Notice of Privacy Practices
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.
Proliance Surgeons, Inc., P.S. is committed to protecting the confidentiality of your health information.
We are required by law to maintain the privacy of your Protected Health Information (commonly called PHI), even in electronic format, and to notify you following a breach of unsecured PHI. We are also required to notify you of our legal duties and privacy practices regarding your PHI and abide by the practices of this current Notice. This Notice applies to all Proliance Surgeons providers and facilities that provide health care to you. This Notice provides detailed information about how we may use and disclose your health information with or without authorization as well as more information about your specific rights with respect to your health information.
Uses and Disclosures of Your Health Information that Require an Authorization
Certain uses and disclosures of your protected health information will be made only with your written authorization. You may revoke an authorization at any time. However, your revocation does not affect information that has already been released pursuant to a valid authorization. These uses and disclosures include uses and disclosures not outlined in this Notice and sale of health information.
Uses and Disclosures of Your Health Information that Do Not Require an Authorization
To Contact You
- Your information may be used to contact you to remind you about appointments, provide test results, advise you about other healthrelated benefits and services, and such.
- Your information may be shared either physically or electronically with any healthcare provider who is providing you with healthcare services. Examples of healthcare providers who may need your information may include your referring provider, pharmacist, and other providers such as a physical therapist.
- Unless you object, we may use and disclose health information about you to a friend or family member who is involved in your medical or payment for care. If you object, we will not use or disclose your health information to your family members or friends.
- In order to obtain payment for your healthcare services, we may have to provide your health information to the party responsible for paying, such as your insurance company. Your insurance company may need your health information to determine your eligibility for coverage or providing authorizations for services.
- Your health information may be used in order to support our business activities and to assure quality healthcare services. Some of these activities can include data aggregation, risk management activities, quality assessments, and audits by regulatory agencies.
Other Uses and Disclosures of Your Health Information that Do Not Require an Authorization
There are other ways that your PHI may be used or disclosed without your authorization. These uses and disclosures are either required by law or for public health and safety purposes.
When Required by Law – We may use or disclose your PHI when required by law.
Public Health – We may use or disclose your health information to a public health authority for public health activities. Public health activities include preventing or controlling disease, injury, disability, and responding to reports of abuse, neglect or domestic violence. We may use or disclose your PHI to a person or agency required to report adverse events, product defects or problems, biologic product deviations, or for product recalls, repairs or replacements.
Health Oversight – We may use or disclose your health information to health oversight agencies for oversight activities authorized by law.
Legal Proceedings – We may use or disclose your health information in response to court or administrative order in an administrative or judicial proceeding, or in response to a subpoena, discovery request, or other legal process.
Law Enforcement – We may use or disclose your PHI for law enforcement purposes such as responding to legal processes, providing limited information to identify or locate a suspect, providing information about crime victims, reporting suspicion that death has occurred as a result of criminal conduct, reporting a crime which has occurred on Proliance’s premise, and for medical emergencies.
Preventing a Serious Threat – We may use or disclose your health information if we believe in good faith that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or of the public.
Research – We may use and disclose your PHI to people preparing to conduct a research project and researchers, provided that the research has been approved and the protocols have been approved to ensure your privacy.
Military Activity – We may use and disclose the health information of Armed Forces personnel for activities deemed necessary by appropriate military commend authorities, for the purpose of a determination by the Department of Veteran Affairs of your eligibility for benefits, or to a foreign military authority if you are a member of that foreign military service.
Workers’ Compensation – We may use and disclose your PHI as necessary to comply with workers’ compensation laws and other similar legally established programs.
Disaster Relief – We may use and disclose your health information to an entity assisting in a disaster relief effort.
Your Privacy Rights
Right to Access Your Health Information
- You have the right to request a physical or electronic copy of your health information that we maintain with some limited exceptions. You may make this request in writing. Ask us about our Authorization for Disclosure of Protected Health Information form.
- You may request that your health information be sent to another entity. We reserve the right to charge a reasonable fee for the cost of producing and providing your health information.
Right to Confidential Communications
- You have the right to request communication with you regarding your PHI by different methods or alternative locations. You may make this request in writing. Please ask our facility administrator how.
Right to Amend Your Health Information
- You have the right to request an amendment of your health information maintained by Proliance. You need to request and submit this amendment in writing. Please ask us about our Request to Correct or Amend Health Information form.
- We will consider the request but are not required to agree to the amendment. We will notify you in writing of any denials. You have the right to appeal our denial by filling a written statement of disagreement, which will be filed in your medical records and included with any valid release of your information.
Right to Restrict Restrictions
- You have the right to request restrictions on the way we use or disclose your health information for treatment, payment, or healthcare operations. Additionally, you have right to request a limit on the health information we disclose about you to someone involved in or payment for your care. You may submit the request in writing. We will consider the request but are not required to agree to the restriction. If we agree to the restriction, we will not use or disclosure your health information in violation of that restriction, unless it is needed for an emergency.
Right to an Accounting of Disclosure
- You have a right to a listing of disclosures we make of your health information, except for those disclosures made for treatment, payment, operations or those made pursuant to your authorization. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months.
Right to Restrict Disclosure to Health Plans
- You may request in writing that we not disclose information to health plans where you have paid for services or items out of pocket in full.
Right to a Copy of the Notice of Privacy Practices
- You have the right to request a paper copy of this Notice of Privacy Practices, even if you agreed to receive the notice electronically.
Electronic Health Record
We participate in an Organized Health Care Arrangement (“OCHA”) with other health care providers in Washington State not otherwise affiliated with us to better manage healthcare of shared patients and for purposes of risk management activities. To further those goals, we and other OCHCA members use a shared electronic health record platform that allows us and others to store, update, and use your health information. The shared electronic health record platform makes it easier for one of your healthcare providers to access all of your relevant health information, including records that were created by another of your providers and stored on the shared electronic health platform. For a list of health care providers that participate and utilize the shared electronic health record platform, please contact the Proliance Privacy Officer at 888-608-7344 or email@example.com.
Questions and Complaints
If you have questions or are concerned that any of your privacy rights have been violated, please contact our Proliance Privacy Officer at 888-608-7344 or firstname.lastname@example.org. You also have the right to complain to the Secretary of Health and Human Services at:
Office of Civil Rights
U.S. Department of Health and Human Services
2201 Sixth Avenue
Seattle, WA 98121
We respect your right to file a complaint with us or the Secretary of Health and Human Services and you will not be retaliated against for filing a complaint.
Changes to Notice of Privacy Practices
Proliance reserves the right to change the terms of our Notice of Privacy Practices at any time and to make the changes effective for all PHI that we maintain. If we make any changes, we will update this Notice. You may receive the most recent copy of this Notice by calling or visiting one of our facilities. You may also find an up to date Notice on our website at www.proliancesurgeons.com.
Effective 04/14/2003 (Revised 09/30/2020)
Consumer Notice of Surprise Billing Rights
Know your rights under the Balance Billing Protection Act
Beginning January 1, 2020, Washington state law protects you from ‘surprise billing’ or ‘balance billing’ if you receive emergency care or are treated at an in-network hospital or outpatient surgical facility
What is ‘surprise billing’ or ‘balance billing’ and when does it happen?
Under your health plan, you’re responsible for certain cost-sharing amounts. This includes copayments, coinsurance and deductibles. You may have additional costs or be responsible for the entire bill if you see a provider or go to a facility that is not in your plan’s provider network.
Some providers and facilities have not signed a contract with your insurer. They are called ‘out-ofnetwork’ providers or facilities. They can bill you the difference between what your insurer pays and the amount the provider or facility bills. This is called ‘surprise billing’ or ‘balance billing.’
Insurers are required to tell you, via their websites or on request, which providers, hospitals and facilities are in their networks. And hospitals, surgical facilities and providers must tell you which provider networks they participate in on their website or on request.
When you CANNOT be balance billed:
The most you can be billed for emergency services is your plan’s in-network cost-sharing amount even if you receive services at an out-of-network hospital in Washington, Oregon or Idaho or from an out-ofnetwork provider that works at the hospital. The provider and facility cannot balance bill you for emergency services.
Certain services at an In-Network Hospital or Outpatient Surgical Facility
When you receive surgery, anesthesia, pathology, radiology, laboratory, or hospitalist services from an out-of-network provider while you are at an in-network hospital or outpatient surgical facility, the most you can be billed is your in-network cost-sharing amount. These providers cannot balance bill you.
In situations when balance billing is not allowed, the following protections also apply:
- Your insurer will pay out-of-network providers and facilities directly. You are only responsible for paying your in-network cost-sharing.
- Your insurer must:
- Base your cost-sharing responsibility on what it would pay an in-network provider or facility in your area and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or certain out-of-network services (described above) toward your deductible and out-of-pocket limit.
- Your provider, hospital, or facility must refund any amount you overpay within 30 business days.
- A provider, hospital, or outpatient surgical facility cannot ask you to limit or give up these rights.
If you receive services from an out-of-network provider, hospital or facility in any OTHER situation, you may still be balance billed, or you may be responsible for the entire bill.
This law does not apply to all health plans. If you get your health insurance from your employer, the law might not protect you. Be sure to check your plan documents or contact your insurer for more information.
If you believe you’ve been wrongly billed, file a complaint with the Washington state Office of the Insurance Commissioner at www.insurance.wa.gov or call 1-800-562-6900.