Patient Notice of Privacy Practices—July 2015

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully.

  • Your rights regarding medical information about you.
    Your health record is the physical property of the Center. The information contained in the record however belongs to you. You have the right to:
  1. Request a restriction or limitation on the medical information we use or disclose about you for your 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 the payment for your care, such as a family member or friend. We are not required to agree to your requested restrictions. If we do not agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
  2. Obtain a copy of this notice by requesting it from the Administrator of the Center.
  3. Inspect and obtain a copy of your health care record in the format requested by submitting a request in writing to the Privacy Officer of the Center.
  4. Amend your healthcare record if you feel that medical information that we have about you is incorrect or incomplete by requesting in writing that the amendment be made. You must provide a reason that supports your request.
  5. Obtain a report of all the disclosures of your health information that we have made.
  6. Request that we communicate with you about your medical information in a certain way or at a certain location.
  7. Revoke our authorization to use and disclose medial information about you, except to the extent that we have already used or disclosed your medical information.
  • Our responsibilities regarding your medical information.
    We are required by law to:
  1. Maintain the privacy of your health information.
  2. Provide you with this notice, which describes our legal duties and privacy practices with respect to information we collect about you.
  3. Abide by the terms of this notice.
  4. Notify you if we are unable to agree to a requested restriction.
  5. Notify affected individual of a breach of unsecured PHI.
  6. Accommodate reasonable requests that you have made to have us communicate your health information to you in a certain way or a certain location.We reserve the right to change this notice. We reserve the right to make the revised and changed notice effective for medical information that we already have about you, as well as any information that we receive in the future. We will post a copy of the current notice in the Center. The notice will contain the effective date on the first page. Each time that you register at the Center, we will offer you a copy of the current notice in effect.
  • How we may use and disclose medical information about you.
    Each time that you visit us a record of your visit is made. We may use or disclose the health information contained in this record. The following categories describe the different ways that we may use and disclose your medical information.

We may use medical information about you to provide you with medical treatment and services. We may disclose medical information about you to doctors, nurses, technicians, or other Center personnel who are involved in taking care of you at the Center.

For example, information obtained by a nurse, physician, or other member of your health care team will be recorded in your medical records and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health team. Members of your healthcare team will then record the actions that they took and their observations. By reading your medical record, the physician will know how you are responding to treatment.

We may use and disclose medical information about you so that the treatment and services you receive at the Center may be billed to and payment may be collected from you, an insurance company or third party.

  • Health care operations.
    We may use and disclose medical information about you for the operations of the Center.

For example, members of the medical staff, the risk or quality management committee may use information in your health record to assess the care and outcomes in your case and others like it. This information will be used in a way to improve the quality and effectiveness of the healthcare and the services that we provide.

  • Appointment reminders.
    We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the Center.
  • Treatment alternatives.
    We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
  • Individuals involved in your care or payment of your care.
    We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care.
  • As required by law.
    We will disclose medical information about you when required to do so by federal, state or local law.
  • Health related benefits and services.
    We may use and disclose medical information to inform you about health related benefits or services that may be of interest to you.

We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. The Center would only disclose the information to someone able to help prevent the threat.

  • Business associates.
    Some of the services provided at the Center are provided by business associates. For example, we contract with certain laboratories to perform lab tests. When we contract for these services, we may disclose your health information to our business associates so that they can perform the job we have hired them to do. To protect your health information, we require our business associates to appropriately safeguard your information.
  • Worker’s compensation.
    We may release medical information about you to the extent authorized by and to the extent necessary to comply with the laws relating to workers compensation or other similar programs established by law.
  • Public health risks.
    As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
  • Health oversight activities.
    We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include for example 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 medical information about you in response to a court or an administrative order. We may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in a dispute but only if efforts have been made to tell you about the request or to obtain an order protecting the information required.
  • Law enforcement.
    We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
  • Coroners, medical examiners and funeral directors.
    We may release medical information to a coroner or medical examiner. We may also disclose health information to a funeral directors consistent with applicable law to carry out the duties.
  • Food and Drug Administration (“FDA”).
    We may disclose to the FDA health information related to adverse events with respect to food, supplements, products and product defects or post marketing surveillance information to enable product recalls, repairs or replacement.

If you are an inmate of a correctional institution or under the custody of a law enforcement agent, we may release medical information about you to the correctional institution or law enforcement official.

  • Marketing Purposes
    As required by law, the Center will not disclose medical information for marketing purposes that constitute the sale of PHI without an authorization from the patient(s).
  • Other uses of medical information.
    Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only upon written authorization you provide to us. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization in writing at any time. If you revoke your authorization we will no longer use or disclose medical information about you for the reasons covered by your written authorization. The revocation however will not have any effect on any action the Center took before it received the revocation.
  • Questions or complaints.
    If you believe that your privacy rights have been violated, or if you have complaints about this Notice of Privacy Practices, contact: the
Administrator, Svetlana Nahum, Surgery Center Phone: (718)-998-5678. If you are not satisfied with the manner in which the Surgery Center handles a complaint, you may submit a formal written complaint to the Department of Health and Human Services, Office for Civil Rights. You will not be retaliated against for filing a complaint.


We are giving you this summary of Advance Directives to help you understand the ways in which our staff will support your rights as an adult patient to make decisions about your health care treatment and to have those wishes honored in the event you are not able to make or communicate your decisions.

Advance Directives are written or oral instructions relating regarding the provision of healthcare in the event an adult over 18 becomes incapacitated. The most common types of Advance Directives are the following.

  • Healthcare Proxy: a document created pursuant to Article 29-C of the Public Health Law which delegates authority to an adult known as the healthcare agent to make healthcare decisions on behalf of another adult when that adult is incapacitated.
  • Do Not Resuscitate Order (DNR): a DNR order means specifically that if cardiac and/or respiratory arrest occurs – that is, if a person stops breathing and/or his/her heart stops beating—cardiopulmonary resuscitation (CPR) will not be performed to revive the person. (However, if the person is not in cardiac or respiratory arrest, appropriate medical treatment for all injuries, pain, difficult or insufficient breathing, hemorrhage and/or other medical conditions will be provided.)
  • Living Will: a document which contains specific instructions concerning an adult’s wishes about health care choices and treatments that the adult does or does not want to receive and which the adult does not want to designate to an agent or healthcare proxy. A living will may be considered clear and convincing evidence of a patient’s wishes.

During the registration process you will be asked if you have Advance Directives. If you do, we will ask you to give us a copy, which will become a part of your medical record. Your physician will discuss with you whether any existing orders you may have regarding withholding life sustaining treatment are appropriate for your care at the Center

If you currently do not have any advance directives and if you wish to complete an Advance Directive, copies of the official State forms are available at our facility or you can got to the following website for more information


Reference: Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual, Appendix L-Guidance for Surveyors: Ambulatory Surgical Centers. March 15, 2013:416.50(c).