SURGERY & ENDOSCOPY CENTER. Patient Handbook, Patient Notice of Privacy Practices and Patient s Bill of Rights and Responsibilities

Transcription

1 31451 SP Patient Privacy_20934 St Peters 5/3/16 10:42 AM Page 1 ST. PETER S SURGERY & ENDOSCOPY CENTER Patient Handbook, Patient Notice of Privacy Practices and Patient s Bill of Rights and Responsibilities 1375 Washington Avenue Suite 201 Albany, New York Ph: / Fax:

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3 31451 SP Patient Privacy_20934 St Peters 5/3/16 10:42 AM Page 3 St. Peter s Ambulatory Surgery Center dba St. Peter s Surgery & Endoscopy Center Welcome to the St. Peter s Surgery & Endoscopy Center, ( The Center ). This Patient Handbook was designed to introduce you to The Center, provide you with some basic information regarding The Center, and most importantly to explain your rights and responsibilities as a patient. Please read this Handbook carefully. If you need assistance in understanding any information in the Handbook, including if necessary an interpreter, please let us know. We will be happy to assist you. It is our intent to assist you, in whatever manner necessary, throughout your visit at The Center. This includes assistance with understanding all aspects of your care, helping you to make informed decisions, and helping you to understand your rights and responsibilities. The Center staff understands that having to undergo surgery or GI procedures can be stressful and frightening. Please rest assured that we will do everything possible to provide you with the finest quality healthcare. We will also do the best we can to accommodate all of your, and your responsible adult and/or family members, non-medical needs. If necessary, multiple patient family members are welcome at The Center. However, we feel compelled to advise that space and seating is sometimes limited. Therefore, we are requesting that patients and parents of patients consider the comfort of their own and other family members, and when possible, limit the number of family members at The Center to as few as is absolutely necessary. Thank you for your understanding. MISSION, GOALS, AND OBJECTIVES OF THE ST. PETER'S SURGERY AND ENDOSCOPY CENTER The purpose of St. Peter s Surgery & Endoscopy Center is to promote the health of a broad section of the community through ownership and operation of an ambulatory surgery center located at 1375 Washington Avenue, Albany, New York. The provision of care to the indigent is an acknowledged component of The Center s purpose. The mission of The Center is to provide cost-effective outpatient services using modern state-of-the-art technology in a friendly and caring environment by highly skilled compassionate staff serving Albany, New York and surrounding communities. OBJECTIVES: * Streamline delivery of medical care to the surgical outpatient and provide the utmost quality services. * Make outpatient surgery experience less anxiety producing. * Utilize the most cost-effective measures for the patient and the healthcare delivery system. * Provide an environment that is aesthetically pleasing for the patient, physician and employee and promote customer service. * Reduce the risk of nosocomial infection for the surgical patient. ADVANCED DIRECTIVES Advance Directives are written or verbal statements made by a patient indicating treatment wishes in the event the patient becomes incapacitated. An Advance Directive may specify medical treatment the individual consents to or refuses, appoint another individual as a healthcare agent, or both. In New York State there are three main types of Advance Directives. They are: Healthcare Proxy Allows the patient to appoint a healthcare agent. A healthcare agent is someone they trust, over the age of 18, to make health care decisions for them if they are unable to make decisions for themselves. Only a Health Care Proxy Form can be used for this purpose. Living Will Allows the patient to leave written instructions that explain their health care wishes, especially about end-of-life care. A living will cannot be used to name a healthcare agent; the Health Care Proxy form must be used for this purpose. Do Not Resuscitate Order, (DNR Order) Allows the patient to express their wish to withhold cardiopulmonary resuscitation, CPR. CPR is emergency treatment to restart the heart and/or lungs when the patient s breathing or circulation stops. St. Peter s Surgery & Endoscopy Center respects a patient s right to make decisions regarding his or her health care, and will assist patients in whatever means necessary to accomplish this. However, due to the elective and lower risk nature of procedures performed at The Center, The Center encourages patients to consider suspending or not issuing DNR Orders or other Advance Directives related to withholding emergent or life-sustaining treatment. Where possible, The Center prefers to use all measures possible to sustain life.

4 31451 SP Patient Privacy_20934 St Peters 5/3/16 10:42 AM Page 4 If you have executed any type of Advanced Directive you need to let us know. You should also bring a copy with you on the day of your procedure. If the Advance Directive is related to withholding life-sustaining treatment, such as a DNR Order, The Center staff and/or your attending physician will discuss with you the benefits and risks of keeping such directive in place. If you agree, you will be asked to execute a temporary consent that suspends your DNR Order or other Advance Directives while receiving treatment at The Center. Such consent will allow The Center staff to perform resuscitative life-sustaining treatment in the event of an emergency. Should an emergency occur, you will be given resuscitative life-sustaining treatment, stabilized, and then transferred to St. Peter s Hospital. Once at the Hospital further treatment or withdrawal of treatment already begun will be ordered in accordance with your wishes and your advance directives pursuant to Hospital policy. If you wish to issue or keep in effect a DNR Order or other Advance Directive related to withholding life-sustaining treatment, The Center will honor your wishes. If your attending physician objects, The Center and the attending physician will work together to make alternative arrangements for your treatment either within The Center with another physician or elsewhere. If you would like more information regarding advanced directives in New York State, you may visit: A summary of this information is contained within this handbook in the section entitled Planning in Advance for your Medical Treatment. A Health Care Proxy Form, instructions for completion, and answers to frequently asked questions is located in the last section of this handbook. You may also obtain New York State Health Care Proxy Forms by downloading them at: ST. PETER S AMBULATORY SURGERY CENTER, IS A JOINT VENTURE BETWEEN, AND OWNED BY: St. Peter s Hospital AGC Associates, LLC 315 South Manning Blvd and 1375 Washington Ave., Suite 101 Albany, NY Albany, NY PHYSICIAN OWNERS OF AGC ASSOCIATES, LLC ARE: William M. Notis, MD Matthew Ben, MD Carla F. Fernando-Gilday, MD Joseph Polito, MD Richard Clift, MD Joseph Choma, MD Edward S. Orris, MD Alan Samuels, MD John Buhac, MD Vittorio Fiorenza, MD Bora Gumustop, MD James Puleo II, MD Nina Sax, MD Sean Sheehan, MD Jeffery Gerson, MD PATIENT NOTICE OF PRIVACY PRACTICES St. Peter s Surgery & Endoscopy Center 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. 1. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU Your health record is the physical property of St. Peter s Surgery & Endoscopy Center. The information contained in the record, however, belongs to you. You have the right to: A. 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, like a family member or friend. We are required to comply with a request that we not disclose your medical information to a health plan for payment or health care operations purposes, if the medical information pertains to a health care item or service for which we have been involved and you have paid for the item or service in full out-of-pocket. For all other requests, we will consider your requested restriction but we are not required to agree to your requested restrictions. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. B. Obtain a written copy of this Notice by requesting one from St. Peter s Surgery & Endoscopy Center. C. Inspect and obtain a copy of your health care record by submitting a request in writing to St. Peter s Surgery & Endoscopy Center.

5 31451 SP Patient Privacy_20934 St Peters 5/3/16 10:42 AM Page 5 D. Amend your healthcare record if you feel that medical information that we have about you is incorrect or incomplete by requesting, in writing, that an amendment be made. You must provide a reason that supports your request. E. Obtain a report of all of the disclosures of your health information that we have made. F. Request that we communicate with you confidentially about your medical information in a certain way or at a certain location within reasonable limits. G. Revoke your authorization to use and disclose medical information about you, except to the extent that we have already used or disclosed your medical information. H. Be notified, in writing, of any breach of your unsecured health information that we discover, unless we determine, based on a risk assessment, that notification is not required by applicable law. You will be notified without unreasonable delay and no later than 60 days after discovery of the breach. Such notification will include information about what happened and what has been done or can be done to mitigate any harm to you as a result of such breach. 2. OUR RESPONSIBILITIES REGARDING YOUR MEDICAL INFORMATION We are required by law to: A. Maintain the privacy of your health information. B. Provide you with this Notice, which describes our legal duties and privacy practices with respect to information we collect about you. C. Abide by the terms of this Notice. D. Notify you if we are unable to agree to a requested restriction. E. Accommodate reasonable requests that you have made to have us communicate your health information to you in a certain way or at 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 we receive in the future. We will post a copy of the current notice in the Center s reception area. The notice will contain the effective date of the revised notice. Each time you register at St. Peter s Surgery & Endoscopy Center for health care services, we will offer you a copy of the current notice in effect. 3. HOW WE TYPICALLY USE AND DISCLOSE YOUR MEDICAL INFORMATION Each time you are a patient at St. Peter s Surgery & Endoscopy Center a record of your visit is made. Typically, we will use or disclose your medical information for the following purposes, or to the following persons: A. Treatment. 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 personnel who are involved in taking care of you at St. Peter s Surgery & Endoscopy Center. We may also disclose your medical information to others involved in your medical care at other offices or facilities, such as your primary care physician, laboratory technicians, and consulting physicians. For example, information obtained by a nurse, physician, or other member of your health care team will be recorded in your medical record 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. B. Payment. We may use and disclose medical information about you so that the treatment and services you receive at St. Peter s Surgery & Endoscopy Center may be billed to and payment may be collected from you, an insurance company, or third party. For example, we may need to give your insurance company information about surgery you received at St. Peter s Surgery & Endoscopy Center so that the insurance company will pay us or reimburse you for the surgery. C. Health Care Operations. We may use and disclose medical information about you for the operations of St. Peter s Surgery & Endoscopy Center. For example, members of the medical staff, the risk management or quality improvement manager, or members of the quality improvement team 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 services that we provide. D. 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 St. Peter s Surgery & Endoscopy Center.

6 31451 SP Patient Privacy_20934 St Peters 5/3/16 10:42 AM Page 6 E. 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. F. 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. G. Individuals Involved in Your Care or Payment for Your Care. With your consent, 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. H. Business Associates. Some of the services provided at St. Peter s Surgery & Endoscopy 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. 4. OTHER LESS TYPICAL USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION THAT MAY BE MADE WITHOUT YOUR CONSENT OR AUTHORIZATION Less typically, we may use or disclose your medical information in special situations set forth in federal and state laws, such as the following: A. As Required by Law. We may use or disclose medical information about you when required to do so by federal, state or local law. B. Emergency. 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. St. Peter s Surgery & Endoscopy Center, however, will only disclose the information to someone able to help prevent the threat. C. Organ and Tissue Donation. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant. D. Workers 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. E. Public Health Activities. AAs required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. F. 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. G. 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 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 requested. H. Law Enforcement. We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. I. Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. We may also disclose health information to funeral directors consistent with applicable law to carry out their duties. J. Food and Drug Administration. 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. K. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. L. Victims of Abuse, Neglect or Domestic Violence. We may release medical information to a government authority if we reasonably believe that you are a victim of abuse, neglect or domestic violence, to the extent authorized or required by law. 5. USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION WHICH REQUIRE YOUR WRITTEN AUTHORIZATION The following uses and disclosures of your medical information, among others, will generally require your written authorization: A. Marketing. Your written authorization is required for us to use or disclose your medical information for marketing purposes, except if we communicate personally with you face-to-face or if we provide you with prescription refill reminders or otherwise communicate with you about a drug or biologic that you are currently prescribed and we do not in exchange receive

7 31451 SP Patient Privacy_20934 St Peters 5/3/16 10:42 AM Page 7 any payment that is unreasonably related to our cost of making such communication to you. It is not considered marketing, and therefore your written authorization is not required, if we communicate with you related to your individual treatment, case management, or care coordination, or if we direct or recommend alternative treatment, therapies, healthcare providers or settings of care, unless we receive payment from a third-party in exchange for making such communication to you. If marketing activities are to result in payment to us from a third party we will state this on the authorization. B. Sale of Medical Information. Your written authorization is required for any use or disclosure which is considered a sale of your medical information. Any authorization for the sale of medical information will state that the disclosure will result in payment to us. C. Psychotherapy Notes. To the extent we possess any psychotherapy notes about you, your written authorization is generally required for any use or disclosure of such notes, except as expressly authorized by law. 6. 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 a specific 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 St. Peter s Surgery & Endoscopy Center took before it received the revocation. 7. SPECIALLY PROTECTED INFORMATION Separate federal and state laws provide special protection to drug and alcohol treatment information, genetic information, HIV/AIDS information, and mental health treatment information. If applicable to you, we will protect such information to the extent we are required to by applicable law, and we may not be able to use or disclose such information to the same extent as we can with your other medical information. 8. QUESTIONS OR COMPLAINTS If you have any questions, complaints, concerns, grievances, and/or would like additional information, you may contact James Torre, the Center Administrator at , or in writing at St. Peter s Surgery & Endoscopy Center, 1375 Washington Ave., Suite 201, Albany, NY If you believe your privacy rights have been violated, you can submit a written complaint describing the circumstances surrounding the violation to: Center Administrator, St. Peter s Surgery & Endoscopy Center, 1375 Washington Ave., Suite 201, Albany, NY , or to the Secretary of Health and Human Services in Washington, D.C. You will not be penalized for filing any complaint. If you have a concern, problem or complaint related to any aspect of the provision of your care, speak to your doctor, nurse or other staff member. If facility staff have not resolved the problem, you may contact the New York State Department of Health by mail or phone. You may call the toll-free number at or you may file a complaint in writing and send it to: New York State Department of Health Centralized Hospital Intake Program Attention: Program Director - Mailstop CA-DCS Empire State Plaza Albany, New York Questions or Comments: hospinfo@health.state.ny.us You may also contact the Medicare Ombudsman at or Policy Effective April 14, 2003 PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES Each patient treated at the St. Peter s Surgery & Endoscopy Center has the right to: * Receive care in a safe setting, free from all forms of abuse or harassment; * Respectful care given by competent personnel with consideration of their privacy concerning their medical care; * Be given the name of their attending physician, the names of all other physicians directly assisting in their care, and the names and functions of other health care persons having direct contact with the patient. The patient also has the right to change physician or health care persons, providing other qualified physicians and/or health care persons are available. * Have records pertaining to their medical care treated as confidential; * Have access to his/her medical record pursuant to the provisions of section 18 of the Public Health Law;

8 31451 SP Patient Privacy_20934 St Peters 5/3/16 10:42 AM Page 8 * Approve or refuse the release or disclosure of the contents of his/her medical record to any health care practitioner and/or health care facility except as required by law or third-party payor contract; * Be informed of the provisions for After Hours emergency care; * Voice grievances and recommended changes in policies and services to The Center s staff, the operator and the New York State Department of Health without fear of reprisal; * Express complaints about the care and services provided and to have The Center investigate such complaints. The Center is responsible for providing the patient or his/her designee with a written response within 30 days, if requested by the patient, indicating the findings of the investigation. The Center is also responsible for notifying the patient or his/her designee that if the patient is not satisfied by The Center s response, the patient may complain to the New York State Department of Health s Office of Health Systems Management, and/or the Medicare Ombudsman; (See Phone Numbers on previous page) * Give an informed consent to the physician prior to the start of a procedure. The consent shall include, at a minimum, the provision of information concerning the specific procedure or treatment or both, the reasonably foreseeable risks involved, and alternatives for care or treatment, if any, as a reasonable medical practitioner under similar circumstances would disclose in a manner permitting the patient to make a knowledgeable decision; * Be informed of charges for services, eligibility for third-party reimbursements and, when applicable, the availability of free or reduced cost care; * Receive an itemized copy of his/her account statement, upon request; * Know what Surgery Center rules and regulations apply to their conduct as a patient; * Expect emergency procedures to be implemented without unnecessary delay; * Expedient and professional transfer to another facility when medically necessary and to have the responsible person and the facility that the patient is transferred to notified prior to transfer; * Good quality care and high professional standards that are continually maintained and reviewed; * Full information in layman's terms concerning your diagnosis, treatment and prognosis; if it is not medically advisable for this information to be sent to the patient, the information shall be given to the responsible person on his/her behalf; * Be advised of participation in a medical care research program or donor program; the patient shall give consent prior to participation in such a program; a patient may also refuse to participate and/or continue in a program that he/she has previously given informed consent to participate in; * Refuse drugs or treatment and be told what effect this may have on your health; * Receive all the information that you need to give informed consent for an order not to resuscitate, DNR Order. You also have the right to designate an individual to give this consent for you should you become incapacitated; * To appoint a Health Care Proxy and make known his/her wishes in regard to anatomical gifts, which the patient may document in a healthcare proxy form available from The Center; * Have his/her rights exercised by the person appointed under State law to act on their behalf, should they be judged incompetent by a court of competent jurisdiction under applicable State law; * Receive medical and nursing services without discrimination based upon age, race, color, religion, sex, sexual orientation, national origin, handicap, disability, or source of payment; * Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors; * Have access to an interpreter whenever possible; * Accurate information regarding the services, competence and capabilities of The Center. Each patient treated at the St. Peter s Surgery & Endoscopy Center has the responsibility to: * Treat all staff and providers with common courtesy and respect; * Follow instructions given by his/her surgeon, anesthesiologist, and operative care givers; * Provide the Surgery Center staff with all medical information which may have a direct effect on the services provided at the Surgery Center; * Provide the Surgery Center with all information regarding third-party insurance coverage; * Fulfill financial responsibility, for all services received, as determined by the patient's insurance carrier; * Have a responsible party drive them home and accompany them for 24 hours following their procedure/surgery.

9 31451 SP Patient Privacy_20934 St Peters 5/3/16 10:42 AM Page 9 ST. PETER S SURGERY & ENDOSCOPY CENTER AFFILIATES AND IMPORTANT BILLING INFORMATION St. Peter s Surgery & Endoscopy Center is affiliated with the following Hospitals: St. Peter s Hospital Samaritan Hospital Albany Memorial Hospital St. Mary s Hospital Troy The Center participates with most major insurance plans. To inquire about participation with your specific insurance plan, please call The Center at , see the list on the following page which is also available in The Center waiting area, or soon you may visit our new website at: Some patients who receive services at The Center require anesthesia and/or pathology services. Anesthesia services at The Center are provided by Anesthesia Group of Albany, P.C. When required, based upon the judgement of your physician, pathology specimens are most often sent to St. Peter s Hospital for preparation and then reviewed by physicians from Maplewood Pathology, P.C. If these service(s) are required, there will be separate bills for each of the three services. There will also be a separate bill from your surgeon or gastroenterologist. To determine which insurance plans Anesthesia Group of Albany, P.C. participates with you may call , or review the letter available in The Center waiting area. To determine which insurance plans Maplewood Pathology, P.C. participates with you may call Med Associates at To determine in which insurance plans St. Peter s Hospital participates please visit the following website, You must contact your surgeon s office directly or the gastroenterology office - Albany Gastroenterology Consultants, PLLC, to determine in which insurance plans they participate. Albany Gastroenterology Consultants PLLC, may be contacted at , or you may visit their website at If you are covered by an insurance plan with which The Center, or any of the above providers, does not participate, claims will still be submitted to your carrier as a courtesy to you. However, you will be responsible for any balance remaining after your insurance has processed the claims. If your insurance plan is non participating with The Center, or with any of the additional healthcare providers listed above, and you would like to request an estimate of the amount that may be due, absent unforeseen medical circumstances, you may contact any of the providers at the same phone numbers listed above. They will all be happy to provide you with a written estimate of this information. Should you have any other questions or need direction with whom to call, please feel free to contact The St. Peter s Surgery & Endoscopy Center billing office at Office hours are 8:30 am to 5:00 pm. Thank you, and we look forward to assisting with both the medical and business aspects of your upcoming gastroenterology procedure or surgery.

10 31451 SP Patient Privacy_20934 St Peters 5/5/16 11:12 AM Page 10 Currently, St. Peter s Surgery & Endoscopy Center participates with the following insurance plans: Aetna Blue Shield of Northeastern NY Cancer Service Program CDPHP Champus / Tricare Cigna Empire Blue Cross Blue Shield, including Blue Card Program and excluding Medicare plans. New York State Empire Plan Fidelis GHI Emblem Health Harvard Pilgrim Medicaid Medicare / Railroad Medicare Multiplan Network MVP PHCS Network Today s Options PPO only United Health Care excluding Medicare/Medicaid No Fault and Workman Compensation Please be advised that this list is subject to change. For the most updated list, please visit our website at or you may call The Center directly, between the hours of 8:30 am and 5:00 pm, at NOTES:

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16 31451 SP Patient Privacy_20934 St Peters 5/3/16 10:42 AM Page 16 ST. PETER S SURGERY & ENDOSCOPY CENTER 1375 Washington Avenue Suite 201 Albany, New York Ph: / Fax: