Patient Information Protection Plan

Patient Information Protection Plan

Effective 04/14/03

As a patient of Tri-State Gastroenterology Associates/Tri-State Digestive Disorder Center, we want to provide you with the best care and we want you to feel free to make full disclosure of information to the physicians so effective treatment can be provided.

As required by the privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Tri-State Gastroenterology Associates/Tri-State Digestive Disorder Center is providing you, the patient or patient’s legal representative, with a copy of our Patient Information Protection Plan. HIPAA regulations have required Tri-State Gastroenterology/Tri-State Digestive Disorder Center to obtain your signature or the signature of your legal representative as proof that you have received our Patient Information Protection Plan.

The policy of Tri-State Gastroenterology Associates/Tri-State Digestive Disorder Center is to protect the confidentiality, integrity, and security of the protected health and personal information of our patients and to prevent unauthorized access to or the use of such information. This policy applies to patients who are current or former patients.

Individually identifiable health and personal information is any information obtained by Tri-State Gastroenterology Associates/Tri-State Digestive Disorder Center in connection with providing healthcare treatment, obtaining payment, and related healthcare operations.

This relates to past, present, or future information that Tri-State Gastroenterology Associates/Tri-State Digestive Disorder Center receives from you as our patient.

We will use this information to provide caring and quality medical care to you. Examples include diagnosis, treatment, and communications, written or oral including answering machines or voicemail, for follow-up and appointments.

As part of our standard healthcare operation, we may share information with a facility such as a hospital, laboratory, diagnostic service, or healthcare provider to efficiently coordinate your treatment plan. For insurance carriers, your information will be used for claims management and to obtain payment for services.

We will exchange data with your insurance carrier for activities such as eligibility, benefit and coverage determinations, precertification/authorization, and utilization review.

Your information is maintained in our office in our practice management computer system. We also maintain information about you in your medical chart.

We limit the access to your protected health information to those employees and business associates who need to know that information.

We do not disclose personal information to other third parties unless one of the following exceptions applies:

  • We receive explicit authorization from you to release information. Tri-State Gastroenterology Associates/Tri-State Digestive Disorder Center will provide you with a release of information form that will need to be signed by the patient or guardian, witnessed, and dated.
  • Federal, state, or other applicable law requires us to share protected information or records.

You have the right to request a review of your health information, to amend your records, and request restrictions of your health information, and receive an accounting of the disclosures of your information.

Any requests for amendments or restrictions must be in writing and we are not obligated to agree to any requested restrictions or amendments.

You have the right to request a copy of your medical record and we will make every effort to provide you with your records within a reasonable time frame, and subject to copying fees.

If you have a complaint about the management of your health information, you may contact the Privacy Officer for Tri-State Gastroenterology/Tri-State Digestive Disorder Center @ 859-341-3575 or contact the Health and Human Services.

There will be no retaliation for filing a complaint.

Acknowledgment of Receipt of Privacy Notice

Tri-State Gastroenterology Associates, Inc. (TSGA)
Tri-State Digestive Disorder Center, ASC (TSDDC)

I acknowledge that I have been offered the Privacy Practices Notice.

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