ADVANCED SURGICAL ASSOCIATES, LTD.
1520 S.DOBSON RD. SUITE 305
MESA, ARIZONA 85202
Protecting the personal information of our patients (protected health information, PHI) is important to Advanced Surgical Associates, LTD., and we will endeavor to have the internal practices to ensure the safety and security of your PHI. We use your PHI for treatment, healthcare reimbursement, and healthcare operations. We maintain policies and procedures along with staff education to better protect your personal health information. We do not allow anyone to enter our clinical facilities unless they are part of our staff or they are escorted to a treatment room, or, in the case of a healthcare operations matter, to our conference room or our offices. We utilize your health information clinically by providing a report to your primary care physician. We utilize your health data to submit requests for reimbursement from your insurance carrier. We also have contracts with transcription services and accountants to perform our daily office operations. We have developed a policy and a written statement all contractors must sign that they will safeguard all information provided to them in the performance of their contractual duties for our office. We have developed internal practices to ensure our electronic data is as secure as possible. Our software supplier has complied with appropriate federal laws by scrambling the data to ensure privacy in transmission. Each of our employees has their individual password to log onto the electronic information. We maintain the policy that computer screens do not remain open with PHI information if the employee is not occupying the computer. These are just a few of the steps that we take to protect your PHI.
As a patient you are entitled to review your personal health information. You may also amend your health record. If you request your medical record for review, we will endeavor to respond as soon as possible, but no later than 30 days. If you wish to amend your medical record after review, then our office has 60 days to respond to you in writing related to agreeing to amend the record. Please note that if you would like to have a copy of your health record (PHI), there will be a charge for the copying and the time to copy the record. This will be at cost. You also have a right to receive an accounting of disclosure of protected information.
Advanced Surgical Associates, LTD. will abide by all laws, federal and state, related to the privacy of protected health information. We will abide by the terms in this notice provided to you, and we will endeavor to review our operations so as to do the very best that we can in protecting your health information. Please if you have questions or concerns related to this notice or your privacy rights contact our practice manager by asking the receptionist or by calling 480-969-4138. You may also share your questions or concerns with your physician or with the Secretary of Health and Human Services if you believe that your privacy rights have been violated. This office reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information that it maintains. We will notify our patients that we have updated our notice April 14, 2003 to protect health information by posting a notice at our reception window. .
We respectfully request that you signify your review of this important notice by your signature and date below.
Patient Name (Please Print):______________________________________________________
Signature:_____________________________________________________________________
DATE
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