Patient Information Protection Plan

Patient Information Protection Plan

Effective 04/14/03

Patient Information Protection Plan.  Patients of Tri-State Gastroenterology Associates/Tri-State Digestive Disorder Center, we provide you with the best care.  Feel free to make full disclosure of information to the physicians so effective treatment can be provided.

Otherwise, as required by the privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Tri-State Gastroenterology provides the patient with a copy of our Patient Information Protection Plan. HIPAA regulations require Tri-State Gastroenterology to obtain your signature or the signature of your legal representative.  This is proof that you have received our Patient Information Protection Plan.


The policy of Tri-State Gastroenterology is to protect the confidentiality, integrity, and security of the protected health and personal information of our patients.  Additionally, preventing 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 Gastro in connection with providing healthcare treatment.  Therefore, it also includes obtaining payment, and related healthcare operations.

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

Tthis information provides caring and quality medical care to you. Generally, examples include diagnosis, treatment, and communications, written or oral including answering machines or voicemail, for follow-up and appointments.


Part of our standard healthcare operation, includes potential sharing of information.  Information is shared with hospitals, laboratory, diagnostic service, or healthcare provider to efficiently coordinate your treatment plan. Consequently, insurance carriers use your information for claims management and to obtain payment for services.

Exchange of data with your insurance carrier is 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.

The limiting of access to your protected health information is only for 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, amend your records, and request restrictions on 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.

Your Rights

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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