PAIN CENTERS OF AMERICA, INC
Belmar Ambulatory Surgical Center, LLC
Charles Ripp, MD
Pain Treatment Centers, LLC
West Denver ASC, LLC
NOTICE OF PRIVACY PRACTICES
EFFECTIVE DATE: September 29, 2008
This notice describes how medical information about you may be used and disclosed
and how you can get access to this information. Please review it carefully.
Our Pledge Regarding Your Health Information: We understand that health information about you and your
health care is personal. We are committed to protecting health information about you. We will create a record
of the care and services you receive from us. We do so to provide you with quality care and to comply with any
legal or regulatory requirements.
Providers Covered By This Notice:
Pain Centers of America, INC
Belmar Ambulatory Surgical Center, LLC
Charles Ripp, MD
Pain Treatment Centers, LLC
West Denver ASC, LLC
Your health information may be shared as needed for your treatment, payment activities, or health care
operations relating to our organized health care arrangement. This Notice will tell you the ways in which we
may use or disclose health information about you. This Notice also describes your rights to the health
information we keep about you, and describe certain obligations we have regarding the use and disclosure of
your health information.
Our pledge regarding your health information is backed-up by Federal Law. The privacy and security
provisions of the Health Insurance Portability and Accountability Act ("HIPAA") require us to:
Make sure that health information that identifies you is kept private;
Make available this Notice of our legal duties and privacy practices with respect to health information
about you; and
Follow the terms of the Notice that is currently effect.
We reserve the right to make changes to this Notice at any time and make the new privacy practices effective
for all information we maintain. The current Notice will be posted in our waiting room and will include the
effective date. In addition, each time you are seen at our facility, we will offer you a copy of the current Notice
in effect. You may also request a copy of this Notice at anytime or you may contact the main Privacy Office on
the back of this Notice.
How We May Use And Disclose Medical Information Without Your Authorization
The following categories describe different ways that we may use or disclose health information about you
without your authorization. Unless we ask for a separate authorization, all of the ways we are permitted to
use and disclose information will fall within one of the categories. If written authorization to disclosure your
health information was received, you have the right to revoke this at any time. The revocation must be made
For Treatment We may use and disclose your health information to provide, coordinate, or manage your
health care and any related services. This includes the coordination or management of you health care with a
third party for treatment purposes. For example, we may disclose your health information to a pharmacy to
fill a prescription or to a laboratory to order a blood test. We may also disclose health information to
physicians who may be treating you or consulting with the provider with respect to your care. In some cases,
we may disclose your health information to an outside treatment provider for purposes of the treatment
activities of the other provider. Additionally, health information may be provided to you for purposes related
to your treatment.
For Payment We may use and disclose health information about you so that the treatment and services you
receive from us may be billed to and payment collected from you or your insurance company. For example, we
may need to give your health plan information about your office visit so your health plan will pay us or
reimburse you for the visit. In some instances, we may need to disclose to your health plan health information
to demonstrate medical necessity for a treatment you are going to obtain prior approval or to determine
whether your plan will cover the treatment.
For Health Care Operations We may use and disclose health information, as necessary, for our own health
care operations to facilitate the function of the physician(s) office or ambulatory surgery center and to provide
quality care to all patients. Health care operations include such activities as: quality assessment and
improvement activities, employee review activities, training programs including those in which trainees or
practitioners in health care learn under supervision, accreditation, certification, licensing or credentialing
activities, review and auditing, including compliance review, medical reviews, legal services, and maintaining
compliance programs, and business management and general administrative activities.
Other Uses and Disclosure As part of treatment, payment, and health care operations, we may also use or
disclose your health information for the following purposes: to contact you as a reminder that you have an
appointment; to contact you after you had a procedure in follow up to your treatment.
Additionally, we may share information with family and friends involved in your care or payment of your care;
to inform you of potential treatment alternatives or options; to inform you of health-related benefits or
services that may be of interest to you.
Other Uses and Disclosures Permitted Without Authorization or Opportunity to Object
As required by federal, state, or local law including the Secretary of the Department of Health and Human
Services to investigate or determine our compliance with HIPAA.
We may, consistent with applicable law and ethical standards of conduct, use or disclose your health
information if we believe, in good faith, that such use and disclosure is necessary to prevent or lessen a
serious and imminent threat to your health or safety or to the health and safety of the public.
When providing emergency health care in response to a medical emergency, other than on our premises.
For specified Government functions. In certain circumstances, federal regulations authorize the facility to
use or disclose your health information to facilitate specified government functions relating to military and
veterans activities, national security and intelligence activities, protective services for the President and
others, medical suitability determinations, correctional institutions, and law enforcement custodial
For health oversight activities such as audits, civil, administrative, or criminal investigations, proceedings,
or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate
oversight as authorized by law.
For public health purposes such as preventing or controlling disease, injury, or disability; to report births
or deaths; to conduct public health surveillance, investigations and interventions as permitted or required
by law; to report reactions to medications or product defects with medical equipment or implants to notify
a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease
or condition; to report to an employer information about an individual who is a member of the workforce
as legally permitted or required by law.
To notify the appropriate government authority if we believe a patient has been the victim of abuse,
neglect, or domestic violence. We will make this disclosure only when specifically required or authorized
by law or when the patient agrees to the disclosure.
For lawsuits and similar proceedings. We may disclose your health information in response to an order of
a court or administrative tribunal or pursuant to a New York State approved authorization form executed
When requested by law enforcement as required by law or court order. For example, in response to a court
order, subpoena, warrant; to identify or locate a suspect, fugitive, material witness, or a missing person; if
you are a victim of a crime and we are unable to obtain your consent; about a death we believe may be the
result of criminal conduct; in an instance of criminal conduct at our facilities; in an emergency to report a
To coroners and health examiners for identification purposes, determine cause of death, or to perform
other duties as required by law. We may disclose your health information funeral directors in order for
them to carryout their duties. We may also disclose your health information in reasonable anticipation of
death. Your health information may be used and disclosed for organ/eye/tissue donation.
To comply with laws relating to workers compensation or other similar programs that is established by law
and provides benefits for work-related injuries or illness regardless of fault.
For research purposes once criteria to disclose your health information has been met.
For disaster relief efforts as long as the agency overseeing the efforts is authorized to notify next of kin.
Your Individual Rights
You have the following rights regarding health information we maintain about you. Requests marked with a
series of stars (**) must be made in writing on appropriate forms. You may request these forms from the
Facility Privacy Coordinator at our office or contact the main Privacy Office at the end of this Notice.
Inspect and copy your health information, including medical and billing records within 10 days. This does
not include psychotherapy notes. If you request a copy of your health information, the cost will be the
current fee allowed by State Law. Under limited circumstances, we may deny you access to a portion of
your health information and you may request a review of the denial. The person conducting the review will
not be the person who denied your initial request. **
Request corrections or additions to your health information. You may request an amendment of health
information about you as long as we maintain this information. We may deny your request if you ask us
to amend information that was not created by us, unless the person or entity that created the information
is no longer available to make the amendment; is not part of the health information kept by or for our
physicians or facilities; is not part of the information which you would be permitted to inspect and copy; is
accurate and complete. If we deny your request for amendment, you have the right to file a statement of
disagreement with us to be added to the information you wanted changed. If we accept your request to
change the information, we will make reasonable efforts to inform others, including people you name, of
the change and to include the changes in any future disclosures of that information. Requests for
amendments must be in writing and must be directed to the Facility Privacy Coordinator at the office you
were seen at. In this written request, you must provide a reason to support the requested amendment(s).
Request an accounting of certain disclosures of your health information made by us. The right applies to
disclosures for purposes other than treatment, payment, or health care operations as described in this
Privacy Notice. We are not required to account for disclosures that you requested, disclosures that you
agreed to by signing an authorization form, disclosures to friends or family members involved in your care,
or certain other disclosures we are permitted to make without your authorization. The request for an
accounting must be made in writing to the Privacy Representative at the office you were seen at. The
request should specify the time period sought for the accounting. We are not required to provide an
accounting for disclosures that take place prior to April 14, 2003. The first accounting is free but a fee will
apply if more than one request is made in a 12 -month period. You will be notified of the cost involved and
you may choose to withdraw or modify your request at that time before any costs are incurred. We will
mail you a list of disclosures in paper form within 30 days of your request or notify you if we are unable to
supply the list within that time period and by what date we can supply the list; but this date should not
exceed a total of 60 days from the date you made the request. **
Request that we use a specific telephone number or address to communicate with you. For example, you
can ask that we only contact you at work or by mail to a post office box. During our intake process, we
will ask you how you wish to receive communications about your health care or for any other instructions
on notifying you about your health information. You may also request that we do not disclose your health
information to family members or friends who may be involved in your care or for notification purposes.
We will accommodate all reasonable requests.
Request restrictions on how we use and share your health information for treatment, payment, or health
care operations. For example, you could ask that access to your health information be denied to a
particular member of our workforce who is known to you personally. We will consider all requests for
restrictions carefully. We are not required to accommodate restrictions if it is not feasible for us to ensure
our compliance with the law or we believe it will negatively impact the care we provide you. **
Request a paper copy of this notice even if you agree to receive it electronically.
A Facility Privacy Coordinator has been assigned to each of our offices. If you would like further information
about our privacy rights, are concerned that your privacy rights have been violated, or disagree with a
decision that we made about access to your health information contact:
Pain Centers of America, Inc.
401 Creekside Drive
Amherst, NY 14228
Phone (716) 691-4123
Fax (716) 691-9579
We will investigate all complaints and will not retaliate against you for filing a complaint. You may also file a
written complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services.
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