SURGERY CENTER

MNA Surgery Center
PRIVACY NOTICE

Uses and Disclosures of Health Information

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

Patient Health Information:

Under federal law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your health information also includes payment, billing, and insurance information. Your information may be stored electronically and if so is subject to electronic disclosure.

How We Use & Disclose Your Patient Health Information:

Treatment: We will use and disclose your health information to provide you with medical treatment or services. For example, nurses, physicians, and other members of your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other health care providers who are participating in your treatment, to pharmacists who are filling your prescriptions, and to family members who are helping with your care.

Payment: We will use and disclose your health information for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment or disclose your information to payors to determine whether you are enrolled or eligible for benefits. We will submit bills and maintain records of payments from your health plan.

Health Care Operations: We will use and disclose your health information to conduct our standard internal operations, including proper administration of records, and evaluation of the quality of treatment.

Special Uses and Disclosures: Following a procedure, we will disclose your discharge instructions and information related to your care to the individual who is driving you home from the facility or who is otherwise identified as assisting in your post-procedure care.

Other Uses and Disclosures
We may be required or permitted to use or disclose the information even without your permission as described below:

Required by Law: We may be required by law to disclose your information, such as to report gunshot wounds, suspected abuse or neglect, or similar injuries and events.

Research: We may use or disclose information for approved medical research.

Public Health Activities: We may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public health authorities.

Health oversight: We may disclose information to assist in investigations and audits, eligibility for government programs, and similar activities.

Judicial and administrative proceedings: We may disclose information in response to an appropriate subpoena, discovery request or court order.

Law enforcement purposes: We may disclose information needed or requested by law enforcement officials or to report a crime on our premises.

Deaths: We may disclose information regarding deaths to coroners, medical examiners, funeral directors, and organ donation agencies.

Serious threat to health or safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Military and Special Government Functions: If you are a member of the armed forces, we may release information as required by military command authorities. We may also disclose information to correctional institutions or for national security purposes.

Workers Compensation: We may release information about you for worker’s compensation or similar programs providing benefits for work-related injuries or illness.

Business Associates: We may disclose your health information to business associates (individuals or entities that perform functions on our behalf) provided they agree to safeguard the information.

Messages: We may contact you to provide appointment reminders or for billing or collections and may leave messages on your answering machine, voicemail, or through other methods.

In any other situation, we will ask for your written authorization before using or disclosing identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.

Individual Rights

You have the following rights with regard to your health information:

You may request restrictions on certain uses and disclosures. We are not required to agree to a requested restriction, except for requests to limit disclosures to your health plan for purposes of payment or health care operations when you have paid in full, out-of-pocket for the item or service covered by the request and when the uses or disclosures are not required by law.

You may ask us to communicate with you confidentially by, for example, sending notices to a special address or not using postcards to remind you of appointments.

In most cases, you have the right to look at or get a copy of your health information. There may be a small charge for copies.

You have the right to request that we amend your information.

You may request a list of disclosures of information about you for reasons other than treatment, payment, or health care operations and except for other exceptions.

You have the right to obtain a paper copy of the current version of this Notice upon request, even if you have previously agreed to receive it electronically.

Our Legal Duty
We are required by law to protect and maintain the privacy of your health information, to provide this Notice about our legal duties and privacy practices regarding protected health information, and to abide by the terms of the Notice currently in effect. We are required to notify affected individuals in the event of a breach involving unsecured protected health information.

Changes in Privacy Practices
We may change this Notice at any time and make the new terms effective for all health information we hold. If we change our Notice, we will post the new Notice in the waiting area.

Complaints
If you are concerned that we have violated your privacy rights, you may contact the Facility Director.

If you think your If your response is still a concern you may file a complaint with:

Midwest Nephrology Associates
Attn: Christine Herbst, VP Operations
335 Mahn Court
Oak Creek, WI 53154
414-762-2020

You are also notified that you may file a complaint with the Secretary of Health and Human Services.

Office for Civil Rights:
Helene Nelson
1 W. Wilson Street #650
Madison, WI 53702

MNA Surgery Center
Patient Rights and Patient Responsibilities

MNA Surgery Center presents the following Patient Rights and Patient Responsibilities to reflect their commitment to providing quality patient care, facilitating dialogue between patients, their physicians and the facility management, as well as promoting satisfaction among the patients and their designated support person(s), physicians and health professionals who collaborate in the provision of care.

This facility recognizes that a personal relationship between the physician and the patient is an essential component for the provision of proper medical care. When the medical care is rendered within an organizational structure, the facility itself has a responsibility to the patient to advocate for expanded personal relationships and open communications between patients and their designated support persons, physicians and the organization’s staff members.

The MNA Surgery Center has many functions to perform, including but not limited to, preventing and treating medical conditions, providing education to health professionals and patients and conducting clinical research. All these activities must be conducted with an overriding concern for the patient and above all the recognition of his or her dignity as a human being. Although no catalogue of rights can provide a guarantee that the patient will receive the kind of treatment he or she has a right to expect, these patient rights are affirmed and actively incorporated into the care provided in the facility.

Patient Rights

The patient has the right to receive considerate and respectful care.
The patient has the right to know the name of the physician responsible for coordinating his or her care.
The patient has the right to obtain information from his or her physician in terms that can be reasonably understood. Information may include but is not limited to his or her diagnosis, treatment, prognosis and medically significant alternatives for care or treatment that may be available. When it is not medically advisable to share specific information with the patient, the information should be made available to an appropriate person on his or her behalf. When medical alternatives are to be incorporated into the plan of care, the patient has the right to know the name of the person(s) responsible for the procedures and treatments.
The patient has the right to obtain the necessary information from his or her physician to give informed consent before the start of any procedure and treatment. Necessary information includes but is not limited to the specific procedure and treatment, the probable duration of incapacitation, the medically significant risks involved and provisions for emergency care.
The patient has the right to expect the MNA Surgery Center provide evaluation, services and referrals as indicated for urgent situations. When medically permissible, the patient or designated support person(s) will receive complete information and explanation about the need for and alternatives to transferring to another facility. The facility to which the patient is to be transferred must first have accepted the patient for transfer.
The patient has the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of his or her action.
The patient has the right to obtain information about any financial and professional relationship that exists between this facility and other health care and educational institutions insofar as his or her care is concerned. The patient has the right to obtain information about any professional relationships that exist among individuals who are involved in his or her procedure or treatment.
The patient has a right to be advised if the MNA Surgery Center proposes to engage in or perform human experimentation affecting his or her care or treatment. The patient has the right to refuse to participate in research projects.
The patient has the right to every consideration for privacy throughout his or her medical care experience, including but not limited to the following:
Confidentiality and discreet conduct during case discussions
Consultations
Examinations
Treatments
Those not directly involved in his or her care must have the permission of the patient to be present. All communications and records pertaining to the patient’s care will be treated as confidential.
The patient has the right to expect reasonable continuity of care, including but not limited to the following:
The right to know in advance what appointment times and physicians are available and where
The right to access information from his or her physician, regarding continuing health care requirements following discharge
The number to call for questions or emergency care
The patient has the right to access and examine an explanation of his or her bill regardless of the source of payment.
The patient and designated support person(s) have the right to know what facility rules and regulations apply to their conduct as a patient and guest during all phases of treatment.
Patient Responsibilities

It is the patient’s responsibility to participate fully in decisions involving his or her own health care and to accept the consequences of these decisions if complications occur.

It is the patient’s responsibility to follow up on his or her physician’s instructions, take medications when prescribed and ask questions’ concerning his or her own health care that he or she feels is necessary.

If you have any grievances (concerns) please contact the Medicare Ombudsman at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

State of Wisconsin Department of Health Services Division of Quality Assurance, Bureau of Health Services P.O. Box 2969 Madison, WI 53701 Phone 608-266-8481.

MNA Surgery Center
Physician Financial Interest and Ownership

The center is owned by physicians. The physician(s) who referred you to this center and who will be performing your procedures may have a financial and ownership interest. Patients have the right to be treated at another health care facility of their choice. We are making this disclosure in accordance with federal regulations.

As of 12/1/2017, the following Physicians have ownership in MNA Surgery Center:

Gregory Warren, MD
Omer Afzal, MD
James Brandes, MD
Amir Daniel, MD
Vasundhara Ganne, MD
Fadi Hussein, MD
Bill Kraklow, MD
Lubna Majeed-Haqqi, MD
Todd Muche, MD
Mark Nunag, MD
Deepak Sharma, MD
Kathleen Uy, MD
Paul Warren, MD

Office Address of All Owners:

335 Mahn Court
Oak Creek, WI 53214
Phone (414) 762-2020
Fax (414) 762-2024

MNA Surgery Center
Advanced Directives

An Advance Directive allows a person to give directions about future medical care or to designate another person to make medical decisions if he or she should lose decision-making capacity. Advance directives may include living wills, durable power of attorney, out-of-hospital do not resuscitate orders, or similar documents portraying the patient’s preference.

In the event of a life-threatening emergency at MNA Surgery Center, emergency medical procedures will be implemented per the physician's orders. Patients will be stabilized and transferred to a hospital where the decision to contribute or terminate emergency measures can be made by the physician and family.

For further information about advance directives in Wisconsin, you can visit the following website: https://www.dhs.wisconsin.gov/forms/advdirectives/adformspoa.htm