HIPAA / Privacy






This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  This Privacy Notice describes how Brighton Surgery Center (the “Facility” or “We”) may use and disclose your protected health information (“PHI”) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.  It also describes your rights with respect to your PHI.  Your "PHI" means any written and verbal health information about you, including demographic data, that can be used to identify you, and includes health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.


I.          Uses and Disclosures of PHI


We  may use your PHI for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations.  Your PHI may be used or disclosed only for these purposes unless the Facility has obtained your authorization or unless the use or disclosure without an authorization is otherwise permitted by HIPAA or state law. 


A.        Treatment.  We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with a third party for treatment purposes.  For example, We may disclose your PHI to a pharmacy to fill a prescription or to a laboratory to order a blood test.  We may also disclose PHI to physicians who may be treating you or consulting with the Facility with respect to your care.  In some cases, We may also disclose your PHI to an outside treatment provider for purposes of the treatment activities of the other provider.


B.        Payment.  Your PHI will be used, as needed, to obtain payment for the services that We provide.  This may include certain communications to your health insurance company to get approval for the procedure that We have scheduled.  For example, We may need to disclose information to your health insurance company to get prior approval for the surgery.  We may also disclose PHI to your health insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan.  In order to get payment for the services We provide to you, We may also need to disclose your PHI to your health insurance company to demonstrate the medical necessity of the services or, as required by your insurance company, for utilization review.  We may also disclose your PHI to another provider involved in your care for the other provider’s payment activities.  This may include disclosure of demographic information to anesthesia care providers for payment of their services.


C.        Operations.  We may use or disclose your PHI, as necessary, for the Facility’s own health care operations.  Health care operations include such activities as: quality assessment and improvement activities, employee review activities, training programs including those in which students, trainees, or practitioners in health care learn under supervision, accreditation, certification, licensing or credentialing activities, review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs, and business management and general administrative activities.


D.        Other Uses and Disclosures.  As part of treatment, payment and health care operations, We may also use or disclose your PHI for the following purposes: to remind you of your surgery date, to inform you of potential treatment alternatives or options, or to inform you of health-related benefits or services that may be of interest to you.


  1. II.                Uses and Disclosures Permitted Without Authorization


HIPAA allows the Facility to use or disclose your PHI without your authorization for a number of reasons including the following: 


A.        When Legally Required.  We will disclose your PHI when We are required to do so by any federal, state or local law.


B.        When There are Risks to Public Health.  We may disclose your PHI for the following public activities and purposes:

  • To prevent, control, or report disease, injury or disability as permitted by law.
  • To report vital events such as birth or death as permitted or required by law.
  • To conduct public health surveillance, investigations and interventions as permitted or required by law.
  • To collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.
  • To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.
  • To report to an employer information about an individual who is a member of the workforce as legally permitted or required.


C.        To Report Suspected Abuse, Neglect or Domestic Violence.  We may notify government authorities if We believe that you are the victim of abuse, neglect or domestic violence.  We will make this disclosure only when specifically required or authorized by law or when you agree to the disclosure.


D.        To Conduct Health Oversight Activities.  We may disclose your PHI to a health oversight agency for activities including: 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.  We will not disclose your PHI under this authority if you are the subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits.


E.        Judicial and Administrative Proceedings.  We may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order.  In certain circumstances, We may disclose your PHI in response to a subpoena to the extent authorized by state law if We receive satisfactory assurances that you have been notified of the request or that an effort was made to secure a protective order. 


F.         For Law Enforcement Purposes.  We may disclose your PHI to a law enforcement official for law enforcement purposes as follows:


  • As required by law for reporting of certain types of wounds or other physical injuries.
  • Pursuant to court order, court-ordered warrant, subpoena, summons or similar process.
  • For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
  • Under certain limited circumstances, when you are the victim of a crime.
  • To a law enforcement official if We have a suspicion that your health condition was the result of criminal conduct.
  • In an emergency to report a crime.



G.        To Coroners, Funeral Directors, and for Organ Donation.  We may disclose PHI to a coroner or medical examiner for identification purposes, to determine cause of death, or for the coroner or medical examiner to perform other duties authorized by law.  We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her  duties.  We may disclose such information in reasonable anticipation of death.  PHI may be used and disclosed for cadaveric organ, eye or tissue donation purposes.


H.        For Research Purposes.  We may use or disclose your PHI for research when the use or disclosure for research has been approved by an institutional review board that has reviewed the research proposal and research protocols to address the privacy of your PHI.


I.          In the Event of a Serious Threat to Health or Safety.  We may, consistent with applicable law and ethical standards of conduct, use or disclose your PHI if We believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health or safety of the public.


J.         For Specified Government Functions.  In certain circumstances, federal regulations authorize the Facility to use or disclose your PHI 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 situations.


K.        For Worker's Compensation.  The Facility may release your PHI to comply with worker's compensation laws or similar programs.


III.                         Uses and Disclosures Permitted without Authorization/ Opportunity to Object


We may disclose your PHI to your family member or a close personal friend if it is directly relevant to the person’s involvement in your surgery or payment related to your surgery.  We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.  


You may object to these disclosures.  If you do not object to these disclosures, or We can infer from the circumstances that you do not object, or We determine, in circumstances where you are not present or cannot object because of your lack of capacity or an emergency, in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to the person’s involvement with your care, We may disclose your PHI as described. 


IV.       Uses and Disclosures which you Authorize


Uses and/or disclosures of your psychotherapy notes (if applicable) that do not fall within an exception, use of your PHI for marketing purposes, disclosures resulting from the sale of your PHI, and any other use and or disclosure not described above will be made only with your written authorization.  You may revoke your authorization in writing at any time, except to the extent that we have taken action in reliance on the authorization.


V.        Your Rights


You have the following rights regarding your PHI:

A.        The right to inspect and copy your PHI. You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the PHI.  A “designated record set” contains medical and billing records and any other records that your surgeon and the Facility use for making decisions about you.

Under HIPAA, however, you may not inspect or copy certain records.  Depending on the circumstances, you may have the right to have a decision to deny access reviewed.

To inspect and copy your PHI, you must submit a written request to the Privacy Officer whose contact information is listed on the last page of this Privacy Notice.  If you request a copy of your PHI, We may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request.

Please contact our Privacy Officer if you have questions about access to your PHI.

B.        The right to request a restriction on uses and disclosures of your PHI.  You may ask us not to use or disclose certain parts of your PHI. Your request must state the specific restriction requested and to whom you want the restriction to apply.  The Facility is not required to agree to a restriction that you may request.  We will notify you if we deny your request to a restriction.  If the Facility does agree to the requested restriction, We may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.  The Facility must agree to a request to restrict disclosure of your PHI to a health plan if: disclosure is for the purpose of carrying out payment or health care operations and is not required by law, and the PHI pertains solely to a health care item or service for which you or someone else has paid the Facility in full.  Under certain circumstances, We may terminate our agreement to a restriction.  You may request a restriction by contacting the Privacy Officer.

C.        The right to request to receive confidential communications from us by alternative means or at an alternative location.  You have the right to request that We communicate with you in certain ways.  We will accommodate reasonable requests.  We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.  We will not require you to provide an explanation for your request.  Requests must be made in writing to the Privacy Officer.

D.        The right to request amendments to your PHI.  You may request an amendment of your PHI as long as We maintain the information.  In certain cases, We may deny your request.  If We deny your request, you have the right to file a statement of disagreement with us and We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.  Requests for amendment must be in writing and must be directed to our Privacy Officer.  In this written request, you must also provide a reason to support the requested amendments.

E.        The right to receive an accounting.  You have the right to request an accounting of certain disclosures of your PHI made by the Facility.  This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. The request for an accounting must be made in writing to the Privacy Officer.  The request should specify the time period sought for the accounting.  Accounting requests may not be made for periods of time in excess of six years.  We will provide the first accounting you request during any 12-month period without charge.  Subsequent accounting requests may be subject to a reasonable cost-based fee.

F.         The right to obtain a paper copy of this notice.  Upon request, We will provide a separate paper copy of this Notice even if you have already received a copy of the Notice or have agreed to accept this Notice electronically.

G.        The right to notice of a breach.  You have the right to be notified following a breach of your unsecured PHI if so required by law.

VI.       Our Duties

The Facility is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice.  We are required to abide by terms of this Notice as may be amended from time to time.  We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all of your PHI that we maintain. 

VII.     Complaints

You have the right to express complaints to the Facility and to the Secretary of Health and Human Services, Office of Civil Rights if you believe that your privacy rights have been violated.  You may contact a regional office of the Office of Civil Rights, which can be found at www.hhs.gov/ocr/office/about/rgn-hqaddress.html. You may complain to the Facility by contacting the Facility’s Privacy Officer verbally or in writing, using the contact information below.  We encourage you to express any concerns you may have regarding the privacy of your PHI.  You will not be retaliated against in any way for filing a complaint. 

VIII.       Contact Person


The Facility’s contact person for all issues regarding your PHI and your rights under HIPAA is the Privacy Officer.  Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer.  If you feel that your privacy rights have been violated by this Facility, you may submit a complaint to the Privacy Officer by sending it to:



Brighton Surgery Center, LLC

980 Westfall Road

Rochester, New York 14618

ATTN: Privacy Officer 


The Privacy Officer can be contacted by telephone at 585-295-8500


IX        Organized Health Care Arrangement

The Facility includes physicians and other providers who provide health care services to you but are legally independent from the Facility.  Although these providers are independent, as you would expect they cooperate to provide an integrated system of care to you.  This type of clinically integrated setting in which you receive health care from more than one health care provider is called an organized health care arrangement (“OHCA”) under HIPAA.  The Facility may share your PHI with participants in the OHCA for treatment, payment and health care operations.  Those participating in the OHCA include, but are not limited to, certified nurse anesthetists, anesthesiologists, and physicians assistants.  This Notice is provided as a joint notice made by each of them.  Each of them will abide by the terms of this Notice.  However, some of the participants in the OHCA may instead provide you with their own privacy notice.  If that occurs, they are still part of the OHCA, but will abide by the terms of their own privacy notice.

X.        Effective Date


This Notice is effective August 1, 2013.