Patient Rights and Ownership Disclosure

As a patient, you have a number of rights with respect to you PHI, including:

The Right to Access, Copy, or Inspect Your PHI. This means you may inspect and copy most of the medical information about you that we maintain. We will normally provide you with access to this information within 30 days of your request. We may also charge you a reasonable fee, as state law permits to provide a copy of any medical information you have the right to access. In limited circumstances, we may deny you access to your medical information, and you may appeal certain types of denials. We have forms available to request access to your PHI and we will provide a written response if we deny you access and let you know your appeal rights. You also have the right to receive confidential communications of your PHI. If you wish to inspect or obtain a copy of your medical information, you should contact our local privacy representative.

The Right to Amend Your PHI. You have the right to ask us to amend written medical information we may have about you. We will generally amend your information within 60 days of your request and will notify you when we have amended the information. We are permitted by law to deny your request to amend your medical information only in certain circumstances, like when we believe the information you have asked us to amend is correct. If you wish to request an amendment of the medical information we have about you, please contact our local privacy representative to obtain an amendment request form.

The Right to Request an Accounting. You may request an accounting from us of certain disclosures of your medical information we have made in the six years prior to the date of your request. However, your requests for an accounting of disclosures cannot precede the implementation date of HIPAA April 14, 2003. We are not required to give you an accounting of information we have used or disclosed for purposes of treatment, payment, or health care operations, or when we share your health information with our business associates, such as our billing company or a medical facility from/to which we have transported you. We are also not required to give you an accounting of our uses of PHI for which you have already given us written authorization. If you wish to request an accounting, contact our local privacy representative.

The Right to Request That We Restrict the Uses and Disclosures of Your PHI. You have the right to request that we restrict how we use and disclose your medical information we have about you. We are not required to agree to any restrictions you request, but any restrictions agreed to by us in writing are binding on us.

Right to Obtain a Paper Copy of the Notice on Request. If you would like a paper copy of this Notice, you may contact us at the address listed below and we will provide you a paper copy of the Notice upon request.

The Right to Specify How We Communicate Confidential Medical Information to You. We will honor reasonable written requests to limit how we contact you for this purpose (by telephone, U.S. mail, or e-mail, for example). You may also specify where we contact you, such as at work, at home, or at some other place, when communicating confidential medical information. You are not required to provide a reason for your request. However, if you specify an alternate means of communication, you must still provide adequate contact information for collecting payment or other matters related to the status of your account.

Revisions to the Notice: We reserve the right to change the terms of this Notice at any time, and the changes will be effective immediately and will apply to all PHI we maintain. Any material changes to the Notice will be promptly posted in our facilities. You can get a copy of the latest version of this Notice by contacting our privacy official.

 

Advance Directive Policy

As a patient, you have the right to participate in your own health care decisions and to make an Advance Directive, or to execute a Power of Attorney that authorizes others to make decisions on your behalf when you are unable to make decisions, or are unable to communicate those decisions. Ophthalmology Surgery Center of Dallas respects and upholds these rights.

However, unlike in an acute care hospital setting, the Surgery Center does not routinely perform “high risk” procedures. Most procedures performed in this facility are considered minimal risk. Of course, no surgery is completely without risk. You will discuss the specifics of your procedure with your physician who will advise you about any associated risks, your expected recovery, and care after your surgery.

Therefore, it is our policy, regardless of the contents of an Advance Directive or instructions from a Health Care Surrogate or Power of Attorney, that if an adverse event occurs during your treatment at this facility, we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. The acute care hospital will order further treatment or withdrawal of treatment measures in accordance with your wishes, Advance Directive or Health Care Power of Attorney.

Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO), is a national consumer engagement initiative to improve care at the end of life. This program includes instructions for completing the Texas Advance Directive for Healthcare, learning options for end-of-life services and care, implementing plans to ensure your wishes are honored, voicing your decisions to family, friends and healthcare providers, engaging in personal or community efforts to improve end-of-life care, and the Texas Durable Power of Attorney for Healthcare. This program can be accessed at: www.caringinfo.org/UserFiles/File/Texas.pdf. The Texas Health & Safety Code, Chapter 166, can be accessed at: http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.166.htm.

You or your representative will be notified in writing prior to the date of surgery regarding the Surgery Center’s Advance Directive Notice policy. The physician’s office scheduling your procedure will be responsible for distributing a copy of this written Advance Directive Policy. At the time of admission to the Surgery Center, you must sign the Advance Directive Notice acknowledging you have read and understand this policy.

Signing the Advance Directive Notice does not invalidate any current Health Care Directive or Health Care Power of Attorney. If you do not agree with this policy, your procedure will be rescheduled at another facility.

OWNERSHIP DISCLOSURE

Drs. Walter Beebe, Bradley Bowman, Henry Gelender, Tyrone McCall, Ronald Fellman, David Godfrey, George Beauchamp, David Stager Jr, Mark Jaffe, Thomas Russell, Linda Burk, Bradley Jost, Rajiv Anand, Lori Coors, Rand Spencer, Robert Wang, Larry Taub, Arvind Neelankantan, Jorge Corona and Bob Pansick all have a financial interest in Ophthalmology Surgery Center of Dallas.

You have the right to choose your provider and where your procedure is performed. For any questions or concerns, please feel free to contact your physician.