Locations ___

Atlanta

Our Lake Hearn location can be found off Lake Hearn Drive in a large white office building. There are several similarly colored buildings across the street from us around a large fountain and pond, but we are the building on the other side of Lake Hearn Drive. Take the elevator to the third floor and you can find us in Suite 360. When you come out of the elevator, turn right and take your first right— the suite will be at the end of the hall. Be sure that you’re going to building 1100 (NOT 1150) as they are easy to confuse.

Address _____

1100 Lake Hearn Dr NE, Suite 360, Atlanta, GA 30342

Phone number _____

404-596-5670

Fax _____

404-334-0479

Office hours _____

Monday–Friday, 8am–5pm

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GEORGIA SPINE AND ORTHOPAEDICS

PRIVACY NOTICE

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.

This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your protected health information 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 to access and control your protected health information in some cases. Your “protected health information” means any written and oral health information about you, including demographic data that can be used to identify you. This is 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 Protected Health Information

1. Uses and Disclosures of Protected Health Information The Organizations may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless the facility has obtained your authorization, or the use or disclosure is otherwise permitted by the HIPAA privacy regulations or state law. Disclosures of your protected health information for the purposes described in this Privacy Notice may be made in writing, orally, or by facsimile.

Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.
Payment. Your protected health information will be used, as needed, to obtain payment for the services that we provide.
Operations. We may use or disclose your protected health information, as necessary, for our own health care operations to facilitate the function of Georgia Spine & Orthopaedics and to provide quality care to all patients.
Other Uses and Disclosures. As part of treatment, payment and health care operations, we may also use or disclose your protected health information.

II. Uses and Disclosures beyond Treatment, Payment and Health Care Operations Permitted without Authorization or Opportunity to Object

Federal privacy rules allow us to use or disclose your protected health information without your permission or authorization for several reasons including the following:

When Legally Required.
When There Are Risks to Public Health.
To Report Suspected Abuse, Neglect or Domestic Violence.
To Conduct Health Oversight Activities.
In Connection with Judicial and Administrative Proceedings.
For Law Enforcement Purposes.
For Research Purposes.
In the Event of a Serious Threat to Health or Safety.
For Specified Government Functions.
For Worker’s Compensation.

The facility may release your health information to comply with worker’s compensation laws or similar programs.

III. USES AND DISCLOSURES PERMITTED WITHOUT AUTHORIZATIONS BUT WITH OPPORUTNITY TO OBJECT

We may disclose your protected health information to your family member if it is directly relevant to the person’s involvement in your care or payment related to your care. 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, in the exercise of our professional judgment, that it is in your best interest for us to make disclosure of information that is directly relevant to that person’s involvement with your care, we may disclose your protected health information as described.

IV. USES AND DISCLOSURES WHICH YOU AUTHORIZE

Other than stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have acted in reliance upon the authorization. We specifically require your written authorization for marketing or the sale of your protected health information. If our facility maintains psychotherapy notes, we will require your written authorization for the use or disclosure of psychotherapy notes other than by the creator of those notes, by the facility for its training programs or for the facility to defend itself in a legal action brought by you.

V. YOUR RIGHTS
You have the following rights regarding your health information:

The right to inspect and copy your protected health information. You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your surgeon and the facility uses for making decisions about you. If information in a “designated record set” is maintained electronically, you may request an electronic copy in a form and format of your choice that is readily producible or, if the form/format is not readily producible, you will be given a readable electronic copy in a timely manner not to exceed 60 days. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed. We may deny your request to inspect or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision. To inspect and copy your medical information, 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 information, 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 Medical Records Custodian if you have questions about access to your medical record.
The right to request a restriction on uses and disclosures of your protected health information. You may ask us not to use or disclose certain parts of your protected health information for the purposes of treatment, payment and health care operation. You may request that we do not file a claim to your health plan if an agreed upon amount is paid out-of-pocket. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in this Privacy Notice. 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 unless your request related to a disclosure to a health plan for items or services that were paid in full by you or someone other than the health plan and the disclosure is not required by law. 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 protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Privacy Officer using the contact information below.
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 our Privacy Officer using the contact information below.
The right to request amendments to your protected health information. You may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. Your request may be denied if we did not create the PHI, if the amendment is not part of normal record keeping of PHI, and if the amendment would never be included for inspection by any other group or party and if we believe the record is accurate and complete without the amendment. If we deny your request for amendment, 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 whose contact information is listed on the last page of this Privacy Notice. In this written request, you must also provide a reason to support the requested amendment.
The right to receive an accounting. You have the right to request an accounting of certain disclosures of your protected health information 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. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, 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 our Privacy Officer. The request should specify the time sought for the accounting. Accounting requests may not be made for periods of time more than six years. We will provide the first accounting you request in any 12-month period without charge, Subsequent accounting requests may be subject to a reasonable cost-based fee.
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.

VI. OUR DUTIES

The facility is required by law to maintain the privacy or your health information and report to you any breach of unsecured protected health information. We are also required to provide you with this Privacy Notice of our duties and privacy practices. 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 future protected health information that we maintain. If the facility changes this Notice, we will post notification at each office location and provide a copy of the revised Notice on our website.

VII. COMPLIANTS

You have the right to express complaints to the facility and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the facility by contacting the 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 information. 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 patient privacy and your rights under the federal privacy standards 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:

Georgia Spine & Orthopaedics

Attn: Privacy Officer

11650 Alpharetta Hwy, Suite 100,

Roswell, GA 30076

Phone: 404-596-5670

Anonymous HIPAA Hotline: 844-333-0850

If you are unable to get your issue resolved, you may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling 1-877-696-6775.

Last Revised:5/19

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