quejas ocurriendo, enfermedades previas y hospitalizaciones, medicamentos, cambios inesperados en la condición del paciente, o cualquier otro asunto de la salud del paciente.
• Observar las reglas prescritos del centro médico durante su estadía y tratamiento y, si no se siguen las instrucciones, perderá de atención en el centro.
• Cumplir de manera oportuna con sus obligaciones financieras para con la institución.
• Identificación de cualquier preocupación de seguridad del paciente.

NOTIFICACIÓN DIRECTIVA ANTICIPADA

Todos los pacientes tienen derecho a participar en sus propias decisiones de atención de salud y hacer directivas anticipadas o ejecutar Poderes que autoricen a otros a tomar decisiones en su nombre sobre la base de que el paciente ha expresado deseos cuando el paciente es incapaz de tomar decisiones o no pueden comunicar decisiones. Aspectos Parkwest Surgery Center y mantiene estos derechos.

Sin embargo, a diferencia de un centro de cuidado grave Parkwest Surgery Center no rutinaria realizar procedimientos “de riesgo elevado”. Mientras que no hay cirugía sin riesgo, la mayoría de los procedimientos realizados en este centro médico se consideran de riesgo mínimo. Usted discutirá los específicos de su procedimiento con su médico quien puede contestar sus preguntas en cuanto a sus riesgos, la recuperación prevista, y cuidado después de su cirugía.

Por lo tanto, es nuestra política, sin importar el contenido de una Directiva Avanzada o instrucciones de un sustituto o un abogado-de-hecho, si un acontecimiento adverso ocurre durante su tratamiento en nuestro centro, vamos a iniciar resucitación u otro estabilizador medidas y les transferiremos a un hospital de agudos para una evaluación adicional. En el hospital de cuidado grave, más tratamientos o el retiro de medidas de tratamiento ya serán pedidos de acuerdo con sus deseos, Directivas Avanzadas, o Poder para Atención Médica. Su acuerdo con la política de este centro médico no revocará ni invalidará ninguna directiva de cuidado médico o el poder para la atención médica.

Si usted desea completar una Directiva Avanzada, las copias de los formularios estatales oficiales están disponibles en nuestro centro.

Si usted no está de acuerdo con la política de este centro médico, estaremos encantados de ayudarle a reprogramar su procedimiento.

AGRAVIOS O QUEJAS DEL PACIENTE
Para presentar una queja o reclamación puede comunicarse con el Administrador del centro medico al (865) 531-0494 o mail a:

Parkwest Surgery Center
9430 Parkwest Boulevard Suite 210 Knoxville, Tennessee 37923

Los beneficiarios de Medicare pueden recibir información con respeto a sus opciones bajo Medicare y sus derechos y protecciones, visite el sitio web de la Oficina del Beneficiarios de Medicare Ombudsman en:

https://www.cms.gov/center/special-topic/ombudsman/medicare-beneficiary-ombudsman-home
https://www.medicare.gov/claims-appeals/how-to-file-a-complaint-grievance
https://www.medicare.gov/basics/your-medicare-rights/get-help-with-your-rights-protections

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.

Who Presents this Notice

The references to “Facility” and “Health Professionals” in this notice refer to the members of the United Surgical Partners International Affiliated Covered Entity. An Affiliated Covered Entity (ACE) is a group of organizations under common ownership or control who designate themselves as a single Affiliated Covered Entity for purposes of compliance with the Health Insurance Portability and Accountability Act (“HIPAA”). The Facility, its employees, workforce members and members of the ACE who are involved in providing and coordinating health care are all bound to follow the terms of this Notice of Privacy Practices (“Notice”). The members of the ACE will share PHI with each other for the treatment, payment and health care operations of the ACE and as permitted by HIPAA and this Notice. For a complete list of the members of the ACE, please contact the Privacy & Security Compliance Office.

Privacy Obligations

Each Facility is required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of legal duties and privacy practices with respect to your Protected Health Information.  The Facility uses computerized systems that may subject your Protected Health Information to electronic disclosure for purposes of treatment, payment and/or health care operations as described below. When the Facility uses or discloses your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

Notifications

The Facility is required by law to protect the privacy of your medical information, distribute this Notice of Privacy Practices to you, and follow the terms of this Notice. The Facility is also required to notify you if there is a breach or impermissible access, use or disclosure of your medical information.

Permissible Uses and Disclosures Without Your Written Authorization

In certain situations your written authorization must be obtained in order to use and/or disclose your PHI.  However, the Facility and Health Professionals do not need any type of authorization from you for the following uses and disclosures:

Uses and Disclosures for Treatment, Payment and Health Care Operations.  Your PHI may be used and disclosed to treat you, obtain payment for services provided to you and conduct “health care operations” as detailed below:

Treatment.  Your PHI may be used and disclosed to provide treatment and other services to you–for example, to diagnose and treat your injury or illness.  In addition, you may be contacted to provide you appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.  Your PHI may also be disclosed to other providers involved in your treatment.  For example, a doctor treating you for a broken leg may need to know if you have diabetes because if you do, this may impact your recovery.

Payment.  Your PHI may be used and disclosed to obtain payment for services provided to you–for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”) to verify that Your Payor will pay for health care.  The physician who reads your x-ray may need to bill you or your Payor for reading of your x-ray therefore your billing information may be shared with the physician who read your x-ray.

Health Care Operations.  Your PHI may be used and disclosed for health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care delivered to you.  For example, PHI may be used to evaluate the quality and competence of physicians, nurses and other health care workers.  PHI may be disclosed to the Privacy & Security Compliance Office in order to resolve any complaints you may have and ensure that you have a comfortable visit.  Your PHI may be provided to various governmental or accreditation entities such as the Joint Commission on Accreditation of Healthcare Organizations to maintain our license and accreditation.  In addition, PHI may be shared with business associates who perform treatment, payment and health care operations services on behalf of the Facility and Health Professionals.

Additionally, your PHI may be used or disclosed for the purpose of allowing students, residents, nurses, physicians and others who are interested in healthcare, pursuing careers in the medical field or desire an opportunity for an educational experience to tour, shadow employees and/or physician faculty members or engage in a clinical Practicum.

Health Information Organizations. Your PHI may be used and disclosed with other health care providers or other health care entities for treatment, payment and health care operations purposes, as permitted by law, through a Health Information Organization. A list of Health Information Organizations in which this facility participates may be obtained upon request.  For example, information about your past medical care and current medical conditions and medications can be available to other primary care physicians if they participate in the Health Information Organization. Exchange of health information can provide faster access, better coordination of care and assist providers and public health officials in making more informed treatment decisions. You may opt out of the Health Information Organization and prevent providers from being able to search for your information through the exchange. You may opt out and prevent your medical information from being searched through the Health Information Organization by completing and submitting an Opt-Out Form to registration.

Use or Disclosure for Directory of Individuals in the Facility.  Facility may include your name, location in the Facility, general health condition and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory.  Information in the directory may be disclosed to anyone who asks for you by name.  Your religious affiliation may be given to a member of the clergy, such as a priest or minister, even if they do not ask for you by name.  If you do not wish to be included in the facility directory, you will be given an opportunity to object at the time of admission.

Disclosure to Relatives, Close Friends and Other Caregivers.  Your PHI may be disclosed to a family member, other relative, a close personal friend or any other person identified by you who is involved in your health care or helps pay for your care.  If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, the Facility and/or Health Professionals may exercise professional judgment to determine whether a disclosure is in your best interests.  If information is disclosed to a family member, other relative or a close personal friend, the Facility and/or Health Professionals would disclose only information believed to be directly relevant to the person’s involvement with your health care or payment related to your health care.  Your PHI also may be disclosed in order to notify (or assist in notifying) such persons of your location or general condition.

Public Health Activities.  Your PHI may be disclosed for the following public health activities:  (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

Victims of Abuse, Neglect or Domestic Violence.  Your PHI may be disclosed to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence if there is a reasonable belief that you are a victim of abuse, neglect or domestic violence.

Health Oversight Activities.  Your PHI may be disclosed to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

Judicial and Administrative Proceedings.  Your PHI may be disclosed in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

Law Enforcement Officials.  Your PHI may be disclosed to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.  For example, your PHI may be disclosed to identify or locate a suspect, fugitive, material witness, or missing person or to report a crime or criminal conduct at the facility.

Correctional Institution.  You PHI may be disclosed to a correctional institution if you are an inmate in a correctional institution and if the correctional institution or law enforcement authority makes certain requests to us.

Organ and Tissue Procurement.  Your PHI may be disclosed to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

Research.  Your PHI may be used or disclosed without your consent or authorization if an Institutional Review Board approves a waiver of authorization for disclosure. 

Health or Safety.  Your PHI may be used or disclosed to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

U.S. Military.  Your PHI may be use or disclosed to U. S. Military Commanders for assuring proper execution of the military mission. Military command authorities receiving protected health information are not covered entities subject to the HIPAA Privacy Rule, but they are subject to the Privacy Act of 1974 and DoD 5400.11-R , “DoD Privacy Program,” May 14, 2007.

Other Specialized Government Functions.  Your PHI may be disclosed to units of the government with special functions, such as the U.S. Department of State under certain circumstances for example the Secret Service or NSA to protect the country or the President.

Workers’ Compensation.  Your PHI may be disclosed as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.

As Required by Law.  Your PHI may be used and disclosed when required to do so by any other law not already referred to in the preceding categories; such as required by the FDA, to monitor the safety of a medical device.

Appointment Reminders.  Your PHI may be used to tell or remind you about appointments.

Fundraising.  Your PHI may be used to contact you as a part of fundraising efforts, unless you elect not to receive this type of information.

USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

Use or Disclosure with Your Authorization.  For any purpose other than the ones described above, your PHI may be used or disclosed only when you provide your written authorization on an authorization form (“Your Authorization”).  For instance, you will need to execute an authorization form before your PHI can be sent to your life insurance company or to the attorney representing the other party in litigation in which you are involved.

Marketing.  Your written authorization (“Your Marketing Authorization”) also must be obtained prior to using your PHI to send you any marketing materials.  (However, marketing materials can be provided to you in a face-to-face encounter without obtaining Your Marketing Authorization.  The Facility and/or Health Professionals are also permitted to give you a promotional gift of nominal value, if they so choose, without obtaining Your Marketing Authorization).  The Facility and/or Health Professionals may communicate with you in a face-to-face encounter about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.

In addition, the Facility and/or Health Professionals may send you treatment communications, unless you elect not to receive this type of communication, for which the Facility and/or Health Professionals may receive financial remuneration.

Sale of PHI.  The Facility and Health Professionals will not disclose your PHI without your authorization in exchange for direct or indirect payment except in limited circumstances permitted by law.  These circumstances include public health activities; research; treatment of the individual; sale, transfer, merger or consolidation of the Facility; services provided by a business associate, pursuant to a business associate agreement; providing an individual with a copy of their PHI; and other purposes deemed necessary and appropriate by the U.S. Department of Health and Human Services (HHS).

Uses and Disclosures of Your Highly Confidential Information.  In addition, federal and state law require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that:  (1) is maintained in psychotherapy notes; (2) is about mental illness, mental retardation and developmental disabilities; (3) is about alcohol or drug abuse or addiction; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about communicable disease(s), including venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult; or (9) is about sexual assault.  In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization is required.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Right to Request Additional Restrictions.  You may request restrictions on the use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition.  While all requests for additional restrictions will be carefully considered, the Facility and Health Professionals are not required to agree to these requested restrictions.

You may also request to restrict disclosures of your PHI to your health plan for payment and healthcare operations purposes (and not for treatment) if the disclosure pertains to a healthcare item or service for which you paid out-of-pocket in full.  The Facility and Health Professionals must agree to abide by the restriction to your health plan EXCEPT when the disclosure is required by law.

If you wish to request additional restrictions, please obtain a request form from the Health Information Management Office and submit the completed form to the Health Information Management Office.  A written response will be sent to you.

Right to Receive Confidential Communications.  You may request, and the Facility and Health Professionals will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.

Right to Revoke Your Authorization.  You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your PHI, except to the extent that the Facility and/or Health Professionals have taken action in reliance upon it, by delivering a written revocation statement to the Facility Health Information Management Office identified below.

Right to Inspect and Copy Your Health Information.  You may request access to your medical record file and billing records maintained by the Facility and Health Professionals in order to inspect and request copies of the records.  Under limited circumstances, you may be denied access to a portion of your records.  If you desire access to your records, please obtain a record request form from the Facility Health Information Management Office and submit the completed form to the Facility Health Information Management Office.  If you request copies of paper records, you will be charged in accordance with federal and state law.  To the extent the request for records includes portions of records which are not in paper form (e.g., x-ray films), you will be charge the reasonable cost of the copies.  You also will be charged for the postage costs, if you request that the copies be mailed to you.  However, you will not be charged for copies that are requested in order to make or complete an application for a federal or state disability benefits program.

Right to Amend Your Records.  You have the right to request that PHI maintained in your medical record file or billing records be amended.  If you desire to amend your records, please obtain an amendment request form from the Facility Health Information Management Office and submit the completed form to the Facility Health Information Management Office.  Your request will be accommodated unless the Facility and/or Health Professionals believe that the information that would be amended is accurate and complete or other special circumstances apply.

Right to Receive an Accounting of Disclosures.  Upon request, you may obtain an accounting of certain disclosures of your PHI made during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.  If you request an accounting more than once during a twelve (12) month period, you will be charged for the accounting statement.

Right to Receive Paper Copy of this Notice.  Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.

For Further Information or Complaints.  If you desire further information about your privacy rights, are concerned that your privacy rights have been violated or disagree with a decision made about access to your PHI, you may contact the Privacy & Security

Office.  You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services.  Upon request, the Privacy & Security Compliance Office will provide you with the correct address for the Director.  The Facility and Health Professionals will not retaliate against you if you file a complaint with the Privacy & Security Compliance Office or the Director.

Effective Date and Duration of This Notice

Effective Date.  This Notice is effective on April 1, 2024.

Right to Change Terms of this Notice.  The terms of this Notice may be changed at any time.  If this Notice is changed, the new notice terms may be made effective for all PHI that the Facility and Health Professionals maintain, including any information created or received prior to issuing the new notice.  If this Notice is changed, the new notice will be posted in waiting areas around the Facility.  You also may obtain any new notice by contacting the Privacy & Security Compliance Office.

FACILITY CONTACTS:

Privacy & Security Compliance Office
P.O. Box 32569
Knoxville, TN 37930
E-mail:  complianceoffice@tocdocs.com

Financial Responsibility
It is expected that deductibles, co-payments, and other amounts not covered by insurance will be paid prior to services being provided. Accepted forms of payment include cash, personal check, and credit card. Payment may be made over the phone prior to your procedure or at check in at Parkwest Surgery Center. If you have questions at any time, let us know.

Questions About Your Bill
After you’re discharged, a statement will be mailed to you for any balance due after your insurance company has processed your claim. Payment is due upon receipt and may be made by cash, personal check or credit card.

When you receive your statement, please contact the phone number printed on your statement.

Financial Assistance Programs

CareCredit

CareCredit® is a credit card issued exclusively for use in paying for your health care expenses. You can apply for a CareCredit® card to cover the facility portion of your bill at participating surgical facilities.

• Depending on the cost of your procedure and the options offered at your surgical facility, you may choose between 6 and 12 month special financing options on qualifying purchases of $200 or more. *
• To apply for a CareCredit® credit card, visit the CareCredit® website www.carecredit.com
• Call them directly at: (800) 677-0718
• Call your surgical facility if you have any questions.
• Click here to learn more from the CareCredit® website.

*Subject to credit approval. Minimum monthly payments required. See provider for details.