Privacy Practices

Ambulatory Surgical Center of Stevens Point




The Ambulatory Surgical Center of Stevens Point (Surgery Center) is required by law to maintain the privacy of your protected health information (PHI). PHI about you is maintained as a written and/or electronic record of your contacts or surgical/procedure visits. Specifically PHI is information about you, including demographic information (i.e. name, address, phone, etc.) that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services.

This notice describes your rights to access and control your PHI. It also describe how we follow applicable rules, and use and disclose your PHI to provide treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

Your Rights Under the Privacy Rule:

The following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff or our Privacy Officer.

You have the right to receive and we are required to provide you with a copy of this Notice of Privacy Practices: We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next surgical/procedural visit. This Notice will also be posted in a conspicuous location within the Surgical Center and maintained on the Surgical Center’s Website (

You have the right to authorize other use and disclosure: This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI or use for marketing purposes. You may revoke an authorization, at any time, in writing except to the extent that your healthcare provider, or our Center’s has taken an action in reliance on the use or disclosure indicated in the authorization.

You have the right to request an alternative means of confidential communication: This means you have the right to ask us to contact you about medical matters using an alternative method (i.e. email, telephone) and to a destination (i.e. cell phone number, alternative address, etc.) designated by you. You must inform us in writing, using a form provided by our Surgical Center how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.

You have the right to inspect and copy your PHI: This means you may inspect, and obtain a copy of your complete medical record. If your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state or federal guidelines.

You have a right to request a restriction of your PHI: This means you may ask us, in writing not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request in writing, that we restrict communication to your health plan regarding a specific treatment or service that you or someone on your behalf has paid in full or out-of-pocket. We are not permitted to deny this specific type of requested restriction.

You have the right to request an amendment to your PHI: This means you may request an amendment of your PHI for as long as we maintain this information. In certain cases, we may deny your request.

You have the right to request a disclosure accountability: This means you may request a listing of disclosures that we have made of your PHI to entities or persons outside of our office.

You have the right to receive a privacy breach notice: You have the right to receive written notification if the Surgical Center discovers a breach of your unsecured PHI and determines through a risk assessment that notification is required.

If you have questions regarding your privacy rights, please feel free to contact our Privacy Officer. Contact information is provided under Privacy Complaints.

How we May Use or Disclose Protected Health Information (PHI)

The following are examples of uses and disclosures of your PHI that we are permitted to make. These examples are not meant to be exhaustive but to describes possible types of uses and disclosures.

Treatment: We may use and disclose your PHI to provide, coordinate or manage, your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example we would disclose your PHI as necessary to a pharmacy that would fill your prescriptions. We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment.

Special Notices: We may use or disclose your PHI as necessary, to contact you to remind you of your surgical procedure and arrival time. We may contact you by phone or other means to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health related benefits and services offered by the Surgical Center.

Payment: Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as, making a determination of eligibility or coverage for insurance benefits.

Healthcare Operations: We may use, or disclose as needed your PHI in order to support the business activities of our Surgical Center. This includes but is not limited to business planning and development, quality assessment and improvement, medical review, legal service and auditing functions and patient safety activities.

Health Information Organization: The Surgical Center may elect to use a health information organization or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment or healthcare operations.

To Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person, that you identify, your PHI that directly relates to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, a personal representative, or any other person that is responsible for your care, or your general condition or death. If you are not present or able to agree or object to the use or disclosure of th PHI, then your healthcare provider may, using professional judgment determine whether the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed.

Other Permitted and Required Uses and Disclosures: We are also permitted to use or disclose your PHI without your written authorization for the following purposes: as required by law; for public health activities, health oversight activities; in cases of abuse or neglect; to comply with Food and Drug Administration requirements; research purposes; legal proceedings; law enforcement purposes; coroners; funeral directors; organ donation; criminal activity; military activity; national security; workers compensation; when an inmate in a correction facility; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

Privacy Complaints: You have the right to complain to us or directly to the Office of Civil Rights (Secretary of the Department of Health and Human Services, 233 N. Michigan Avenue, Suite 240, Chicago, IL 60601) if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer at 715-345-0500 or sending correspondence to 500 Vincent Street, Stevens Point, WI 54481.

We will not retaliate against you for filing a complaint.

Revision Date: September 15, 2013 Publication Date: September 15, 2013