HSS Patient Policies and Guidelines

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs,  like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health  plan to provide services. Out-of-network providers may be allowed to bill you for the difference  between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or hospital, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in a stable condition, unless you give written consent and give up your protections not to be balanced billed for these  post-stabilization services.  If your insurance ID card says “fully insured coverage,” you can’t give written consent and give up your protections not to be balance billed for post-stabilization services. 

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. If your insurance ID card says “fully insured coverage,” you can’t give up your protections for these other services if they are a surprise bill. Surprise bills are when you’re at an in-network hospital or ambulatory surgical facility and a participating doctor was not available, a non-participating doctor provided services without your knowledge, or unforeseen medical services were provided.  

Services referred by your in-network doctor  

If your insurance ID card says “fully insured coverage,” surprise bills include when your in-network doctor refers you to an out-of-network provider without your consent (including lab and pathology services). These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. You may need to sign a form (available on the Department of Financial Services’ website) for the full balance billing protection to apply.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance,   and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services   toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed and your coverage is subject to New York law (“fully insured coverage”), contact the New York State Department of Financial Services at 1.800.342.3736 or surprisemedicalbills@dfs.ny.gov. Visit New York's Department of Financial Services for information about your rights under state law.  

Contact CMS at 1.800.985.3059 for self-funded coverage or coverage bought outside New York.  Visit the Centers for Medicare & Medicaid Services Medical bill rights for information about your rights under federal law.

What Is the CARE Act?

A New York State public health law that requires a hospital to provide each patient or legal guardian with an opportunity to identify a caregiver prior to discharge. If the patient is discharged directly home, the caregiver may be trained in after-care tasks.

Before leaving the hospital, staff will contact the designated caregiver to provide instructions in all after-care tasks. This will often include instructions on your medications, follow up appointments and other important information regarding the recovery. We encourage caregivers to visit during special designated daily times for instruction on after-care tasks – and to ask questions and receive answers. Designated caregiver visiting hours are 7 days per week:

• 10 – 11 am
• 2 – 3 pm
• 8 – 9 pm

If a designated caregiver is unavailable during those hours, efforts will be made to accommodate.

For more information on the law, please refer to this link: https://www.nysenate.gov/legislation/bills/2015/s676.

Who Can Be a Caregiver?

A caregiver can be anyone (such as a relative, partner, friend or neighbor) who will be helping the patient recover after they leave the hospital. The patient must sign a consent for the staff to provide personal health information to this person upon admission to the hospital.

What Is the Role of a Caregiver?

A caregiver will need to provide contact information (name, telephone #, email address) and be available to receive instructions from the hospital staff about any after-care tasks.

Does a Caregiver Have to Be Chosen?

No, patients can decline to designate a caregiver. Instructions related to after-care assistance will always be given to the patient and any available family/support person prior to leaving the hospital.

Common After-Care Tasks for the Caregiver

Preparing the Home for Safety

• Be present and available.
• Remove clutter.
• Arrange furniture so that it is easy to move around.
• Secure or remove throw rugs.
• Secure all hand rails.
• Use non-slip mats in the bathtub and shower.
• Improve lighting - use nightlights in bathrooms and hallways.
• Make sure the patient has non–slip footwear with rubber soles and a closed back.
• Keep a list of emergency numbers by the phone.

At Home Assistance to Prevent Complications

Complications are rare but important to follow some rules to reduce the risks of:

Infection prevention:

• Help keep surgical incision clean and dry.
• Wash hands frequently.
• Observe for redness, drainage, odor.
• Follow additional instructions as directed.

Constipation prevention & management:

• Encourage 6-8 glasses of water each day.
• Assist with food preparation to include fresh fruits and vegetables.
• Encourage exercise and walking.
• Review medications.

Pain Management

There are numerous strategies available to help manage pain following surgery.

• Review medications.
• Be aware of side effects (nausea, vomiting, constipation, itch and/or rash).
• Assist with cold therapy application.
• Remind patients of positioning, activity and rest.

Physical Therapy

Depending on the patient’s procedure, physical therapy may be required for the patient’s recovery.

• Review exercises.
• Educate on safe mobility.
• Help prepare for therapy sessions at home.
• Visit HSS Rehabilitation and Performance for more information.

Medical Equipment

After surgery certain medical equipment is helpful. Staff may recommend specific equipment with the patient.

• Assist with use of durable medical equipment.
• Observe for safety.
• Encourage exercise and walking.
• Review medication.

 

As a patient in a hospital in New York State, you have the right, consistent with law, to:

1. Understand and use these rights. If for any reason you do not understand or you need help, the hospital MUST provide assistance, including an interpreter.
2. Receive treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation, source of payment, or age.
3. Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints.
4. Receive emergency care if you need it.
5. Be informed of the name and position of the doctor who will be in charge of your care in the hospital.
6. Know the names, positions and functions of any hospital staff involved in your care and refuse their treatment, examination or observation.
7. Identify a caregiver who will be included in your discharge planning and sharing of post-discharge care information or instruction.
8. Receive complete information about your diagnosis, treatment and prognosis.
9. Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment.
10. Receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask for a copy of the pamphlet "Deciding About Health Care — A Guide for Patients and Families."
11. Refuse treatment and be told what effect this may have on your health.
12. Refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation.
13. Privacy while in the hospital and confidentiality of all information and records regarding your care.
14. Participate in all decisions about your treatment and discharge from the hospital. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge.
15. Review your medical record without charge. Obtain a copy of your medical record for which the hospital can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay.
16. Receive an itemized bill and explanation of all charges.
17. View a list of the hospital's standard charges for items and services and the health plans the hospital participates with.
18. Challenge an unexpected bill through the Independent Dispute Resolution process.
19. Complain without fear of reprisals about the care and services you are receiving and to have the hospital respond to you and if you request it, a written response. If you are not satisfied with the hospital's response, you can complain to the New York State Health Department. The hospital must provide you with the State Health Department telephone number.
20. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors.
21. Make known your wishes in regard to anatomical gifts. Persons sixteen years of age or older may document their consent to donate their organs, eyes and/or tissues, upon their death, by enrolling in the NYS Donate Life Registry or by documenting their authorization for organ and/or tissue donation in writing in a number of ways (such as a health care proxy, will, donor card, or other signed paper). The health care proxy is available from the hospital.

Contact Information for Questions or Concerns

Should you have questions about any of these rights, or wish to express a recommendation or concern, you may contact one or more of the following:

• HSS Office of the Patient Experience for New York 212.774.2403, for Connecticut, New Jersey and Florida Toll-Free 855-477-4344 or e-mail at patientexperience@hss.edu.
• HSS Chief Executive Officer at 212.606.1236, or by letter sent to Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021.
• You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services: 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 or by phone 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
• Joint Commission at 800.994.6610, or by letter sent to Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181, or e-mail to complaint@jointcommission.org.
• Centers for Medicare and Medicaid Services: Toll-free: 877.267.2323 TTY Toll-free: 866-226-1819. Medicare Only: Toll-free: 800-MEDICARE (800-633-4227); TTY Toll-free: 877-486-2048. 7500 Security Boulevard, Baltimore, MD 21244 New York State Department of Health by phone at: 800.804.5447 or letter sent to NYS Department of Health, Centralized Hospital Intake Program, Mailstop: CA/DCS, Empire State Plaza, Albany, NY 12237.

The Statement of Patient’s Responsibilities, designed as a companion to the Patient’s Bill of Rights, encourages patients to participate in their own health care and treatment. Hospital for Special Surgery believes that a mutual understanding of the Patient’s Bill of Rights and Responsibilities will result in more effective delivery of health care services.

The Statement of Patient Responsibilities reads as follows:

To the extent possible, Hospital for Special Surgery requests that you, as our patient:

1. Provide accurate and complete information about your past illnesses, hospitalizations, medications and other matters relating to your health, and answer any questions concerning these matters.
2. Participate in your health care planning by talking openly and honestly about your concerns with your physician and other health care professionals.
3. Understand your health problems, treatment course and care decisions to your own satisfaction and ask questions if you do not understand.
4. Cooperate with your physician and other health care professionals in carrying out your health care plan both as an inpatient and after discharge.
5. Participate and cooperate with our health care professionals in creating a discharge plan that meets your medical and social needs.
6. Inform the hospital or any of its professionals of the existence of any advanced directive (proxy, DNR, living will) you have created.
7. Take responsibility for the consequences and outcomes if you do not follow the care, service or treatment plan.
8. Provide accurate information related to insurance or other sources of payment. You are responsible for ensuring payment of your bills and you may be responsible for charges not covered by your insurance.
9. Treat other patients, visitors and staff with respect and consideration. Support mutual consideration and respect by maintaining civil language and conduct in interactions with staff and providers.
10. Support our commitment to a diverse and inclusive environment in which racist and/or discriminatory behaviors and acts of intolerance towards others are not tolerated.
11. Follow instructions, policies, rules, and regulations in place to support quality care for patients and a safe environment for all individuals in the hospital.
12. Be considerate of your fellow patients, respecting their need for privacy and a quiet environment.

Hospital for Special Surgery (HSS) is committed to providing each child with the best care possible and to ensuring that you, as your child’s primary protector and caregiver, are assured certain rights and freedoms. HSS views every parent and legal guardian as a valued member of the health care team and encourages you to speak with HSS staff about your child’s care.

HSS Parent’s and Legal Guardian Bill of Rights, in addition to the “Patient’s Bill of Rights,” sets forth the rights of patients, parents of minors, legal guardians or other persons with decision- making authority to certain minimum protections required by the regulations governing the provision of care in New York State’s hospitals.

HSS Parent’s and Legal Guardian Bill of Rights is subject to laws and regulations governing confidentiality and is in effect if your child is admitted to the hospital.

As a parent, legal guardian or person with decision-making authority for a patient receiving care in this hospital, you have the right, consistent with the law, to the following:

1. To inform the hospital of the name of your child’s primary care provider, if known, and have this information documented in your child’s medical record.
2. To be assured our hospital will only admit pediatric patients to the extent consistent with our hospital’s ability to provide qualified staff, space and size appropriate equipment necessary for the unique needs of pediatric patients.
3. To allow at least one parent or guardian to remain with your child at all times, to the extent possible given your child’s health and safety needs.
4. That all test results completed during your child’s admission or emergency room visit be reviewed by a physician, physician assistant, or nurse practitioner who is familiar with your child’s presenting condition.
5. For your child not to be discharged from our hospital or emergency room until any tests that could reasonably be expected to yield critical value results are reviewed by a physician, physician assistant, and/or nurse practitioner and communicated to you or other decision makers, and your child, if appropriate. Critical value results are results that suggest a life-threatening or otherwise significant condition that requires immediate medical attention.
6. For your child not to be discharged from our hospital or emergency room until you or your child, if appropriate, receives a written discharge plan, which will also be verbally communicated to you and your child or other medical decision makers. The written discharge plan will specifically identify any critical results of laboratory or other diagnostic tests ordered during your child’s stay and will identify any other tests that have not yet been concluded.
7. To be provided critical value results and the discharge plan for your child in a manner that reasonably ensures that you, your child (if appropriate), or other medical decision makers understand the health information provided in order to make appropriate health decisions.
8. For your child’s primary care provider, if known, to be provided all laboratory results of this hospitalization or emergency room visit.
9. To request information about the diagnosis or possible diagnoses that were considered during this episode of care and complications that could develop as well as information about any contact that was made with your child’s primary care provider.
10. To be provided, upon discharge of your child from the hospital or emergency department, with a phone number that you can call for advice in the event that complications or questions arise concerning your child’s condition.

If you are concerned that you may not be able to pay for your care, we may be able to help.

Hospital for Special Surgery provides financial aid for medically necessary services based on a patient's financial need and includes a sliding scale discount for patients who qualify. Aid may be available for patients who do not have insurance and for those who are underinsured. We may be able to work with you to arrange a manageable payment plan.

Our financial assistance policy applies to services provided by the Hospital, and some services provided by certain HSS physicians and other clinical staff.

Access the full policy, an application and additional information, including a full list of providers who participate in the Hospital's financial assistance policy:

• Financial Assistance – New York Hospital
• Financial Assistance – HSS ASC of Manhattan
• Financial Assistance – West Side ASC

You can also call the Financial Advisory Department at 212.606.1505, and we would be glad to provide information to you and answer any questions you may have.

Hospital for Special Surgery is committed to providing high quality care and skilled and compassionate service to our community. Consistent with this commitment, Hospital for Special Surgery complies with applicable federal, state, and local civil rights laws and does not discriminate on the basis of actual or perceived race, color, creed, ethnicity, religion, national origin, alienage or citizenship status, culture, language, age, disability, socioeconomic status, sex, sexual orientation, gender identity or expression, partnership or marital status, veteran or military status, or any other prohibited basis.

Hospital for Special Surgery:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  
  • Qualified sign language interpreters.
  • Written information in other formats, such as large print, audio, and accessible electronic formats.
• Provides free language assistance services to people whose primary language is not English, such as:
  
  • Qualified interpreters.
  • Information written in other languages.
  • Auxiliary aids to patients who are deaf and blind.

If you need these services, contact the Language Services Department languageservices@hss.edu, Tel.: 1-212-606-1760.

If you believe that Hospital for Special Surgery has failed to provide these services or discriminated in another way, you can file a grievance with Section 1557 Coordinator at Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, TTY: 1-800-676-3777 or 1- 855-477-4344, patientexperience@hss.edu.

You also have the right to file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD). Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html.

ATENCIÓN: Si usted habla español, le avisamos que tenemos servicios lingüísticos gratuitos a su disposición. Llame al: 1-212-606-1760, TTY: 1-800-676-3777.

注意：如果您講中文，可向您提供免費語言服務。致電 1-212-606-1760，TTY: 1-800-676-3777。

Внимание: Если Вы говорите по русски, примите к сведению, что Вы можете воспользоваться бесплатными услугами переводчика. Звоните по номеру: 1-212-606-1760, TTY: 1-800-676-3777.

ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis asistans nan lang ki disponib pou ou gratis. Rele nan 1-212-606-1760, TTY: 1-800-676-3777.

알려드립니다: 귀하께서 한국어를 하시는 경우, 무료로 언어 도움 서비스를 이용하실 수 있습니다. 1-212-606-1760 (TTY: 1-800-676-3777) 번으로 전화하십시오.

ATTENZIONE: se parli italiano sono disponibili servizi di assistenza linguistica gratuiti. Chiama il numero 1-212-606-1760, TTY: 1-800-676-3777.

אכטונג׃ אױב איר רעדט אידיש, זענען פאר אײך דא צו באקומען שפראך הילף סערװיסעס פרײ פון אפצאל. רופט 1-212-606-1760, TTY: 1-800-676-3777.

দৃষ্টি আকর্ষণ: যদি আপনি বাংলায় কথা বলেন, তাহলে আপনি বিনামূল্যে ভাষাগত সহায়তা পরিষেবা পেতে পারেন৷ ফোন করুন: 1-212-606-1760, TTY:  1-800-676-3777.

UWAGA: Jeżeli mówi Pan/Pani po polsku, dostępne są dla Państwa bezpłatne usługi pomocy językowej. Proszę zadzwonić pod numer 1-212-606-1760, TTY:  1-800-676-3777.

ملاحظة: إذا كنت تتحدث اللغة العربية، فإننا نوفر لك خدمات مساعدة لغوية بالمجان. اتصل على
1-212-606-1760، هاتف نصي (TTY): 1-800-676-3777.

VEUILLEZ NOTER: Si vous parlez français, des services d’assistance linguistique gratuits, sont à votre disposition. Appelez le 1-212-606-1760, TTY: 1-800-676-3777.

توجہ فرمائیں: اگر آپ کی زبان اردو ہے تو آپ کے لیے زبان میں معاونت فراہم کرنے والی سروسز (لینگوئج اسسٹنس سروسز) بلامعاوضہ دستیاب ہیں کال کریں 1-212-606-1760 TTY: 1-800-676-3777۔

PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuha kang mga libreng serbisyo ng tulong sa wika. Tumawag sa 1-212-606-1760, TTY: 1-800-676-3777.

ΠΡΟΣΟΧΗ: Εάν μιλάτε ελληνικά, διατίθενται δωρεάν υπηρεσίες γλωσσικής βοήθειας για εσάς. Καλέστε το 1-212-606-1760. TTY: 1-800-676-3777.

VINI RE: Nëse flisni shqip, keni në dispozicion shërbime ndihme për gjuhën pa pagesë. Telefononi 1-212-606-1760, TTY: 1-800-676-3777.

As a patient in an ambulatory surgery center in New York State, you have the right, consistent with law, to:

1. Receive service(s) without regard to age, race, color, sexual orientation, religion, marital status, sex, disability, gender identity or expression, national origin or sponsor.
2. Be treated with consideration, respect and dignity including privacy in treatment.
3. Be informed of the services available at the center.
4. Be informed of the provisions of off-hour emergency coverage.
5. Be informed of the charges for services, eligibility for third-party reimbursements and, when applicable, the availability of free or reduced care costs.
6. Receive an itemized copy of his or her account statement, upon request.
7. Obtain from his or her health care practitioner, or the health care practitioner’s delegate, complete and current information concerning his or her diagnosis, treatment and prognosis in terms the patient can be reasonably expected to understand.
8. Receive from his or her physician information necessary to give informed consent prior to the start of any nonemergency procedure or treatment or both. An informed consent shall include, as a minimum, the provision of information concerning the specific procedure or treatment or both, the reasonably foreseeable risks involved, and alternatives for care or treatment, if any, as a reasonable medical practitioner under similar circumstances would disclose in a manner permitting the patient to make a knowledgeable decision.
9. Refuse treatment to the extent permitted by law and to be fully informed of the medical consequences of his or her action.
10. Refuse to participate in experimental research.
11. Voice grievances and recommend changes in policies and services to the center’s staff, the operator and the New York State Department of Health without fear of reprisal.
12. Express complaints about the care and services provided and to have the center investigate such complaints. The center is responsible for providing the patient or his/her designee with a written response within 30 days if requested by the patient indicating the findings of the investigation. The center is also responsible for notifying the patient or his or her designee that if the patient is not satisfied by the center response, the patient may complain to the New York State Department of Health’s Office of Health Systems Management.
13. Privacy and confidentiality of all information and records pertaining to the patient’s treatment.
14. Approve or refuse the release or disclosure of the contents of his or her medical record to any healthcare practitioner and/or healthcare facility except as required by law or third-party payment contract.
15. Access his or her medical record pursuant to the provision of section 18 of the Public Health Law, and Subpart 50-3 of Title 10 of the Compilation of Codes, Rules and Regulations of the State of New York. For additional information link to: http://www.health.ny.gov/publications/1449/section_1.htm#access.
16. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors.
17. When applicable, make known your wishes in regard to anatomical gifts. Persons sixteen years of age or older may document their consent to donate their organs, eyes and/or tissues, upon their death, by enrolling in the NYS Donate Life Registry or by documenting their authorization for organ and/or tissue donation in writing in a number of ways (such as health care proxy, will, donor card, or other signed paper). The health care proxy is available from the center.
18. View a list of the health plans and the hospitals that the center participates with.
19. Receive an estimate of the amount that you will be billed after services are rendered.

Contact Information for Questions or Concerns

Should you have questions about any of these rights, or wish to express a recommendation or concern, you may contact one or more of the following:

• To report a complaint or grievance, you can contact the Clinical Nursing Director of the relevant ASC by mail: 
  • HSS ASC of Manhattan, 1233 Second Avenue, New York, NY 10065, phone 1. 212-548-2469; phone TTY 1.800.676.3777 or e-mail MASCleadership@HSS.edu.
• You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services: 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 or by phone 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
• Joint Commission at 800.994.6610, or by letter sent to Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181, or e-mail to complaint@jointcommission.org.
• Centers for Medicare and Medicaid Services: Toll-free: 877.267.2323 TTY Toll-free: 866-226-1819. Medicare Only: Toll-free: 800-MEDICARE (800-633-4227); TTY Toll-free: 877-486-2048. 7500 Security Boulevard, Baltimore, MD 21244.
• New York State Department of Health by phone at: 800.804.5447 or letter sent to NYS Department of Health, Centralized Hospital Intake Program, Mailstop: CA/DCS, Empire State Plaza, Albany, NY 12237.

The Statement of Patient’s Responsibilities, designed as a companion to the Patient’s Bill of Rights, encourages patients to participate in their own health care and treatment. Hospital for Special Surgery believes that a mutual understanding of the Patient’s Bill of Rights and Responsibilities will result in more effective delivery of health care services.

The Statement of Patient Responsibilities reads as follows:

To the extent possible, Hospital for Special Surgery requests that you, as our patient:

1. Provide accurate and complete information about your past illnesses, hospitalizations, medications and other matters relating to your health, and answer any questions concerning these matters.
2. Participate in your health care planning by talking openly and honestly about your concerns with your physician and other health care professionals.
3. Understand your health problems, treatment course and care decisions to your own satisfaction and ask questions if you do not understand.
4. Cooperate with your physician and other health care professionals in carrying out your health care plan both as an inpatient and after discharge.
5. Participate and cooperate with our health care professionals in creating a discharge plan that meets your medical and social needs.
6. Inform the hospital or any of its professionals of the existence of any advanced directive (proxy, DNR, living will) you have created.
7. Take responsibility for the consequences and outcomes if you do not follow the care, service or treatment plan.
8. Provide accurate information related to insurance or other sources of payment. You are responsible for ensuring payment of your bills and you may be responsible for charges not covered by your insurance.
9. Treat other patients, visitors and staff with respect and consideration. Support mutual consideration and respect by maintaining civil language and conduct in interactions with staff and providers.
10. Support our commitment to a diverse and inclusive environment in which racist and/or discriminatory behaviors and acts of intolerance towards others are not tolerated.
11. Follow instructions, policies, rules, and regulations in place to support quality care for patients and a safe environment for all individuals in the hospital.
12. Be considerate of your fellow patients, respecting their need for privacy and a quiet environment.

The HSS ASC of Manhattan is committed to providing high quality care and skilled and compassionate service to our community. Consistent with this commitment, the HSS ASC of Manhattan complies with applicable federal, state, and local civil rights laws and does not discriminate on the basis of actual or perceived race, color, creed, ethnicity, religion, national origin, alienage or citizenship status, culture, language, age, disability, socioeconomic status, sex, sexual orientation, gender identity or expression, partnership or marital status, veteran or military status, or any other prohibited basis.

The HSS ASC of Manhattan:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters.
  • Written information in other formats, such as large print, audio, and accessible electronic formats.
• Provides free language assistance services to people whose primary language is not English, such as:
  • Qualified interpreters.
  • Information written in other languages.
  • Auxiliary aids to patients who are deaf and blind.

If you need these services, contact the Language Services Department languageservices@hss.edu, Tel.: 1-212-606-1760.

If you believe that the HSS ASC of Manhattan has failed to provide these services or discriminated in another way, you can file a grievance with Bryan Guss, Senior Director, HSS ASC of Manhattan, 1233 Second Avenue, New York, NY 10065, TTY: 1.800.676.3777, Fax: 212.548.2510, gussb@hss.edu.

You can file a grievance in person or by mail, fax, or email.  If you need help filing a grievance, you may contact the office of Bryan Guss for assistance.

You also have the right to file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1.800.368.1019, 800.537.7697 (TDD). Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html.

ATENCIÓN: Si usted habla español, le avisamos que tenemos servicios lingüísticos gratuitos a su disposición. Llame al: 1-212-606-1760, TTY: 1-800-676-3777.

注意：如果您講中文，可向您提供免費語言服務。致電 1-212-606-1760，TTY: 1-800-676-3777。

Внимание: Если Вы говорите по русски, примите к сведению, что Вы можете воспользоваться бесплатными услугами переводчика. Звоните по номеру: 1-212-606-1760, TTY: 1-800-676-3777.

ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis asistans nan lang ki disponib pou ou gratis. Rele nan 1-212-606-1760, TTY: 1-800-676-3777.

알려드립니다: 귀하께서 한국어를 하시는 경우, 무료로 언어 도움 서비스를 이용하실 수 있습니다. 1-212-606-1760 (TTY: 1-800-676-3777) 번으로 전화하십시오.

ATTENZIONE: se parli italiano sono disponibili servizi di assistenza linguistica gratuiti. Chiama il numero 1-212-606-1760, TTY: 1-800-676-3777.

אכטונג׃ אױב איר רעדט אידיש, זענען פאר אײך דא צו באקומען שפראך הילף סערװיסעס פרײ פון אפצאל. רופט 1-212-606-1760, TTY: 1-800-676-3777.

দৃষ্টি আকর্ষণ: যদি আপনি বাংলায় কথা বলেন, তাহলে আপনি বিনামূল্যে ভাষাগত সহায়তা পরিষেবা পেতে পারেন৷ ফোন করুন: 1-212-606-1760, TTY:  1-800-676-3777.

UWAGA: Jeżeli mówi Pan/Pani po polsku, dostępne są dla Państwa bezpłatne usługi pomocy językowej. Proszę zadzwonić pod numer 1-212-606-1760, TTY:  1-800-676-3777.

ملاحظة: إذا كنت تتحدث اللغة العربية، فإننا نوفر لك خدمات مساعدة لغوية بالمجان. اتصل على
1-212-606-1760، هاتف نصي (TTY): 1-800-676-3777.

VEUILLEZ NOTER: Si vous parlez français, des services d’assistance linguistique gratuits, sont à votre disposition. Appelez le 1-212-606-1760, TTY: 1-800-676-3777.

توجہ فرمائیں: اگر آپ کی زبان اردو ہے تو آپ کے لیے زبان میں معاونت فراہم کرنے والی سروسز (لینگوئج اسسٹنس سروسز) بلامعاوضہ دستیاب ہیں کال کریں 1-212-606-1760 TTY: 1-800-676-3777۔

PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuha kang mga libreng serbisyo ng tulong sa wika. Tumawag sa 1-212-606-1760, TTY: 1-800-676-3777.

ΠΡΟΣΟΧΗ: Εάν μιλάτε ελληνικά, διατίθενται δωρεάν υπηρεσίες γλωσσικής βοήθειας για εσάς. Καλέστε το 1-212-606-1760. TTY: 1-800-676-3777.

VINI RE: Nëse flisni shqip, keni në dispozicion shërbime ndihme për gjuhën pa pagesë. Telefononi 1-212-606-1760, TTY: 1-800-676-3777.

Effective Date: July 12, 2017
Revision Date: October 30, 2025

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

HSS ASC of Manhattan (“HSS ASC”) values respect for our patients’ privacy. Not only is it what our patients expect, it is the right way to conduct health care. As required by law, we will protect the privacy of health information that may reveal your identity, and we will provide you a copy of this Notice, which describes the health information privacy practices of HSS ASC, its medical staff and affiliated health care providers when providing health care services for HSS ASC. If you have any questions about this Notice or would like further information, please contact HSS ASC’s Privacy Officer at (212) 548-2510.

WHO WILL FOLLOW THE PRACTICES IN THIS NOTICE?

HSS ASC of Manhattan (“HSS ASC”) provides health care to our patients together with physicians and other health care professionals and organizations. The privacy practices described in this Notice will be followed by:

• Health care professionals who provide direct services to treat you at HSS ASC;
  All employees, medical staff, trainees, students, and volunteers at HSS ASC who provide direct services to you; and
• HSS ASC’s business associates and their subcontractors.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

For information about how we use and disclose information collected through the MyHSS patient portal, please refer to our MyHSS Privacy Policy and MyHSS Terms of Use. If there is a conflict between this Notice and the MyHSS Privacy Policy or MyHSS Terms of Use, this Notice will apply to the extent that Protected Health Information (as defined by the Department of Health and Human Services) is involved.

We will generally obtain your written authorization before using your health information or sharing it with others outside of HSS ASC. There are some situations, described below, when we do not need your written authorization before using your health information or sharing it with others. If your health information is disclosed to a recipient pursuant to any of the applicable purposes described in this Notice, it is possible that such health information may be subject to further redisclosure by the recipient and no longer protected by the requirements of this Notice.

1.    Treatment, Payment, and Health Care Operations

We may use your health information or share it with others to treat you, obtain payment for that treatment, and run our health care operations. In some cases, we may also disclose your health information for payment activities and certain health care operations of another health care provider or payor.

Treatment. We may share your health information with doctors, nurses and other health care providers who are involved in taking care of you, and they may in turn use that information to diagnose or treat you. Your doctor may also share your health information with another doctor or provider to whom you have been referred for further health care.

Payment. We may use your health information or share it with others so that we may obtain payment for your health care services. For example, we may share information about you with your health insurance company to obtain reimbursement after we have treated you, or to determine whether it will cover your treatment. We might also need to inform your health insurance company about your health condition to obtain pre-approval for your treatment, such as a particular type of surgery. Finally, we may share your information with other health care providers and payors for their payment activities.

Health Care Operations. We may use your health information or share it with others to conduct our health care operations. For example, we may use your health information to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care they provide. In addition, we may share your health information with other health care providers and payors for certain health care operations if the information is related to a relationship the provider or payor currently has or previously had with you, and if the provider or payor is required by federal law to protect the privacy of your health information.
 
Recording and Transcription of Clinical Encounters. To help our health care providers document and manage your care, we may use voice recording technology that records and transcribes conversations between you and your HSS health care provider during your visit. This technology allows your provider to focus more on you and less on note taking, helping ensure you receive the highest quality care. Your recorded protected health information may only be used in accordance with this notice.

Health Information Exchanges. We may participate in health information exchanges, enabling us to share your health information electronically with other health care providers in the course of providing care for you, as permitted by state and federal law. If you are interested in opting out or changing your health information exchange choice, please contact HSS Health Information Management at (212) 606-1254.

Appointment Reminders, Treatment Alternatives, or Distribution of Health-Related Benefits and Services. In the course of providing treatment to you, we may use your health information to contact you with a reminder that you have an appointment for treatment or services. We may also use your health information to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you. However, to the extent a third party provides financial remuneration to us so that we make these treatment-related or health care operations-related communications to you, we will secure your authorization in advance as we would with any other marketing communication (as described later in this Notice).

Fundraising. Fundraising is a communication from HSS ASC or one of its business associates, or by HSS ASC’s affiliated support organization, The Hospital for Special Surgery Fund, Inc. (the Fund), for the purpose of raising funds to further our missions of patient care, research, and education, including appeals for money or sponsorship of events. We may use certain information about you for fundraising, including demographic information (such as your age, date of birth, and gender, and where you live or work), your insurance status, the dates when you received services from us, and information about where you received services, the identity of your treating doctor(s), and the outcome of your treatment. You have the right to opt-out of future fundraising communications and can do so by following the opt-out instructions provided as part of the fundraising communication.

Business Associates. We may disclose your health information to contractors, agents and other business associates who need the information to assist us with obtaining payment or carrying out our health care operations. For example, we may share your health information with a billing company that helps us to obtain payment from your insurance company. Another example is that we may share your health information with an accounting firm or law firm that provides professional advice to us about how to improve our health care services and comply with the law. If we do disclose your health information to a business associate, we will have a written contract that requires our business associate to protect the privacy of your health information. We may also allow for our business associates to de-identify your health information to be used for the benefit of HSS ASC or the benefit of the business associate, or to create, use and disclose limited data sets as described below in the section titled “Completely De-identified or Partially De-identified Information.”

2.    Patient Directory and Family and Friends Involved in Your Care

We may use your health information in, and disclose it from, our patient directory, or share it with family and friends involved in your care, without your written authorization. You will have an opportunity to object to these uses and disclosures of your health information, unless there is insufficient time because of a medical emergency (in which case we will discuss your preferences with you as soon as the emergency is over). We will follow your wishes, unless we are required by law to do otherwise.

Patient Directory. We generate and maintain a daily list of patients currently admitted. If you do not object, we will include your name and your location in this list. This information may be released to people who ask for you by name (e.g., family members accompanying you to your surgical appointment). If you would prefer that we not include your information, you may contact HSS ASC’s Privacy Officer at (212) 548-2510.

Family and Friends Involved in Your Care. If you do not object, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for that care. We may also notify a family member, personal representative, or another person responsible for your care about your location and general condition. In some cases, we may need to share your information with a disaster relief organization that will help us notify these persons.

3.    Emergencies or Public Need

We may use your health information, and share it with others, to treat you in an emergency or to meet important public needs. We will not be required to obtain your written authorization or to provide you with an opportunity to object before we use or disclose your health information for these reasons. We will, however, obtain your written authorization for, or provide you with an opportunity to object to, the use and disclosure of your health information in these situations when state law specifically requires that we do so.

Emergencies. We may use or disclose your health information if you need emergency treatment or if we are required by law to treat you.

As Required by Law. We may use or disclose your health information if we are required by law to do so. In certain situations, we may notify you of disclosures we make that were required by law.

Public Health Activities. We may disclose your health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities. For example, we may share your health information with government officials that are responsible for controlling disease, injury, or disability. We may also disclose your health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if the law requires or permits us to do so. Further, we may release some health information about you to your employer if your employer hires us to provide you with a physical exam and we discover you have a work-related injury or disease that your employer must know about to comply with employment laws.

Victims of Abuse, Neglect, or Domestic Violence. We may release your health information to a public health authority that is authorized to receive reports of abuse, neglect, or domestic violence. For example, we may report your information to government officials if we reasonably believe you have been a victim of abuse, neglect, or domestic violence. We will make efforts to obtain your permission before releasing this information, but in some cases, we may be required or authorized to act without your permission.

Health Oversight Activities. We may release your health information to government agencies authorized to conduct audits, investigations, and inspections of our facilities. These government agencies monitor the operation of the health care system, government benefit programs such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws.

Product Monitoring, Repair, and Recall. We may disclose your health information to a person or company regulated by the Food and Drug Administration for the purpose of: (1) reporting or tracking product defects or problems; (2) repairing, replacing, or recalling defective or dangerous products; or (3) monitoring the performance of a product after it has been approved for use by the general public.

Lawsuits and Disputes. We may disclose your health information if we are ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute.

Law Enforcement, & Judicial and Administrative Proceedings. We may disclose your health information to law enforcement officials for the following reasons:

• To comply with court orders or laws we are required to follow;
• To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person;
• If you have been the victim of a crime and we determine: (1) we have been unable to obtain your agreement because of an emergency or your incapacity; (2) law enforcement officials need this information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these officers is in your best interests;
• If we suspect your death resulted from criminal conduct;
• If necessary to report a crime that occurred on our property; or
• If necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical personnel at the scene of a crime).

To Avert a Serious and Imminent Threat to Health or Safety. We may use your health information or share it with others when necessary to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public. In such cases, we will share your information only with someone able to help prevent the threat. We may also disclose your health information to law enforcement officers if you tell us that you participated in a violent crime that may have caused serious physical harm to another person (unless you admitted that fact while in counseling), or if we determine you escaped from lawful custody (such as a prison or mental health institution).

National Security and Intelligence Activities or Protective Services. We may disclose your health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials.

Military and Veterans. If you are in the Armed Forces, we may disclose health information about you to appropriate military command authorities for activities they deem necessary to carry out their military mission. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Inmates and Correctional Institutions. If you are an inmate or you are detained by a law enforcement officer, we may disclose your health information to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security, and good order at the place where you are confined. This includes sharing information that is necessary to protect the health and safety of other inmates or persons involved in supervising or transporting inmates.

Workers’ Compensation. We may disclose your health information for workers’ compensation or similar programs that provide benefits for work-related injuries.

Coroners, Medical Examiners, and Funeral Directors. In the unfortunate event of your death, we may disclose your health information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release your health information to funeral directors as necessary to carry out their duties.
 
Organ and Tissue Donation. In the unfortunate event of your death, we may disclose your health information to organizations that procure or store organs, eyes, or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws.

Research. In most cases, we will ask for your written authorization before using your health information or sharing it with others to conduct research. However, under some circumstances, we may use and disclose your health information without your written authorization if we obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. We may also disclose your health information without your written authorization to people who are preparing a future research project, or to allow researchers to determine if you might be eligible for a particular research study provided that such a disclosure is made solely within our secure records, databases, electronic systems or facilities. In the unfortunate event of your death, we may share your health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facilities any information that identifies you.
We may allow researchers to use specimens or tissues removed from your body during a diagnostic procedure, survey, or medical treatment that would otherwise be discarded. Those specimens or tissues may be used together with your health information to conduct medical research in the same manner as other health information.

4.    Completely De-identified or Partially De-identified Information

We and our business associates may use and disclose your health information if we or our business associates have removed any information that has the potential to identify you so that the health information is “completely de-identified.” Such de-identified information is no longer subject to the terms of this Notice. We and our business associates may also use and disclose “partially de-identified” health information, known as a “limited data set,” about you for research, public health, or health care operations purposes if the person who will receive the limited data set signs an agreement to protect the privacy of the information, as required by federal and state law. Limited data sets will not contain any information that would directly identify you (such as your name, street address, SSN, phone number, fax number, electronic mail address, website address, or license number).

5.    Incidental Disclosures

While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during, or as an unavoidable result of, our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION REQUIRING AUTHORIZATION

As stated above, we cannot and will not use or disclose your health information without your written authorization for any reason except those described in this Notice. For example, we require your written authorization for most uses or disclosures of your health information for certain marketing purposes, for the sale of health information, or with respect to psychotherapy notes.

If you provide us with written authorization, you may revoke, or cancel, that written authorization at any time, except to the extent that we have already relied upon it. If you revoke the authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization. Your revocation will not affect any uses or disclosures we have already made prior to the date we receive notice of the revocation. To revoke a written authorization, please write to HSS Health Information Management at 535 East 70th Street, New York, NY 10021 or to ROIrequest@hss.edu.

Special Protections for Certain Types of Health Information. Special privacy protections apply to AIDS and HIV-related information, substance use disorder treatment information, mental health information, and genetic information. For example, New York law prohibits the disclosure of confidential AIDS and HIV-related information, unless authorized by law or pursuant to a properly executed release form. If your treatment involves any of these types of information, you may be provided with special authorization forms in connection with the disclosure of such information by HSS ASC. To request copies of these forms, please contact HSS Health Information Management at (212) 606-1254.

YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION

We want you to know that you have the following rights to access and control your health information. These rights are important because they will help you make sure that the health information we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you about your medical matters. Unless otherwise specified, to exercise your rights below, please submit your request in writing to HSS Health Information Management, 535 East 70th Street, New York, NY 10021 or to ROIrequest@hss.edu.

1.    Right to Inspect and Copy Records

You have the right to inspect and obtain a copy, including an electronic copy, from us in a timely manner of any of your health information that may be used to make decisions about you and your treatment, for as long as we maintain this information in our records. This includes medical and billing records. You can also access your health information directly using the MyHSS patient portal, available at https://myhss.hss.edu/myhss or through the Apple App Store or Google Play.

• A request to inspect or obtain a copy of your health information must include: (1) the desired form or format of access; (2) a description of the health information to which the request applies; and (3) appropriate contact information.
• If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies we use to fulfill your request, which must generally be paid before or at the time we give the copies to you.
• If the information you request is stored electronically, we will provide the information in the form and format you request if the information is readily producible in that format, or, if not, we will reach an agreement with you as to alternative readable electronic format.
• We will respond to your request for inspection of records within 10 days. We ordinarily will respond to requests for copies within 30 days. If we need additional time to respond to a request for copies, we will notify you in writing within the time frame above to explain the reason for the delay and when you can expect to have a final answer to your request.
• Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If we do, we may provide you with a summary of the information instead. We will also provide a written notice that explains our reasons for providing only a summary, and a complete description of your rights to have that decision reviewed and how you can exercise those rights. The notice will also include information on how to file a complaint about these issues with us or with the Secretary of the Department of Health and Human Services. If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we will not let you inspect or copy.

2.    Right to Transfer Records

You have a right to initiate a transfer of your records to another person or organization by completing a written authorization form. Your request must include the person(s) authorized to use and/or receive the information, and a description of the information that will be used or disclosed. Ordinarily, we respond to your request within 30 days. To request or revoke a written authorization, please write to HSS Health Information Management at 535 East 70th Street, New York, NY 10021 or ROIrequest@hss.edu.

3.    Right to Amend Records

If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept in our records. Your request must include a description of the amendment requested and should include the reasons why you think we should make the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request.

Your request for an amendment may be denied if you request an amendment of health information that we determine: (1) was not created by HSS ASC, unless the originator of the health information is no longer available to make the amendment; (2) is not part of HSS ASC’s records; (3) is not health information you would be permitted to inspect or copy; or (4) is accurate and complete. If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement, which we will include in your records. We will also provide you with information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.

4.    Right to an Accounting of Disclosures

You have a right to request an accounting of certain disclosures of your health information we have made in the previous six years, such as for research, public health, health oversight and other specific purposes that are not for treatment, payment or health care operations.

An accounting of disclosures does not describe the ways that your health information has been shared within HSS ASC, as long as all other protections described in this Notice have been followed. An accounting of disclosures also does not include information about the following disclosures: disclosures we made to you or your personal representative; disclosures we made pursuant to your written authorization; disclosures we made for treatment, payment or health care operations; disclosures made from the patient directory; disclosures made to your friends and family involved in your care or payment for your care; disclosures that were incidental to permissible uses and disclosures of your health information (for example, when information is overheard by another patient passing by); disclosures for purposes of research, public health or our health care operations of limited portions of your health information that do not directly identify you; disclosures made to federal officials for national security and intelligence activities; and disclosures about inmates to correctional institutions or law enforcement officers.

Your request must state a time period within the past six years for the disclosures you want us to include. For example, you may request a list of the disclosures that we made between January 1 of a given year to December 31 of that same year, so long as the dates are within the past six years. You have a right to receive one free accounting within every 12-month period. However, we may charge you for the cost of providing any additional accounting in that same 12-month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred. The scope of your right to request an accounting may be modified from time to time to comply with changes in federal law or state law.

Ordinarily we will respond to your request for an accounting within 60 days. If we need additional time to prepare the accounting you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting. In rare cases, we may have to delay providing you with the accounting without notifying you because a law enforcement official or government agency has asked us to do so.

5.    Right to Request Additional Privacy Protections, Including Restriction on Disclosures to Health Plans

You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, or run our health care operations. You may also request that we limit how we disclose information about you to family or friends involved in your care. For example, you could request that we not disclose information about a surgery you had. In addition, you have the right to restrict certain disclosures of your health information to a health plan when you pay, or another person on your behalf pays, out-of- pocket in full for the health care item or service. Your request should include: (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.

We are not always required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. We do not need to agree to the restriction unless: (1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and (2) the health information relates only to a health care item or service that you or someone on your behalf has paid for out-of-pocket and in full. However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.

6.    Right to Request Confidential Communications

You have the right to request that we communicate with you about your medical matters in a more confidential way by requesting that we communicate with you by alternative means or at alternative locations. For example, you may ask that we contact you at home instead of at work. Your request should specify how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests.

7.    Right to Notice of Breach of Unsecured Health Information

We are required by law to maintain the privacy of your health information, to provide you with this Notice containing our legal duties and privacy practices with respect to your health information, and to abide by the terms of this Notice. It is our policy to safeguard your health information so as to protect the information from those who should not have access to it. If, however, for some reason we experience a breach of your unsecured health information, we will notify you of the breach.

8.    Right to Obtain a Copy of This Notice

You have the right to a paper copy of this Notice. You may request a paper copy at any time, even if you have previously agreed to receive this Notice electronically. To do so, please call HSS ASC’s Privacy Officer at (212) 548-2510 or send a letter to HSS ASC of Manhattan, Attn. Privacy Officer, 1233 Second Avenue, New York, NY, 10065. You may also obtain a copy of this Notice from our website at www.hss.edu/asc or by requesting a copy at your next visit.

9.    Right to Have Someone Act on Your Behalf

You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control the privacy of health information about minors, unless the minors are permitted by law to act on their own behalf. To name a personal representative, please contact your treating provider’s office.

CHANGES TO THIS NOTICE

We may change our privacy practices from time to time. If we do, we will revise this Notice so you will have an accurate summary of our practices, and the revised Notice will apply to all of your health information. We will post any revised Notice in our admitting areas and other locations in HSS ASC. You may obtain your own copy of the revised Notice by calling HSS ASC’s Privacy Officer at (212) 548-2510 or sending a letter to HSS ASC of Manhattan, Attn. Privacy Officer, 1233 Second Avenue, New York, NY, 10065. You may also obtain a copy of this Notice from our website at www.hss.edu/asc or by requesting a copy at your next visit. The effective date of the Notice will always be noted in the cover page. We are required to abide by the terms of the Notice that is currently in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact HSS ASC’s Privacy Officer at (212) 548-2510 or send a letter to HSS ASC of Manhattan, Attn. Privacy Officer, 1233 Second Avenue, New York, NY, 10065. To file a complaint with the Department of Health and Human Services you may send a letter to the Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201, or call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. No one will retaliate or take action against you for filing a complaint.

As a patient in an ambulatory surgery center in New York State, you have the right, consistent with law, to:

1. Receive services without regard to age, race, color, sexual orientation, religion, marital status, sex, disability, sexual orientation, gender identity or expression, national origin or sponsor.
2. Be treated with consideration, respect and dignity including privacy in treatment.
3. Be informed of the services available at the center.
4. Be informed of the provisions of off-hour emergency coverage.
5. Be informed of the charges for services, eligibility for third-party reimbursements and, when applicable, the availability of free or reduced care costs.
6. Receive an itemized copy of his or her account statement, upon request.
7. Obtain from his or her health care practitioner, or the health care practitioner’s delegate, complete and current information concerning his or her diagnosis, treatment and prognosis in terms the patient can be reasonably expected to understand.
8. Receive from his or her physician information necessary to give informed consent prior to the start of any nonemergency procedure or treatment or both. An informed consent shall include, as a minimum, the provision of information concerning the specific procedure or treatment or both, the reasonably foreseeable risks involved, and alternatives for care or treatment, if any, as a reasonable medical practitioner under similar circumstances would disclose in a manner permitting the patient to make a knowledgeable decision.
9. Refuse treatment to the extent permitted by law and to be fully informed of the medical consequences of his or her action.
10. Refuse to participate in experimental research.
11. Voice grievances and recommend changes in policies and services to the center’s staff, the operator and the New York State Department of Health without fear of reprisal.
12. Express complaints about the care and services provided and to have the center investigate such complaints. The center is responsible for providing the patient or his/her designee with a written response within 30 days if requested by the patient indicating the findings of the investigation. The center is also responsible for notifying the patient or his or her designee that if the patient is not satisfied by the center response, the patient may complain to the New York State Department of Health’s Office of Health Systems Management.
13. Privacy and confidentiality of all information and records pertaining to the patient’s treatment.
14. Approve or refuse the release or disclosure of the contents of his or her medical record to any healthcare practitioner and/or healthcare facility except as required by law or third-party payment contract.
15. Access his or her medical record pursuant to the provision of section 18 of the Public Health Law, and Subpart 50-3 of Title 10 of the Compilation of Codes, Rules and Regulations of the State of New York. For additional information link to: http://www.health.ny.gov/publications/1449/section_1.htm#access.
16. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors.
17. When applicable, make known your wishes in regard to anatomical gifts. Persons sixteen years of age or older may document their consent to donate their organs, eyes and/or tissues, upon their death, by enrolling in the NYS Donate Life Registry or by documenting their authorization for organ and/or tissue donation in writing in a number of ways (such as health care proxy, will, donor card, or other signed paper). The health care proxy is available from the center.
18. View a list of the health plans and the hospitals that the center participates with.
19. Receive an estimate of the amount that you will be billed after services are rendered.

Contact Information for Questions or Concerns

Should you have questions about any of these rights, or wish to express a recommendation or concern, you may contact one or more of the following:

• To report a complaint or grievance, you can contact the Clinical Nursing Director by mail: HSS West Side ASC, 610 West 58th Street, New York, NY 10019, phone 1.646.495.3300, or e-mail WASCleadership@hss.edu.
• You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services: 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 or by phone 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
• Joint Commission at 800.994.6610, or by letter sent to Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181, or e-mail to complaint@jointcommission.org.
• Centers for Medicare and Medicaid Services: Toll-free: 877.267.2323 TTY Toll-free: 866-226-1819. Medicare Only: Toll-free: 800-MEDICARE (800-633-4227); TTY Toll-free: 877-486-2048. 7500 Security Boulevard, Baltimore, MD 21244.
• New York State Department of Health by phone at: 800.804.5447 or letter sent to NYS Department of Health, Centralized Hospital Intake Program, Mailstop: CA/DCS, Empire State Plaza, Albany, NY 12237.

The Statement of Patient’s Responsibilities, designed as a companion to the Patient’s Bill of Rights, encourages patients to participate in their own health care and treatment. Hospital for Special Surgery believes that a mutual understanding of the Patient’s Bill of Rights and Responsibilities will result in more effective delivery of health care services.

The Statement of Patient Responsibilities reads as follows:

To the extent possible, Hospital for Special Surgery requests that you, as our patient:

1. Provide accurate and complete information about your past illnesses, hospitalizations, medications and other matters relating to your health, and answer any questions concerning these matters.
2. Participate in your health care planning by talking openly and honestly about your concerns with your physician and other health care professionals.
3. Understand your health problems, treatment course and care decisions to your own satisfaction and ask questions if you do not understand.
4. Cooperate with your physician and other health care professionals in carrying out your health care plan both as an inpatient and after discharge.
5. Participate and cooperate with our health care professionals in creating a discharge plan that meets your medical and social needs.
6. Inform the hospital or any of its professionals of the existence of any advanced directive (proxy, DNR, living will) you have created.
7. Take responsibility for the consequences and outcomes if you do not follow the care, service or treatment plan.
8. Provide accurate information related to insurance or other sources of payment. You are responsible for ensuring payment of your bills and you may be responsible for charges not covered by your insurance.
9. Treat other patients, visitors and staff with respect and consideration. Support mutual consideration and respect by maintaining civil language and conduct in interactions with staff and providers.
10. Support our commitment to a diverse and inclusive environment in which racist and/or discriminatory behaviors and acts of intolerance towards others are not tolerated.
11. Follow instructions, policies, rules, and regulations in place to support quality care for patients and a safe environment for all individuals in the hospital.
12. Be considerate of your fellow patients, respecting their need for privacy and a quiet environment.

The HSS West Side ASC is committed to providing high quality care and skilled and compassionate service to our community. Consistent with this commitment, the HSS West Side ASC complies with applicable federal, state, and local civil rights laws and does not discriminate on the basis of actual or perceived race, color, creed, ethnicity, religion, national origin, alienage or citizenship status, culture, language, age, disability, socioeconomic status, sex, sexual orientation, gender identity or expression, partnership or marital status, veteran or military status, or any other prohibited basis.

The HSS West Side ASC:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters; and
  • Written information in other formats, such as large print, audio, and accessible electronic formats.
• Provides free language assistance services to people whose primary language is not English, such as:
  • Qualified interpreters.
  • Information written in other languages.
  • Auxiliary aids to patients who are deaf and blind.

If you need these services, contact the Language Services Department languageservices@hss.edu, Tel.: 1-212-606-1760.

If you believe that the HSS West Side ASC has failed to provide these services or discriminated in another way, you can file a grievance with:
Augastin Kozhimala, Senior Director
HSS West Side ASC
610 West 58th Street, New York, NY 10019
Tel: 1.212.774.7026
Email: kozhimalaa@hss.edu

You can file a grievance in person or by mail, or email. If you need help filing a grievance, you may contact the office of Augastin Kozhimala for assistance.

You also have the right to file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1.800.368.1019, 800.537.7697 (TDD). Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html

ATENCIÓN: Si usted habla español, le avisamos que tenemos servicios lingüísticos gratuitos a su disposición. Llame al: 1-212-606-1760, TTY: 1-800-676-3777.

注意：如果您講中文，可向您提供免費語言服務。致電 1-212-606-1760，TTY: 1-800-676-3777。

Внимание: Если Вы говорите по русски, примите к сведению, что Вы можете воспользоваться бесплатными услугами переводчика. Звоните по номеру: 1-212-606-1760, TTY: 1-800-676-3777.

ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis asistans nan lang ki disponib pou ou gratis. Rele nan 1-212-606-1760, TTY: 1-800-676-3777.

알려드립니다: 귀하께서 한국어를 하시는 경우, 무료로 언어 도움 서비스를 이용하실 수 있습니다. 1-212-606-1760 (TTY: 1-800-676-3777) 번으로 전화하십시오.

ATTENZIONE: se parli italiano sono disponibili servizi di assistenza linguistica gratuiti. Chiama il numero 1-212-606-1760, TTY: 1-800-676-3777.

אכטונג׃ אױב איר רעדט אידיש, זענען פאר אײך דא צו באקומען שפראך הילף סערװיסעס פרײ פון אפצאל. רופט 1-212-606-1760, TTY: 1-800-676-3777.

দৃষ্টি আকর্ষণ: যদি আপনি বাংলায় কথা বলেন, তাহলে আপনি বিনামূল্যে ভাষাগত সহায়তা পরিষেবা পেতে পারেন৷ ফোন করুন: 1-212-606-1760, TTY:  1-800-676-3777

UWAGA: Jeżeli mówi Pan/Pani po polsku, dostępne są dla Państwa bezpłatne usługi pomocy językowej. Proszę zadzwonić pod numer 1-212-606-1760, TTY:  1-800-676-3777.

ملاحظة: إذا كنت تتحدث اللغة العربية، فإننا نوفر لك خدمات مساعدة لغوية بالمجان. اتصل على
1-212-606-1760، هاتف نصي (TTY): 1-800-676-3777.

VEUILLEZ NOTER: Si vous parlez français, des services d’assistance linguistique gratuits, sont à votre disposition. Appelez le 1-212-606-1760, TTY: 1-800-676-3777.

توجہ فرمائیں: اگر آپ کی زبان اردو ہے تو آپ کے لیے زبان میں معاونت فراہم کرنے والی سروسز (لینگوئج اسسٹنس سروسز) بلامعاوضہ دستیاب ہیں کال کریں 1-212-606-1760 TTY: 1-800-676-3777۔

PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuha kang mga libreng serbisyo ng tulong sa wika. Tumawag sa 1-212-606-1760, TTY: 1-800-676-3777.

ΠΡΟΣΟΧΗ: Εάν μιλάτε ελληνικά, διατίθενται δωρεάν υπηρεσίες γλωσσικής βοήθειας για εσάς. Καλέστε το 1-212-606-1760. TTY: 1-800-676-3777.

VINI RE: Nëse flisni shqip, keni në dispozicion shërbime ndihme për gjuhën pa pagesë. Telefononi 1-212-606-1760, TTY: 1-800-676-3777

Effective Date: July 12, 2017
Revision Date: October 30, 2025

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

HSS West Side ASC (“HSS ASC”) values respect for our patients’ privacy. Not only is it what our patients expect, it is the right way to conduct health care. As required by law, we will protect the privacy of health information that may reveal your identity, and we will provide you a copy of this Notice, which describes the health information privacy practices of HSS ASC, its medical staff and affiliated health care providers when providing health care services for HSS ASC. If you have any questions about this Notice or would like further information, please contact HSS ASC’s Privacy Officer at (646) 495-3300.

WHO WILL FOLLOW THE PRACTICES IN THIS NOTICE?

HSS West Side ASC (“HSS ASC”) provides health care to our patients together with physicians and other health care professionals and organizations. The privacy practices described in this Notice will be followed by:

• Health care professionals who provide direct services to treat you at HSS ASC;
  All employees, medical staff, trainees, students, and volunteers at HSS ASC who provide direct services to you; and
• HSS ASC’s business associates and their subcontractors.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

For information about how we use and disclose information collected through the MyHSS patient portal, please refer to our MyHSS Privacy Policy and MyHSS Terms of Use. If there is a conflict between this Notice and the MyHSS Privacy Policy or MyHSS Terms of Use, this Notice will apply to the extent that Protected Health Information (as defined by the Department of Health and Human Services) is involved.

We will generally obtain your written authorization before using your health information or sharing it with others outside of HSS ASC. There are some situations, described below, when we do not need your written authorization before using your health information or sharing it with others. If your health information is disclosed to a recipient pursuant to any of the applicable purposes described in this Notice, it is possible that such health information may be subject to further redisclosure by the recipient and no longer protected by the requirements of this Notice.

1.    Treatment, Payment, and Health Care Operations

We may use your health information or share it with others to treat you, obtain payment for that treatment, and run our health care operations. In some cases, we may also disclose your health information for payment activities and certain health care operations of another health care provider or payor.

Treatment. We may share your health information with doctors, nurses and other health care providers who are involved in taking care of you, and they may in turn use that information to diagnose or treat you. Your doctor may also share your health information with another doctor or provider to whom you have been referred for further health care.

Payment. We may use your health information or share it with others so that we may obtain payment for your health care services. For example, we may share information about you with your health insurance company to obtain reimbursement after we have treated you, or to determine whether it will cover your treatment. We might also need to inform your health insurance company about your health condition to obtain pre-approval for your treatment, such as a particular type of surgery. Finally, we may share your information with other health care providers and payors for their payment activities.

Health Care Operations. We may use your health information or share it with others to conduct our health care operations. For example, we may use your health information to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care they provide. In addition, we may share your health information with other health care providers and payors for certain health care operations if the information is related to a relationship the provider or payor currently has or previously had with you, and if the provider or payor is required by federal law to protect the privacy of your health information.
 
Recording and Transcription of Clinical Encounters. To help our health care providers document and manage your care, we may use voice recording technology that records and transcribes conversations between you and your HSS health care provider during your visit. This technology allows your provider to focus more on you and less on note taking, helping ensure you receive the highest quality care. Your recorded protected health information may only be used in accordance with this notice.

Health Information Exchanges. We may participate in health information exchanges, enabling us to share your health information electronically with other health care providers in the course of providing care for you, as permitted by state and federal law. If you are interested in opting out or changing your health information exchange choice, please contact HSS Health Information Management at (212) 606-1254.

Appointment Reminders, Treatment Alternatives, or Distribution of Health-Related Benefits and Services. In the course of providing treatment to you, we may use your health information to contact you with a reminder that you have an appointment for treatment or services. We may also use your health information to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you. However, to the extent a third party provides financial remuneration to us so that we make these treatment-related or health care operations-related communications to you, we will secure your authorization in advance as we would with any other marketing communication (as described later in this Notice).

Fundraising. Fundraising is a communication from HSS ASC or one of its business associates, or by HSS ASC’s affiliated support organization, The Hospital for Special Surgery Fund, Inc. (the Fund), for the purpose of raising funds to further our missions of patient care, research, and education, including appeals for money or sponsorship of events. We may use certain information about you for fundraising, including demographic information (such as your age, date of birth, and gender, and where you live or work), your insurance status, the dates when you received services from us, and information about where you received services, the identity of your treating doctor(s), and the outcome of your treatment. You have the right to opt-out of future fundraising communications and can do so by following the opt-out instructions provided as part of the fundraising communication.

Business Associates. We may disclose your health information to contractors, agents and other business associates who need the information to assist us with obtaining payment or carrying out our health care operations. For example, we may share your health information with a billing company that helps us to obtain payment from your insurance company. Another example is that we may share your health information with an accounting firm or law firm that provides professional advice to us about how to improve our health care services and comply with the law. If we do disclose your health information to a business associate, we will have a written contract that requires our business associate to protect the privacy of your health information. We may also allow for our business associates to de-identify your health information to be used for the benefit of HSS ASC or the benefit of the business associate, or to create, use and disclose limited data sets as described below in the section titled “Completely De-identified or Partially De-identified Information.”

2.    Patient Directory and Family and Friends Involved in Your Care

We may use your health information in, and disclose it from, our patient directory, or share it with family and friends involved in your care, without your written authorization. You will have an opportunity to object to these uses and disclosures of your health information, unless there is insufficient time because of a medical emergency (in which case we will discuss your preferences with you as soon as the emergency is over). We will follow your wishes, unless we are required by law to do otherwise.

Patient Directory. We generate and maintain a daily list of patients currently admitted. If you do not object, we will include your name and your location in this list. This information may be released to people who ask for you by name (e.g., family members accompanying you to your surgical appointment). If you would prefer that we not include your information, you may contact HSS ASC’s Privacy Officer at (646) 495-3300.

Family and Friends Involved in Your Care. If you do not object, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for that care. We may also notify a family member, personal representative, or another person responsible for your care about your location and general condition. In some cases, we may need to share your information with a disaster relief organization that will help us notify these persons.

3.    Emergencies or Public Need

We may use your health information, and share it with others, to treat you in an emergency or to meet important public needs. We will not be required to obtain your written authorization or to provide you with an opportunity to object before we use or disclose your health information for these reasons. We will, however, obtain your written authorization for, or provide you with an opportunity to object to, the use and disclosure of your health information in these situations when state law specifically requires that we do so.

Emergencies. We may use or disclose your health information if you need emergency treatment or if we are required by law to treat you.

As Required by Law. We may use or disclose your health information if we are required by law to do so. In certain situations, we may notify you of disclosures we make that were required by law.

Public Health Activities. We may disclose your health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities. For example, we may share your health information with government officials that are responsible for controlling disease, injury, or disability. We may also disclose your health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if the law requires or permits us to do so. Further, we may release some health information about you to your employer if your employer hires us to provide you with a physical exam and we discover you have a work-related injury or disease that your employer must know about to comply with employment laws.

Victims of Abuse, Neglect, or Domestic Violence. We may release your health information to a public health authority that is authorized to receive reports of abuse, neglect, or domestic violence. For example, we may report your information to government officials if we reasonably believe you have been a victim of abuse, neglect, or domestic violence. We will make efforts to obtain your permission before releasing this information, but in some cases, we may be required or authorized to act without your permission.

Health Oversight Activities. We may release your health information to government agencies authorized to conduct audits, investigations, and inspections of our facilities. These government agencies monitor the operation of the health care system, government benefit programs such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws.

Product Monitoring, Repair, and Recall. We may disclose your health information to a person or company regulated by the Food and Drug Administration for the purpose of: (1) reporting or tracking product defects or problems; (2) repairing, replacing, or recalling defective or dangerous products; or (3) monitoring the performance of a product after it has been approved for use by the general public.

Lawsuits and Disputes. We may disclose your health information if we are ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute.

Law Enforcement, & Judicial and Administrative Proceedings. We may disclose your health information to law enforcement officials for the following reasons:

• To comply with court orders or laws we are required to follow;
• To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person;
• If you have been the victim of a crime and we determine: (1) we have been unable to obtain your agreement because of an emergency or your incapacity; (2) law enforcement officials need this information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these officers is in your best interests;
• If we suspect your death resulted from criminal conduct;
• If necessary to report a crime that occurred on our property; or
• If necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical personnel at the scene of a crime).

To Avert a Serious and Imminent Threat to Health or Safety. We may use your health information or share it with others when necessary to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public. In such cases, we will share your information only with someone able to help prevent the threat. We may also disclose your health information to law enforcement officers if you tell us that you participated in a violent crime that may have caused serious physical harm to another person (unless you admitted that fact while in counseling), or if we determine you escaped from lawful custody (such as a prison or mental health institution).

National Security and Intelligence Activities or Protective Services. We may disclose your health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials.

Military and Veterans. If you are in the Armed Forces, we may disclose health information about you to appropriate military command authorities for activities they deem necessary to carry out their military mission. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Inmates and Correctional Institutions. If you are an inmate or you are detained by a law enforcement officer, we may disclose your health information to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security, and good order at the place where you are confined. This includes sharing information that is necessary to protect the health and safety of other inmates or persons involved in supervising or transporting inmates.

Workers’ Compensation. We may disclose your health information for workers’ compensation or similar programs that provide benefits for work-related injuries.

Coroners, Medical Examiners, and Funeral Directors. In the unfortunate event of your death, we may disclose your health information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release your health information to funeral directors as necessary to carry out their duties.
 
Organ and Tissue Donation. In the unfortunate event of your death, we may disclose your health information to organizations that procure or store organs, eyes, or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws.

Research. In most cases, we will ask for your written authorization before using your health information or sharing it with others to conduct research. However, under some circumstances, we may use and disclose your health information without your written authorization if we obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. We may also disclose your health information without your written authorization to people who are preparing a future research project, or to allow researchers to determine if you might be eligible for a particular research study provided that such a disclosure is made solely within our secure records, databases, electronic systems or facilities. In the unfortunate event of your death, we may share your health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facilities any information that identifies you.
We may allow researchers to use specimens or tissues removed from your body during a diagnostic procedure, survey, or medical treatment that would otherwise be discarded. Those specimens or tissues may be used together with your health information to conduct medical research in the same manner as other health information.

4.    Completely De-identified or Partially De-identified Information

We and our business associates may use and disclose your health information if we or our business associates have removed any information that has the potential to identify you so that the health information is “completely de-identified.” Such de-identified information is no longer subject to the terms of this Notice. We and our business associates may also use and disclose “partially de-identified” health information, known as a “limited data set,” about you for research, public health, or health care operations purposes if the person who will receive the limited data set signs an agreement to protect the privacy of the information, as required by federal and state law. Limited data sets will not contain any information that would directly identify you (such as your name, street address, SSN, phone number, fax number, electronic mail address, website address, or license number).

5.    Incidental Disclosures

While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during, or as an unavoidable result of, our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION REQUIRING AUTHORIZATION

As stated above, we cannot and will not use or disclose your health information without your written authorization for any reason except those described in this Notice. For example, we require your written authorization for most uses or disclosures of your health information for certain marketing purposes, for the sale of health information, or with respect to psychotherapy notes.

If you provide us with written authorization, you may revoke, or cancel, that written authorization at any time, except to the extent that we have already relied upon it. If you revoke the authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization. Your revocation will not affect any uses or disclosures we have already made prior to the date we receive notice of the revocation. To revoke a written authorization, please write to HSS Health Information Management at 535 East 70th Street, New York, NY 10021 or to ROIrequest@hss.edu.

Special Protections for Certain Types of Health Information. Special privacy protections apply to AIDS and HIV-related information, substance use disorder treatment information, mental health information, and genetic information. For example, New York law prohibits the disclosure of confidential AIDS and HIV-related information, unless authorized by law or pursuant to a properly executed release form. If your treatment involves any of these types of information, you may be provided with special authorization forms in connection with the disclosure of such information by the facility. To request copies of these forms, please contact HSS Health Information Management at (212) 606-1254.

YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION

We want you to know that you have the following rights to access and control your health information. These rights are important because they will help you make sure that the health information we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you about your medical matters. Unless otherwise specified, to exercise your rights below, please submit your request in writing to HSS Health Information Management, 535 East 70th Street, New York, NY 10021 or to ROIrequest@hss.edu.

1.    Right to Inspect and Copy Records

You have the right to inspect and obtain a copy, including an electronic copy, from us in a timely manner of any of your health information that may be used to make decisions about you and your treatment, for as long as we maintain this information in our records. This includes medical and billing records. You can also access your health information directly using the MyHSS patient portal, available at https://myhss.hss.edu/myhss or through the Apple App Store or Google Play.

• A request to inspect or obtain a copy of your health information must include: (1) the desired form or format of access; (2) a description of the health information to which the request applies; and (3) appropriate contact information.
• If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies we use to fulfill your request, which must generally be paid before or at the time we give the copies to you.
• If the information you request is stored electronically, we will provide the information in the form and format you request if the information is readily producible in that format, or, if not, we will reach an agreement with you as to alternative readable electronic format.
• We will respond to your request for inspection of records within 10 days. We ordinarily will respond to requests for copies within 30 days. If we need additional time to respond to a request for copies, we will notify you in writing within the time frame above to explain the reason for the delay and when you can expect to have a final answer to your request.
• Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If we do, we may provide you with a summary of the information instead. We will also provide a written notice that explains our reasons for providing only a summary, and a complete description of your rights to have that decision reviewed and how you can exercise those rights. The notice will also include information on how to file a complaint about these issues with us or with the Secretary of the Department of Health and Human Services. If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we will not let you inspect or copy.

2.    Right to Transfer Records

You have a right to initiate a transfer of your records to another person or organization by completing a written authorization form. Your request must include the person(s) authorized to use and/or receive the information, and a description of the information that will be used or disclosed. Ordinarily, we respond to your request within 30 days. To request or revoke a written authorization, please write to HSS Health Information Management at 535 East 70th Street, New York, NY 10021 or ROIrequest@hss.edu.

3.    Right to Amend Records

If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept in our records. Your request must include a description of the amendment requested and should include the reasons why you think we should make the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request.

Your request for an amendment may be denied if you request an amendment of health information that we determine: (1) was not created by the facility, unless the originator of the health information is no longer available to make the amendment; (2) is not part of the facility’s records; (3) is not health information you would be permitted to inspect or copy; or (4) is accurate and complete. If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement, which we will include in your records. We will also provide you with information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.

4.    Right to an Accounting of Disclosures

You have a right to request an accounting of certain disclosures of your health information we have made in the previous six years, such as for research, public health, health oversight and other specific purposes that are not for treatment, payment or health care operations.

An accounting of disclosures does not describe the ways that your health information has been shared within HSS ASC, as long as all other protections described in this Notice have been followed. An accounting of disclosures also does not include information about the following disclosures: disclosures we made to you or your personal representative; disclosures we made pursuant to your written authorization; disclosures we made for treatment, payment or health care operations; disclosures made from the patient directory; disclosures made to your friends and family involved in your care or payment for your care; disclosures that were incidental to permissible uses and disclosures of your health information (for example, when information is overheard by another patient passing by); disclosures for purposes of research, public health or our health care operations of limited portions of your health information that do not directly identify you; disclosures made to federal officials for national security and intelligence activities; and disclosures about inmates to correctional institutions or law enforcement officers.

Your request must state a time period within the past six years for the disclosures you want us to include. For example, you may request a list of the disclosures that we made between January 1 of a given year to December 31 of that same year, so long as the dates are within the past six years. You have a right to receive one free accounting within every 12-month period. However, we may charge you for the cost of providing any additional accounting in that same 12-month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred. The scope of your right to request an accounting may be modified from time to time to comply with changes in federal law or state law.

Ordinarily we will respond to your request for an accounting within 60 days. If we need additional time to prepare the accounting you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting. In rare cases, we may have to delay providing you with the accounting without notifying you because a law enforcement official or government agency has asked us to do so.

5.    Right to Request Additional Privacy Protections, Including Restriction on Disclosures to Health Plans

You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, or run our health care operations. You may also request that we limit how we disclose information about you to family or friends involved in your care. For example, you could request that we not disclose information about a surgery you had. In addition, you have the right to restrict certain disclosures of your health information to a health plan when you pay, or another person on your behalf pays, out-of- pocket in full for the health care item or service. Your request should include: (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.

We are not always required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. We do not need to agree to the restriction unless: (1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and (2) the health information relates only to a health care item or service that you or someone on your behalf has paid for out-of-pocket and in full. However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.

6.    Right to Request Confidential Communications

You have the right to request that we communicate with you about your medical matters in a more confidential way by requesting that we communicate with you by alternative means or at alternative locations. For example, you may ask that we contact you at home instead of at work. Your request should specify how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests.

7.    Right to Notice of Breach of Unsecured Health Information

We are required by law to maintain the privacy of your health information, to provide you with this Notice containing our legal duties and privacy practices with respect to your health information, and to abide by the terms of this Notice. It is our policy to safeguard your health information so as to protect the information from those who should not have access to it. If, however, for some reason we experience a breach of your unsecured health information, we will notify you of the breach.

8.    Right to Obtain a Copy of This Notice

You have the right to a paper copy of this Notice. You may request a paper copy at any time, even if you have previously agreed to receive this Notice electronically. To do so, please call HSS ASC’s Privacy Officer at (646) 495-3300 or send a letter to HSS West Side ASC, Attn. Privacy Officer, 610 West 58th Street, New York, NY 10019. You may also obtain a copy of this Notice from our website at https://www.hss.edu/locations/ny/west-side-asc or by requesting a copy at your next visit.

9.    Right to Have Someone Act on Your Behalf

You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control the privacy of health information about minors, unless the minors are permitted by law to act on their own behalf. To name a personal representative, please contact your treating provider’s office.

CHANGES TO THIS NOTICE

We may change our privacy practices from time to time. If we do, we will revise this Notice so you will have an accurate summary of our practices, and the revised Notice will apply to all of your health information. We will post any revised Notice in our admitting areas and other locations in HSS ASC. You may obtain your own copy of the revised Notice by calling HSS ASC’s Privacy Officer at (646) 495-3300, or sending a letter to HSS West Side ASC, Attn. Privacy Officer, 610 West 58th Street, New York, NY 10019. You may also obtain a copy of this Notice from our website at https://www.hss.edu/locations/ny/west-side-asc or by requesting a copy at your next visit. The effective date of the Notice will always be noted in the cover page. We are required to abide by the terms of the Notice that is currently in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact HSS West Side ASC’s Privacy Officer at (646) 495-3300, or send a letter HSS West Side ASC, Attn. Privacy Officer, 610 West 58th Street, New York, NY 10019. To file a complaint with the Department of Health and Human Services you may send a letter to the Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201, or call 1-877-696-6775, or visit https://www.hhs.gov/ocr/privacy/hipaa/complaints/. No one will retaliate or take action against you for filing a complaint.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service. 

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most they can bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance, and deductibles). You cannot be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

For emergency services, New Jersey law provides the same protections as federal law.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.

You are never required to give up your protections from balance billing. You also are not required to get out-of-network care. You can choose a provider or facility in your plan’s network.

New Jersey law provides similar protections as federal law.

When balance billing is not allowed, you also have these protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you have been wrongly billed, you may contact the following agencies to file a complaint:

New Jersey Department of Banking and Insurance at the Office of Managed Care 1.888.393.1062.  Visit New Jersey Department of Banking and Insurance Out-of-network Consumer Protections for more information about your rights under New Jersey law.

The federal phone number for information and complaints is: 1.800.985.3059. Visit Centers for Medicare & Medicaid Services Medical bill of rights for more information about your rights under federal law.

If you are concerned that you may not be able to pay for your care, we may be able to help.

Hospital for Special Surgery provides financial aid for medically necessary services based on a patient's financial need and includes a sliding scale discount for patients who qualify. Aid may be available for patients who do not have insurance and for those who are underinsured. We may be able to work with you to arrange a manageable payment plan.

Our financial assistance policy applies to services provided by the Hospital, and some services provided by certain HSS physicians and other clinical staff.

On these pages, you can access the full policy, an application and additional information. including a full list of providers who participate in the Hospital's financial assistance policy.

• Financial Assistance – HSS Main Campus (New York)
• Financial Assistance – HSS Northern NJ Surgery Center

The policies and procedures that guide Hospital for Special Surgery’s interaction with and care of patients demonstrate its recognition and support of patients’ rights.

In the State of New Jersey, each patient receiving services in an ambulatory care facility shall have the following rights:

1. To be informed of these rights, as evidenced by the patient’s written acknowledgment, or by documentation by staff in the medical record, that the patient was offered a written copy of these rights and given a written or verbal explanation of these rights, in terms the patient could understand. The facility shall have a means to notify patients of any rules and regulations it has adopted governing patient conduct in the facility.
2. To be informed of services available in the facility, of the names and professional status of the personnel providing and/or responsible for the patient’s care, and of fees and related charges, including the payment, fee, deposit, and refund policy of the facility and any charges for services not covered by sources of third-party payment or not covered by the facility’s basic rate.
3. To be informed if the facility has authorized other health care and educational institutions to participate in the patient’s treatment. The patient also shall have a right to know the identity and function of these institutions, and to refuse to allow their participation in the patient’s treatment;
4. To receive from the patient’s physician(s) or clinical practitioner(s), in terms that the patient understands, an explanation of his or her complete medical/health condition or diagnosis, recommended treatment, treatment options, including the option of no treatment, risk(s) of treatment, and expected result(s). If this information would be detrimental to the patient’s health, or if the patient is not capable of understanding the information, the explanation shall be provided to the patient’s next of kin or guardian. This release of information to the next of kin or guardian, along with the reason for not informing the patient directly, shall be documented in the patient’s medical record.
5. To participate in the planning of the patient’s care and treatment, and to refuse medication and treatment. Such refusal shall be documented in the patient’s medical record.
6. To be included in experimental research only when the patient gives informed, written consent to such participation, or when a guardian gives such consent for an incompetent patient in accordance with law, rule and regulation. The patient may refuse to participate in experimental research, including the investigation of new drugs and medical devices.
7. To voice grievances or recommend changes in policies and services to facility personnel, the governing authority, and/or outside representatives of the patient’s choice either individually or as a group, and free from restraint, interference, coercion, discrimination, or reprisal.
8. To be free from mental and physical abuse, free from exploitation, and free from use of restraints unless they are authorized by a physician for a limited period of time to protect the patient or others from injury. Drugs and other medications shall not be used for discipline of patients or for convenience of facility personnel.
9. To confidential treatment of information about the patient. Information in the patient’s medical record shall not be released to anyone outside the facility without the patient’s approval, unless another health care facility to which the patient was transferred requires the information, or unless the release of the information is required and permitted by law, a third-party payment contract, or a peer review, or unless the information is needed by the New Jersey State Department of Health for statutorily authorized purposes. The facility may release data about the patient for studies containing aggregated statistics when the patient’s identity is masked.
10. To be treated with courtesy, consideration, respect, and recognition of the patient’s dignity, individuality, and right to privacy, including, but not limited to, auditory and visual privacy. The patient’s privacy shall also be respected when facility personnel are discussing the patient.
11. To not be required to perform work for the facility unless the work is part of the patient’s treatment and is performed voluntarily by the patient. Such work shall be in accordance with local, State, and Federal laws and rules.
12. To exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, or any attendance at religious services, shall be imposed upon any patient.
13. To not be discriminated against because of age, citizenship status, color, disability or handicap, gender, gender identity or expression, sexual orientation, marital status, national origin, nationality, race, religion, veteran status or ability to pay/source of payment for care; to not be deprived of any constitutional, civil, and/or legal rights solely because of receiving services from the facility.
14. To expect and receive appropriate assessment, management and treatment of pain as an integral component of that person’s care in accordance with N.J.A.C. 8:43E-6.

Contact Information for Questions or Concerns

Should you have questions about any of these rights, or wish to express a recommendation or concern, you may contact one or more of the following:

• HSS Office of the Patient Experience for New York 212.774.2403, for Connecticut, New Jersey and Florida Toll-Free 855-477-4344 or e-mail at patientexperience@hss.edu.
• HSS Chief Executive Officer at 212.606.1236, or by letter sent to Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021.
• You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services: 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 or by phone 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
• Joint Commission at 800.994.6610, or by letter sent to Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181, or e-mail to complaint@jointcommission.org.
• Centers for Medicare and Medicaid Services: Toll-free: 877.267.2323 TTY Toll-free: 866-226-1819. Medicare Only: Toll-free: 800-MEDICARE (800-633-4227); TTY Toll-free: 877-486-2048. 7500 Security Boulevard, Baltimore, MD 21244.
• New York State Department of Health by phone at: 800.804.5447 or letter sent to NYS Department of Health, Centralized Hospital Intake Program, Mailstop: CA/DCS, Empire State Plaza, Albany, NY 12237.
• New Jersey State Department of Health by phone at: 800.367.6543 or letter PO Box 360 Trenton, NJ 08625-0360, website: http://www.state.nj.us/health/.

The Statement of Patient’s Responsibilities, designed as a companion to the Patient’s Bill of Rights, encourages patients to participate in their own health care and treatment. Hospital for Special Surgery believes that a mutual understanding of the Patient’s Bill of Rights and Responsibilities will result in more effective delivery of health care services.

The Statement of Patient Responsibilities reads as follows:

To the extent possible, Hospital for Special Surgery requests that you, as our patient:

• Provide accurate and complete information about your past illnesses, hospitalizations, medications and other matters relating to your health, and  answer any questions concerning these matters.
• Participate in your health care planning by talking openly and honestly about your concerns with your physician and other health care professionals.
• Understand your health problems, treatment course and care decisions to your own satisfaction and ask questions if you do not understand.
• Cooperate with your physician and other health care professionals in carrying out your health care plan both as an inpatient and after discharge.
• Participate and cooperate with our health care professionals in creating a discharge plan that meets your medical and social needs.
• Inform the hospital or any of its professionals of the existence of any advanced directive (proxy, DNR, living will) you  have created.
• Take responsibility for the consequences and outcomes if you do not follow the care, service or treatment plan.
• Provide accurate information related to insurance or other sources of payment. You are responsible for ensuring payment of your bills and you may be responsible for charges not covered by your insurance. 
• Treat other patients, visitors and staff with respect and consideration. Support mutual consideration and respect by maintaining civil language and conduct in interactions with staff and providers.
• Support our commitment to a diverse and inclusive environment in which racist and/or discriminatory behaviors and acts of intolerance towards others are not tolerated. 
• Follow instructions, policies, rules, and regulations in place to support quality care for patients and a safe environment for all individuals in the hospital.
• Be considerate of your fellow patients, respecting their need for privacy and a quiet environment.

Hospital for Special Surgery is committed to providing high quality care and skilled and compassionate service to our community. Consistent with this commitment, Hospital for Special Surgery complies with applicable federal, state, and local civil rights laws and does not discriminate on the basis of actual or perceived race, color, creed, ethnicity, religion, national origin, alienage or citizenship status, culture, language, age, disability, socioeconomic status, sex, sexual orientation, gender identity or expression, partnership or marital status, veteran or military status, or any other prohibited basis.

Hospital for Special Surgery:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters; and
  • Written information in other formats, such as large print, audio, and accessible electronic formats.
• Provides free language services to people whose primary language is not English, such as:
  • Provides free language assistance services to people whose primary language is not English, such as:
    • Qualified interpreters.
    • Information written in other languages.
    • Auxiliary aids to patients who are deaf and blind.

If you need these services, contact the Language Services Department languageservices@hss.edu, Tel.: 1-212-606-1760.

If you believe that Hospital for Special Surgery has failed to provide these services or discriminated in another way, you can file a grievance with Section 1557 Coordinator at Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, TTY: 1-800-676-3777 or 1- 855-477-4344, patientexperience@hss.edu. 

You also have the right to file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD). Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html.

ATENCIÓN: Si usted habla español, le avisamos que tenemos servicios lingüísticos gratuitos a su disposición. Llame al: 1-212-606-1760, TTY: 1-800-676-3777.

注意：如果您講中文，可向您提供免費語言服務。致電 1-212-606-1760，TTY: 1-800-676-3777。

Внимание: Если Вы говорите по русски, примите к сведению, что Вы можете воспользоваться бесплатными услугами переводчика. Звоните по номеру: 1-212-606-1760, TTY: 1-800-676-3777.

ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis asistans nan lang ki disponib pou ou gratis. Rele nan 1-212-606-1760, TTY: 1-800-676-3777.

알려드립니다: 귀하께서 한국어를 하시는 경우, 무료로 언어 도움 서비스를 이용하실 수 있습니다. 1-212-606-1760 (TTY: 1-800-676-3777) 번으로 전화하십시오.

ATTENZIONE: se parli italiano sono disponibili servizi di assistenza linguistica gratuiti. Chiama il numero 1-212-606-1760, TTY: 1-800-676-3777.

אכטונג׃ אױב איר רעדט אידיש, זענען פאר אײך דא צו באקומען שפראך הילף סערװיסעס פרײ פון אפצאל. רופט 1-212-606-1760, TTY: 1-800-676-3777.

দৃষ্টি আকর্ষণ: যদি আপনি বাংলায় কথা বলেন, তাহলে আপনি বিনামূল্যে ভাষাগত সহায়তা পরিষেবা পেতে পারেন৷ ফোন করুন: 1-212-606-1760, TTY:  1-800-676-3777

UWAGA: Jeżeli mówi Pan/Pani po polsku, dostępne są dla Państwa bezpłatne usługi pomocy językowej. Proszę zadzwonić pod numer 1-212-606-1760, TTY:  1-800-676-3777.

ملاحظة: إذا كنت تتحدث اللغة العربية، فإننا نوفر لك خدمات مساعدة لغوية بالمجان. اتصل على
1-212-606-1760، هاتف نصي (TTY): 1-800-676-3777.

VEUILLEZ NOTER: Si vous parlez français, des services d’assistance linguistique gratuits, sont à votre disposition. Appelez le 1-212-606-1760, TTY: 1-800-676-3777.

توجہ فرمائیں: اگر آپ کی زبان اردو ہے تو آپ کے لیے زبان میں معاونت فراہم کرنے والی سروسز (لینگوئج اسسٹنس سروسز) بلامعاوضہ دستیاب ہیں کال کریں 1-212-606-1760 TTY: 1-800-676-3777۔

PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuha kang mga libreng serbisyo ng tulong sa wika. Tumawag sa 1-212-606-1760, TTY: 1-800-676-3777.

ΠΡΟΣΟΧΗ: Εάν μιλάτε ελληνικά, διατίθενται δωρεάν υπηρεσίες γλωσσικής βοήθειας για εσάς. Καλέστε το 1-212-606-1760. TTY: 1-800-676-3777.

VINI RE: Nëse flisni shqip, keni në dispozicion shërbime ndihme për gjuhën pa pagesë. Telefononi 1-212-606-1760, TTY: 1-800-676-3777.

The policies and procedures that guide Hospital for Special Surgery’s interaction with and care of patients demonstrate its recognition and support of patients’ rights.

In the State of New Jersey, each patient receiving services in an ambulatory care facility shall have the following rights:

1. To be informed of these rights, as evidenced by the patient’s written acknowledgment, or by documentation by staff in the medical record, that the patient was offered a written copy of these rights and given a written or verbal explanation of these rights, in terms the patient could understand. The facility shall have a means to notify patients of any rules and regulations it has adopted governing patient conduct in the facility.
2. To be informed of services available in the facility, of the names and professional status of the personnel providing and/or responsible for the patient’s care, and of fees and related charges, including the payment, fee, deposit, and refund policy of the facility and any charges for services not covered by sources of third-party payment or not covered by the facility’s basic rate.
3. To be informed if the facility has authorized other health care and educational institutions to participate in the patient’s treatment. The patient also shall have a right to know the identity and function of these institutions, and to refuse to allow their participation in the patient’s treatment.
4. To receive from the patient’s physician(s) or clinical practitioner(s), in terms that the patient understands, an explanation of his or her complete medical/health condition or diagnosis, recommended treatment, treatment options, including the option of no treatment, risk(s) of treatment, and expected result(s). If this information would be detrimental to the patient’s health, or if the patient is not capable of understanding the information, the explanation shall be provided to the patient’s next of kin or guardian. This release of information to the next of kin or guardian, along with the reason for not informing the patient directly, shall be documented in the patient’s medical record.
5. To participate in the planning of the patient’s care and treatment, and to refuse medication and treatment. Such refusal shall be documented in the patient’s medical record.
6. To be included in experimental research only when the patient gives informed, written consent to such participation, or when a guardian gives such consent for an incompetent patient in accordance with law, rule and regulation. The patient may refuse to participate in experimental research, including the investigation of new drugs and medical devices.
7. To voice grievances or recommend changes in policies and services to facility personnel, the governing authority, and/or outside representatives of the patient’s choice either individually or as a group, and free from restraint, interference, coercion, discrimination, or reprisal.
8. To be free from mental and physical abuse, free from exploitation, and free from use of restraints unless they are authorized by a physician for a limited period of time to protect the patient or others from injury. Drugs and other medications shall not be used for discipline of patients or for convenience of facility personnel.
9. To confidential treatment of information about the patient. Information in the patient’s medical record shall not be released to anyone outside the facility without the patient’s approval, unless another health care facility to which the patient was transferred requires the information, or unless the release of the information is required and permitted by law, a third-party payment contract, or a peer review, or unless the information is needed by the New Jersey State Department of Health for statutorily authorized purposes. The facility may release data about the patient for studies containing aggregated statistics when the patient’s identity is masked.
10. To be treated with courtesy, consideration, respect, and recognition of the patient’s dignity, individuality, and right to privacy, including, but not limited to, auditory and visual privacy. The patient’s privacy shall also be respected when facility personnel are discussing the patient.
11. To not be required to perform work for the facility unless the work is part of the patient’s treatment and is performed voluntarily by the patient. Such work shall be in accordance with local, State, and Federal laws and rules.
12. To exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, or any attendance at religious services, shall be imposed upon any patient.
13. To not be discriminated against because of age, citizenship status, color, disability or handicap, gender, gender identity or expression, sexual orientation, marital status, national origin, nationality, race, religion, veteran status or ability to pay/source of payment for care; to not be deprived of any constitutional, civil, and/or legal rights solely because of receiving services from the facility.
14. To expect and receive appropriate assessment, management and treatment of pain as an integral component of that person’s care in accordance with N.J.A.C. 8:43E-6.

Contact Information for Questions or Concerns

Should you have questions about any of these rights, or wish to express a recommendation or concern, you may contact one or more of the following:

• To report a complaint or grievance, you can contact the office of Geoffrey Canlas, Clinical Nursing Director by mail HSS Northern NJ ASC, 400 Franklin Turnpike, Suite 200, Mahwah, NJ 07430, phone 1.201.267.9799, or e-mail canlasg@hss.edu.
• You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services: 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 or by phone 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 
• Joint Commission at 800.994.6610, or by letter sent to Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181, or e-mail to complaint@jointcommission.org.
• Centers for Medicare and Medicaid Services: Toll-free: 877.267.2323 TTY Toll-free: 866-226-1819. Medicare Only: Toll-free: 800-MEDICARE (800-633-4227); TTY Toll-free: 877-486-2048. 7500 Security Boulevard, Baltimore, MD 21244.
• New York State Department of Health by phone at: 800.804.5447 or letter sent to NYS Department of Health, Centralized Hospital Intake Program, Mailstop: CA/DCS, Empire State Plaza, Albany, NY 12237.
• New Jersey State Department of Health by phone at: 800.367.6543 or letter PO Box 360 Trenton, NJ 08625-0360, website: http://www.state.nj.us/health/.

The Statement of Patient’s Responsibilities, designed as a companion to the Patient’s Bill of Rights, encourages patients to participate in their own health care and treatment. Hospital for Special Surgery believes that a mutual understanding of the Patient’s Bill of Rights and Responsibilities will result in more effective delivery of health care services.

The Statement of Patient Responsibilities reads as follows:

To the extent possible, Hospital for Special Surgery requests that you, as our patient: 

• Provide accurate and complete information about your past illnesses, hospitalizations, medications and other matters relating to your health, and  answer any questions concerning these matters.
• Participate in your health care planning by talking openly and honestly about your concerns with your physician and other health care professionals.
• Understand your health problems, treatment course and care decisions to your own satisfaction and ask questions if you do not understand.
• Cooperate with your physician and other health care professionals in carrying out your health care plan both as an inpatient and after discharge.
• Participate and cooperate with our health care professionals in creating a discharge plan that meets your medical and social needs.
• Inform the hospital or any of its professionals of the existence of any advanced directive (proxy, DNR, living will) you  have created.
• Take responsibility for the consequences and outcomes if you do not follow the care, service or treatment plan.
• Provide accurate information related to insurance or other sources of payment. You are responsible for ensuring payment of your bills and you may be responsible for charges not covered by your insurance. 
• Treat other patients, visitors and staff with respect and consideration. Support mutual consideration and respect by maintaining civil language and conduct in interactions with staff and providers.
• Support our commitment to a diverse and inclusive environment in which racist and/or discriminatory behaviors and acts of intolerance towards others are not tolerated. 
• Follow instructions, policies, rules, and regulations in place to support quality care for patients and a safe environment for all individuals in the hospital.

Be considerate of your fellow patients, respecting their need for privacy and a quiet environment.

The HSS Northern NJ ASC is committed to providing high quality care and skilled and compassionate service to our community. Consistent with this commitment, the HSS Northern NJ ASC complies with applicable federal, state, and local civil rights laws and does not discriminate on the basis of actual or perceived race, color, creed, ethnicity, religion, national origin, alienage or citizenship status, culture, language, age, disability, socioeconomic status, sex, sexual orientation, gender identity or expression, partnership or marital status, veteran or military status, or any other prohibited basis.

The HSS Northern NJ ASC:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters; and
  • Written information in other formats, such as large print, audio, and accessible electronic formats.
• Provides free language assistance services to people whose primary language is not English, such as:
  • Qualified interpreters.
  • Information written in other languages.
  • Auxiliary aids to patients who are deaf and blind.

If you need these services, contact the Language Services Department languageservices@hss.edu, Tel.: 1-212-606-1760.

If you believe that the HSS Northern NJ ASC has failed to provide these services or discriminated in another way, you can file a grievance with:

Geoffrey Canlas, Clinical Nursing Director
HSS Northern NJ ASC
400 Franklin Turnpike, Suite 200, Mahwah, NJ 07430
Tel: 1.201.267.9799
Email: canlasg@hss.edu 

You can file a grievance in person or by mail, or email. If you need help filing a grievance, you may contact the office of Geoffrey Canlas for assistance. 

You also have the right to file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1.800.368.1019, 800.537.7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htm

ATENCIÓN: Si usted habla español, le avisamos que tenemos servicios lingüísticos gratuitos a su disposición. Llame al: 1-212-606-1760, TTY: 1-800-676-3777.

注意：如果您講中文，可向您提供免費語言服務。致電 1-212-606-1760，TTY: 1-800-676-3777。

Внимание: Если Вы говорите по русски, примите к сведению, что Вы можете воспользоваться бесплатными услугами переводчика. Звоните по номеру: 1-212-606-1760, TTY: 1-800-676-3777.

ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis asistans nan lang ki disponib pou ou gratis. Rele nan 1-212-606-1760, TTY: 1-800-676-3777.

알려드립니다: 귀하께서 한국어를 하시는 경우, 무료로 언어 도움 서비스를 이용하실 수 있습니다. 1-212-606-1760 (TTY: 1-800-676-3777) 번으로 전화하십시오.

ATTENZIONE: se parli italiano sono disponibili servizi di assistenza linguistica gratuiti. Chiama il numero 1-212-606-1760, TTY: 1-800-676-3777.

אכטונג׃ אױב איר רעדט אידיש, זענען פאר אײך דא צו באקומען שפראך הילף סערװיסעס פרײ פון אפצאל. רופט 1-212-606-1760, TTY: 1-800-676-3777.

দৃষ্টি আকর্ষণ: যদি আপনি বাংলায় কথা বলেন, তাহলে আপনি বিনামূল্যে ভাষাগত সহায়তা পরিষেবা পেতে পারেন৷ ফোন করুন: 1-212-606-1760, TTY:  1-800-676-3777

UWAGA: Jeżeli mówi Pan/Pani po polsku, dostępne są dla Państwa bezpłatne usługi pomocy językowej. Proszę zadzwonić pod numer 1-212-606-1760, TTY:  1-800-676-3777.

ملاحظة: إذا كنت تتحدث اللغة العربية، فإننا نوفر لك خدمات مساعدة لغوية بالمجان. اتصل على
1-212-606-1760، هاتف نصي (TTY): 1-800-676-3777.

VEUILLEZ NOTER: Si vous parlez français, des services d’assistance linguistique gratuits, sont à votre disposition. Appelez le 1-212-606-1760, TTY: 1-800-676-3777.

توجہ فرمائیں: اگر آپ کی زبان اردو ہے تو آپ کے لیے زبان میں معاونت فراہم کرنے والی سروسز (لینگوئج اسسٹنس سروسز) بلامعاوضہ دستیاب ہیں کال کریں 1-212-606-1760 TTY: 1-800-676-3777۔

PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuha kang mga libreng serbisyo ng tulong sa wika. Tumawag sa 1-212-606-1760, TTY: 1-800-676-3777.

ΠΡΟΣΟΧΗ: Εάν μιλάτε ελληνικά, διατίθενται δωρεάν υπηρεσίες γλωσσικής βοήθειας για εσάς. Καλέστε το 1-212-606-1760. TTY: 1-800-676-3777.

VINI RE: Nëse flisni shqip, keni në dispozicion shërbime ndihme për gjuhën pa pagesë. Telefononi 1-212-606-1760, TTY: 1-800-676-3777

Effective Date: March 26, 2025
Revision Date: October 30, 2025

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Mahwah ASC, LLC values respect for our patients’ privacy. Not only is it what our patients expect, it is the right way to conduct health care. As required by law, we will protect the privacy of health information that may reveal your identity, and we will provide you a copy of this Notice, which describes the health information privacy practices of our ambulatory surgery center facility and its medical staff and affiliated health care providers when providing health care services for Mahwah ASC. If you have any questions about this Notice or would like further information, please contact our Privacy Officer at (201) 267-7000 or MahwahASCleadership@hss.edu.

WHO WILL FOLLOW THE PRACTICES IN THIS NOTICE?

We provide health care to our patients together with physicians and other health care professionals and organizations. The privacy practices described in this Notice will be followed by:

• Health care professionals who provide direct services to treat you at Mahwah ASC;
• Employees, medical staff, trainees, students, and volunteers at Mahwah ASC who provide direct services to you; and
• Mahwah ASC’s business associates and their subcontractors.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

For information about how we use and disclose information collected through the MyHSS patient portal, please refer to our MyHSS Privacy Policy and MyHSS Terms of Use. If there is a conflict between this Notice and the MyHSS Privacy Policy or MyHSS Terms of Use, this Notice will apply to the extent that Protected Health Information (as defined by the Department of Health and Human Services) is involved.

We will generally obtain your written authorization before using your health information or sharing it with others outside of Mahwah ASC. There are some situations, described below, when we do not need your written authorization before using your health information or sharing it with others. If your health information is disclosed to a recipient pursuant to any of the applicable purposes described in this Notice, it is possible that such health information may be subject to further redisclosure by the recipient and no longer protected by the requirements of this Notice.

1.    Treatment, Payment, and Health Care Operations

We may use your health information or share it with others to treat you, obtain payment for that treatment, and run our health care operations. In some cases, we may also disclose your health information for payment activities and certain health care operations of another health care provider or payor.

Treatment. We may share your health information with doctors, nurses and other health care providers who are involved in taking care of you, and they may in turn use that information to diagnose or treat you. Your doctor may also share your health information with another doctor or provider to whom you have been referred for further health care.

Payment. We may use your health information or share it with others so that we may obtain payment for your health care services. For example, we may share information about you with your health insurance company to obtain reimbursement after we have treated you, or to determine whether it will cover your treatment. We might also need to inform your health insurance company about your health condition to obtain pre-approval for your treatment, such as a particular type of surgery. Finally, we may share your information with other health care providers and payors for their payment activities.

Health Care Operations. We may use your health information or share it with others to conduct our health care operations. For example, we may use your health information to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care they provide. In addition, we may share your health information with other health care providers and payors for certain of their health care operations if the information is related to a relationship the provider or payor currently has or previously had with you, and if the provider or payor is required by federal law to protect the privacy of your health information.
 
Recording and Transcription of Clinical Encounters. To help our health care providers document and manage your care, we may use voice recording technology that records and transcribes conversations between you and your HSS Mahwah health care provider during your visit. This technology allows your provider to focus more on you and less on note taking, helping ensure you receive the highest quality care. Your recorded protected health information may only be used in accordance with this notice.

Health Information Exchanges. We may participate in health information exchanges, enabling us to share your health information electronically with other health care providers in the course of providing care for you, as permitted by state and federal law. If you are interested in opting out or changing your health information exchange choice, please contact us at (201) 267-7000 or MahwahASCleadership@hss.edu.

Appointment Reminders, Treatment Alternatives, or Distribution of Health-Related Benefits and Services. In the course of providing treatment to you, we may use your health information to contact you with a reminder that you have an appointment for treatment or services. We may also use your health information to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you. However, to the extent a third party provides financial remuneration to us so that we make these treatment-related or health care operations-related communications to you, we will secure your authorization in advance as we would with any other marketing communication (as described later in this Notice).

Fundraising. Fundraising is a communication from HSS Mahwah or one of its business associates, or by HSS Mahwah’s affiliated support organization, The Hospital for Special Surgery Fund, Inc. (the Fund), for the purpose of raising funds to further our missions of patient care, research, and education, including appeals for money or sponsorship of events. We may use certain information about you for fundraising, including demographic information (such as your age, date of birth, and gender, and where you live or work), your insurance status, the dates when you received services from us, and information about where you received services, the identity of your treating doctor(s), and the outcome of your treatment. You have the right to opt-out of future fundraising communications and can do so by following the opt-out instructions provided as part of the fundraising communication.

Business Associates. We may disclose your health information to contractors, agents and other business associates who need the information to assist us with obtaining payment or carrying out our health care operations. For example, we may share your health information with a billing company that helps us to obtain payment from your insurance company. Another example is that we may share your health information with an accounting firm or law firm that provides professional advice to us about how to improve our health care services and comply with the law. If we do disclose your health information to a business associate, we will have a written contract that requires our business associate to protect the privacy of your health information. We may also allow for our business associates to de-identify your health information to be used for the benefit of HSS Mahwah or the benefit of the business associate, or to create, use and disclose limited data sets as described below in the section titled “Completely De-identified or Partially De-identified Information.”

2.    Patient Directory and Family and Friends Involved in Your Care

We may use your health information in, and disclose it from, our patient directory, or share it with family and friends involved in your care, without your written authorization. You will have an opportunity to object to these uses and disclosures of your health information, unless there is insufficient time because of a medical emergency (in which case we will discuss your preferences with you as soon as the emergency is over). We will follow your wishes, unless we are required by law to do otherwise.

Patient Directory. We generate and maintain a daily list of patients currently admitted. If you do not object, we will include your name and your location in this list. This information may be released to people who ask for you by name (e.g., family members accompanying you to your surgical appointment). If you would prefer that we not include your information, you may contact us at (201) 267-7000 or MahwahASCleadership@hss.edu.

Family and Friends Involved in Your Care. If you do not object, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for that care. We may also notify a family member, personal representative, or another person responsible for your care about your location and general condition. In some cases, we may need to share your information with a disaster relief organization that will help us notify these persons.

3.    Emergencies or Public Need

We may use your health information, and share it with others, to treat you in an emergency or to meet important public needs. We will not be required to obtain your written authorization or to provide you with an opportunity to object before we use or disclose your health information for these reasons. We will, however, obtain your written authorization for, or provide you with an opportunity to object to, the use and disclosure of your health information in these situations when state law specifically requires that we do so.

Emergencies. We may use or disclose your health information if you need emergency treatment or if we are required by law to treat you.

As Required by Law. We may use or disclose your health information if we are required by law to do so. In certain situations, we may notify you of disclosures we make that were required by law.

Public Health Activities. We may disclose your health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities. For example, we may share your health information with government officials that are responsible for controlling disease, injury, or disability. We may also disclose your health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if the law requires or permits us to do so. Further, we may release some health information about you to your employer if your employer hires us to provide you with a physical exam and we discover you have a work-related injury or disease that your employer must know about to comply with employment laws.

Victims of Abuse, Neglect, or Domestic Violence. We may release your health information to a public health authority that is authorized to receive reports of abuse, neglect, or domestic violence. For example, we may report your information to government officials if we reasonably believe you have been a victim of abuse, neglect, or domestic violence. We will make efforts to obtain your permission before releasing this information, but in some cases, we may be required or authorized to act without your permission.

Health Oversight Activities. We may release your health information to government agencies authorized to conduct audits, investigations, and inspections of our facilities. These government agencies monitor the operation of the health care system, government benefit programs such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws.

Product Monitoring, Repair, and Recall. We may disclose your health information to a person or company regulated by the Food and Drug Administration for the purpose of: (1) reporting or tracking product defects or problems; (2) repairing, replacing, or recalling defective or dangerous products; or (3) monitoring the performance of a product after it has been approved for use by the general public.

Lawsuits and Disputes. We may disclose your health information if we are ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute.

Law Enforcement, & Judicial and Administrative Proceedings. We may disclose your health information to law enforcement officials for the following reasons:

• To comply with court orders or laws we are required to follow;
• To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person;
• If you have been the victim of a crime and we determine: (1) we have been unable to obtain your agreement because of an emergency or your incapacity; (2) law enforcement officials need this information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these officers is in your best interests;
• If we suspect your death resulted from criminal conduct;
• If necessary to report a crime that occurred on our property; or
• If necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical personnel at the scene of a crime).

To Avert a Serious and Imminent Threat to Health or Safety. We may use your health information or share it with others when necessary to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public. In such cases, we will share your information only with someone able to help prevent the threat. We may also disclose your health information to law enforcement officers if you tell us that you participated in a violent crime that may have caused serious physical harm to another person (unless you admitted that fact while in counseling), or if we determine you escaped from lawful custody (such as a prison or mental health institution).

National Security and Intelligence Activities or Protective Services. We may disclose your health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials.

Military and Veterans. If you are in the Armed Forces, we may disclose health information about you to appropriate military command authorities for activities they deem necessary to carry out their military mission. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Inmates and Correctional Institutions. If you are an inmate or you are detained by a law enforcement officer, we may disclose your health information to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security, and good order at the place where you are confined. This includes sharing information that is necessary to protect the health and safety of other inmates or persons involved in supervising or transporting inmates.

Workers’ Compensation. We may disclose your health information for workers’ compensation or similar programs that provide benefits for work-related injuries.

Coroners, Medical Examiners, and Funeral Directors. In the unfortunate event of your death, we may disclose your health information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release your health information to funeral directors as necessary to carry out their duties.
 
Organ and Tissue Donation. In the unfortunate event of your death, we may disclose your health information to organizations that procure or store organs, eyes, or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws.

Research. In most cases, we will ask for your written authorization before using your health information or sharing it with others to conduct research. However, under some circumstances, we may use and disclose your health information without your written authorization if we obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. We may also disclose your health information without your written authorization to people who are preparing a future research project, or to allow researchers to determine if you might be eligible for a particular research study provided that such a disclosure is made solely within our secure records, databases, electronic systems or facilities. In the unfortunate event of your death, we may share your health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facilities any information that identifies you.
We may allow researchers to use specimens or tissues removed from your body during a diagnostic procedure, survey, or medical treatment that would otherwise be discarded. Those specimens or tissues may be used together with your health information to conduct medical research in the same manner as other health information.

4.    Completely De-identified or Partially De-identified Information

We and our business associates may use and disclose your health information if we or our business associates have removed any information that has the potential to identify you so that the health information is “completely de-identified.” Such de-identified information is no longer subject to the terms of this Notice. We and our business associates may also use and disclose “partially de-identified” health information, known as a “limited data set,” about you for research, public health, or health care operations purposes if the person who will receive the limited data set signs an agreement to protect the privacy of the information, as required by federal and state law. Limited data sets will not contain any information that would directly identify you (such as your name, street address, SSN, phone number, fax number, electronic mail address, website address, or license number).

5.    Incidental Disclosures

While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during, or as an unavoidable result of, our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION REQUIRING AUTHORIZATION

As stated above, we cannot and will not use or disclose your health information without your written authorization for any reason except those described in this Notice. For example, we require your written authorization for most uses or disclosures of your health information for certain marketing purposes, for the sale of health information, or with respect to psychotherapy notes.

If you provide us with written authorization, you may revoke, or cancel, that written authorization at any time, except to the extent that we have already relied upon it. If you revoke the authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization. Your revocation will not affect any uses or disclosures we have already made prior to the date we receive notice of the revocation. To revoke a written authorization, please write to HSS Health Information Management at 535 East 70th Street, New York, NY 10021 or to ROIrequest@hss.edu.

Special Protections for Certain Types of Health Information. Special privacy protections apply to AIDS and HIV-related information, substance use disorder treatment information, mental health information, and genetic information. For example, New Jersey law prohibits the disclosure of confidential AIDS and HIV-related information, unless authorized by law or pursuant to a properly executed release form. If your treatment involves any of these types of information, you may be provided with special authorization forms in connection with the disclosure of such information by HSS Mahwah. To request copies of these forms, please contact HSS Health Information Management at (212) 606-1254.

YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION

We want you to know that you have the following rights to access and control your health information. These rights are important because they will help you make sure that the health information we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you about your medical matters. Unless otherwise specified, to exercise your rights below, please submit your request in writing to HSS Health Information Management, 535 East 70th Street, New York, NY 10021 or to ROIrequest@hss.edu.

1.    Right to Inspect and Copy Records

You have the right to inspect and obtain a copy, including an electronic copy, from us in a timely manner of any of your health information that may be used to make decisions about you and your treatment, for as long as we maintain this information in our records. This includes medical and billing records. You can also access your health information directly using the MyHSS patient portal, available at https://myhss.hss.edu/myhss or through the Apple App Store or Google Play.

• A request to inspect or obtain a copy of your health information must include: (1) the desired form or format of access; (2) a description of the health information to which the request applies; and (3) appropriate contact information.
• If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies we use to fulfill your request, which must generally be paid before or at the time we give the copies to you.
• If the information you request is stored electronically, we will provide the information in the form and format you request if the information is readily producible in that format, or, if not, we will reach an agreement with you as to alternative readable electronic format.
• We will respond to your request for inspection of records within 10 days. We ordinarily will respond to requests for copies within 30 days. If we need additional time to respond to a request for copies, we will notify you in writing within the time frame above to explain the reason for the delay and when you can expect to have a final answer to your request.
• Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If we do, we may provide you with a summary of the information instead. We will also provide a written notice that explains our reasons for providing only a summary, and a complete description of your rights to have that decision reviewed and how you can exercise those rights. The notice will also include information on how to file a complaint about these issues with us or with the Secretary of the Department of Health and Human Services. If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we will not let you inspect or copy.

2.    Right to Transfer Records

You have a right to initiate a transfer of your records to another person or organization by completing a written authorization form. Your request must include the person(s) authorized to use and/or receive the information, and a description of the information that will be used or disclosed. Ordinarily, we respond to your request within 30 days. To request or revoke a written authorization, please write to HSS Health Information Management at 535 East 70th Street, New York, NY 10021 or ROIrequest@hss.edu.

3.    Right to Amend Records

If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept in our records. Your request must include a description of the amendment requested and should include the reasons why you think we should make the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request.

Your request for an amendment may be denied if you request an amendment of health information that we determine: (1) was not created by HSS Mahwah, unless the originator of the health information is no longer available to make the amendment; (2) is not part of HSS Mahwah’s records; (3) is not health information you would be permitted to inspect or copy; or (4) is accurate and complete. If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement, which we will include in your records. We will also provide you with information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.

4.    Right to an Accounting of Disclosures

You have a right to request an accounting of certain disclosures of your health information we have made in the previous six years, such as for research, public health, health oversight and other specific purposes that are not for treatment, payment or health care operations.

An accounting of disclosures does not describe the ways that your health information has been shared within HSS Mahwah, as long as all other protections described in this Notice have been followed. An accounting of disclosures also does not include information about the following disclosures: disclosures we made to you or your personal representative; disclosures we made pursuant to your written authorization; disclosures we made for treatment, payment or health care operations; disclosures made from the patient directory; disclosures made to your friends and family involved in your care or payment for your care; disclosures that were incidental to permissible uses and disclosures of your health information (for example, when information is overheard by another patient passing by); disclosures for purposes of research, public health or our health care operations of limited portions of your health information that do not directly identify you; disclosures made to federal officials for national security and intelligence activities; and disclosures about inmates to correctional institutions or law enforcement officers.

Your request must state a time period within the past six years for the disclosures you want us to include. For example, you may request a list of the disclosures that we made between January 1 of a given year to December 31 of that same year, so long as the dates are within the past six years. You have a right to receive one free accounting within every 12-month period. However, we may charge you for the cost of providing any additional accounting in that same 12-month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred. The scope of your right to request an accounting may be modified from time to time to comply with changes in federal law or state law.

Ordinarily we will respond to your request for an accounting within 60 days. If we need additional time to prepare the accounting you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting. In rare cases, we may have to delay providing you with the accounting without notifying you because a law enforcement official or government agency has asked us to do so.

5.    Right to Request Additional Privacy Protections, Including Restriction on Disclosures to Health Plans

You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, or run our health care operations. You may also request that we limit how we disclose information about you to family or friends involved in your care. For example, you could request that we not disclose information about a surgery you had. In addition, you have the right to restrict certain disclosures of your health information to a health plan when you pay, or another person on your behalf pays, out-of- pocket in full for the health care item or service. Your request should include: (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.

We are not always required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. We do not need to agree to the restriction unless: (1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and (2) the health information relates only to a health care item or service that you or someone on your behalf has paid for out-of-pocket and in full. However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.

6.    Right to Request Confidential Communications

You have the right to request that we communicate with you about your medical matters in a more confidential way by requesting that we communicate with you by alternative means or at alternative locations. For example, you may ask that we contact you at home instead of at work. Your request should specify how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests.

7.    Right to Notice of Breach of Unsecured Health Information

We are required by law to maintain the privacy of your health information, to provide you with this Notice containing our legal duties and privacy practices with respect to your health information, and to abide by the terms of this Notice. It is our policy to safeguard your health information so as to protect the information from those who should not have access to it. If, however, for some reason we experience a breach of your unsecured health information, we will notify you of the breach.

8.    Right to Obtain a Copy of This Notice

You have the right to a paper copy of this Notice. You may request a paper copy at any time, even if you have previously agreed to receive this Notice electronically. To do so, please contact our Privacy Officer at (201) 267-7000 or MahwahASCleadership@hss.edu. You may also obtain a copy of this Notice from our website at HSS Northern NJ Surgery Center or by requesting a copy at your next visit.

9.    Right to Have Someone Act on Your Behalf

You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control the privacy of health information about minors, unless the minors are permitted by law to act on their own behalf. To name a personal representative, please contact your treating provider’s office.

CHANGES TO THIS NOTICE

We may change our privacy practices from time to time. If we do, we will revise this Notice so you will have an accurate summary of our practices, and the revised Notice will apply to all of your health information. We will post any revised Notice in our facility. You will also be able to obtain your own copy of the revised Notice by accessing our website at HSS Northern NJ Surgery Center contacting us at (201) 267-7000 or MahwahASCleadership@hss.edu, or asking for a Notice at the time of your next visit. The effective date of the Notice will always be noted in the cover page. We are required to abide by the terms of the Notice that is currently in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact the Privacy Officer at (201) 267-7000 or MahwahASCleadership@hss.edu. To file a complaint with the Department of Health and Human Services you may send a letter to the Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201, or call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. No one will retaliate or take action against you for filing a complaint.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service. 

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most they can bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance, and deductibles). You cannot be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

For emergency services, New Jersey law provides the same protections as federal law.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.

You are never required to give up your protections from balance billing. You also are not required to get out-of-network care. You can choose a provider or facility in your plan’s network.

New Jersey law provides similar protections as federal law.

When balance billing is not allowed, you also have these protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you have been wrongly billed, you may contact the following agencies to file a complaint:

New Jersey Department of Banking and Insurance at the Office of Managed Care 1.888.393.1062.  Visit New Jersey Department of Banking and Insurance Out-of-network Consumer Protections for more information about your rights under New Jersey law.

The federal phone number for information and complaints is: 1.800.985.3059. Visit Centers for Medicare & Medicaid Services Medical bill of rights for more information about your rights under federal law.

As a hospital patient in Connecticut, you have the following rights:

1. A patient has the right to be involved in all aspects of care, including the plan of care. To the extent authorized by a patient, or permitted by law, the patient’s family shall participate in decisions concerning care, treatment and discharge. A patient has the right to have a family member or personal representative of the patient’s choice and the patient’s own physician notified promptly of admission to the hospital.
2. The hospitals will not unlawfully discriminate in providing medical treatment because of age, sex, sexual orientation, gender identity or expression, physical or mental disability, religion, race, national origin, ethnicity or culture, language, socio-economic or financial status. All clinical decision making will be directed by the patient’s hospital physician(s), according to medical need.
3. Care shall be provided in a manner that supports a patient’s privacy, safety, dignity, individuality, cultural, emotional, spiritual and personal values to the best of our ability. Each patient has the right to be free from all forms of abuse or harassment, including seclusion or restraints that are not medically indicated, or are used as a means of coercion, discipline, convenience or staff retaliation.
4. Each patient or duly authorized personal representative has the right to be informed by the physician and give or refuse to give informed consent prior to the start of those specified, non-emergency, medical procedures or treatments requiring informed consent. The physician should explain to the patient in words the patient understands, specific details about the recommended procedure or treatment, the benefits and risks involved, time required to recovery, and any reasonable alternatives. All patients have the right to be informed about the clinical outcomes, including any clinically significant unanticipated outcomes.
5. The patient has the right to request or refuse treatment, medication and services, including the right to forgo or withdraw life-sustaining treatment or withhold resuscitative services in accordance with the law and regulation once you have been informed of the medical risks of such a decision.
6. The patient has the right to consent or refuse to consent to recordings, films or other images made for external use, and not for diagnosis or treatment purposes.
7. The patient has the right to receive, as soon as possible, translator and interpreter services, if the patient needs one to help communicate with hospital staff and understand their plan of care.
8. Each patient has the right to personal privacy and confidentiality of the patient’s medical records. As required by law, the confidentiality of the patient’s medical care, source of payment and medical record will be protected by the hospitals.
9. Each patient has the right to be informed of the names and functions of all healthcare professionals providing personal care, except where the healthcare professional’s safety may be jeopardized.
10. At a patient’s own request and expense, the patient has the right to consult with other physicians.
11. With the approval of the Institutional Review Board, physicians may ask patients to participate in research. A patient may participate in research only if the patient or the patient’s personal representative has been fully informed and gives written consent. Each patient also has the right to refuse to participate, and refusal, in no way, jeopardizes the right to access to care, treatment or services unrelated to the research.
12. Each patient is requested to cooperate in the education of physicians, nurses and other healthcare professionals. The teaching program is one Hospital for Special Surgery’s greatest strength and allows the hospital to provide round-the-clock supervised medical care to all patients.
13. Each patient has the right to receive a summary of the patient’s rights and responsibilities that includes the name and phone number of the hospital representative to whom the patient can address questions or concerns about any possible violation of patient rights. Each patient has the right to voice complaints, to have those complaints reviewed and, when possible, resolved.
14. Each patient has the right to file a grievance for resolution of patient concerns regarding quality of care, patient safety, service or perceived premature discharge.
15. The patient has the right to access information contained in the patient’s clinical records within a reasonable period of time. Each patient has the right to obtain a copy of the patient’s medical records, at a reasonable fee, within a reasonable time frame.
16. The hospitals support a patient’s rights to formulate Advance Directives. Lack of an Advance Directive does not hamper access to care. Advance Directive information is offered upon admission and is available at any time during a patient’s stay.
17. Each patient can expect effective pain management, complete information about pain management and staff committed to effective pain management.
18. Each patient has the right to receive information about an explanation of costs related to care provided.
19. Should it become necessary, the patient’s personal representative may request to have an autopsy performed.

Contact Information for Questions or Concerns

Should you have questions about any of these rights, or wish to express a recommendation or concern, you may contact one or more of the following:

• HSS Office of the Patient Experience for New York 212.774.2403, for Connecticut, New Jersey and Florida Toll-Free 855-477-4344 or e-mail at patientexperience@hss.edu.
• HSS Chief Executive Officer at 212.606.1236, or by letter sent to Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
• You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services: 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 or by phone 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html;
• Joint Commission at 800.994.6610, or by letter sent to Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181, or e-mail to complaint@jointcommission.org
• Centers for Medicare and Medicaid Services: Toll-free: 877.267.2323 TTY Toll-free: 866-226-1819. Medicare Only: Toll-free: 800-MEDICARE (800-633-4227); TTY Toll-free: 877-486-2048. 7500 Security Boulevard, Baltimore, MD 21244
• New York State Department of Health by phone at: 800.804.5447 or letter sent to NYS Department of Health, Centralized Hospital Intake Program, Mailstop: CA/DCS, Empire State Plaza, Albany, NY 12237
• Connecticut State Department of Health by phone at: 860.509.7801 or e-mail at ask.dph@ct.gov or letter to 410 Capitol Ave, Hartford, CT 06134

The Statement of Patient’s Responsibilities, designed as a companion to the Patient’s Bill of Rights, encourages patients to participate in their own health care and treatment. Hospital for Special Surgery believes that a mutual understanding of the Patient’s Bill of Rights and Responsibilities will result in more effective delivery of health care services.

The Statement of Patient Responsibilities reads as follows:

To the extent possible, Hospital for Special Surgery requests that you, as our patient:

• Provide accurate and complete information about your past illnesses, hospitalizations, medications and other matters relating to your health, and answer any questions concerning these matters.
• Participate in your health care planning by talking openly and honestly about your concerns with your physician and other health care professionals.
• Understand your health problems, treatment course and care decisions to your own satisfaction and ask questions if you do not understand.
• Cooperate with your physician and other health care professionals in carrying out your health care plan both as an inpatient and after discharge.
• Participate and cooperate with our health care professionals in creating a discharge plan that meets your medical and social needs.
• Inform the hospital or any of its professionals of the existence of any advanced directive (proxy, DNR, living will) you have created.
• Take responsibility for the consequences and outcomes if you do not follow the care, service or treatment plan.
• Provide accurate information related to insurance or other sources of payment. You are responsible for ensuring payment of your bills and you may be responsible for charges not covered by your insurance.
• Treat other patients, visitors and staff with respect and consideration. Support mutual consideration and respect by maintaining civil language and conduct in interactions with staff and providers.
• Support our commitment to a diverse and inclusive environment in which racist and/or discriminatory behaviors and acts of intolerance towards others are not tolerated.
• Follow instructions, policies, rules, and regulations in place to support quality care for patients and a safe environment for all individuals in the hospital.
• Be considerate of your fellow patients, respecting their need for privacy and a quiet environment.

If you are concerned that you may not be able to pay for your care, we may be able to help.
Hospital for Special Surgery provides financial aid for medically necessary services based on a patient's financial need and includes a sliding scale discount for patients who qualify. Aid may be available for patients who do not have insurance and for those who are underinsured. We may be able to work with you to arrange a manageable payment plan.

Our financial assistance policy applies to services provided by the Hospital, and some services provided by certain HSS physicians and other clinical staff.

On our Financial Assistance webpage, you can access the full policy, an application and additional information. including a full list of providers who participate in the Hospital's financial assistance policy.

You can also call the Financial Advisory Department at 212.606.1505, and we would be glad to provide information to you and answer any questions you may have.

Hospital for Special Surgery is committed to providing high quality care and skilled and compassionate service to our community. Consistent with this commitment, Hospital for Special Surgery complies with applicable federal, state, and local civil rights laws and does not discriminate on the basis of actual or perceived race, color, creed, ethnicity, religion, national origin, alienage or citizenship status, culture, language, age, disability, socioeconomic status, sex, sexual orientation, gender identity or expression, partnership or marital status, veteran or military status, or any other prohibited basis.
Hospital for Special Surgery:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters; and
  • Written information in other formats, such as large print, audio, and accessible electronic formats.
• Provides free language services to people whose primary language is not English, such as:
  • Provides free language assistance services to people whose primary language is not English, such as:
    • Qualified interpreters.
    • Information written in other languages.
    • Auxiliary aids to patients who are deaf and blind.

If you need these services, contact the Language Services Department languageservices@hss.edu, Tel.: 1-212-606-1760.
If you believe that Hospital for Special Surgery has failed to provide these services or discriminated in another way, you can file a grievance with Section 1557 Coordinator at Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, TTY: 1-800-676-3777 or 1- 855-477-4344, patientexperience@hss.edu.

You also have the right to file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD). Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html.

ATENCIÓN: Si usted habla español, le avisamos que tenemos servicios lingüísticos gratuitos a su disposición. Llame al: 1-212-606-1760, TTY: 1-800-676-3777.

注意：如果您講中文，可向您提供免費語言服務。致電 1-212-606-1760，TTY: 1-800-676-3777。

Внимание: Если Вы говорите по русски, примите к сведению, что Вы можете воспользоваться бесплатными услугами переводчика. Звоните по номеру: 1-212-606-1760, TTY: 1-800-676-3777.

ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis asistans nan lang ki disponib pou ou gratis. Rele nan 1-212-606-1760, TTY: 1-800-676-3777.

알려드립니다: 귀하께서 한국어를 하시는 경우, 무료로 언어 도움 서비스를 이용하실 수 있습니다. 1-212-606-1760 (TTY: 1-800-676-3777) 번으로 전화하십시오.

ATTENZIONE: se parli italiano sono disponibili servizi di assistenza linguistica gratuiti. Chiama il numero 1-212-606-1760, TTY: 1-800-676-3777.

אכטונג׃ אױב איר רעדט אידיש, זענען פאר אײך דא צו באקומען שפראך הילף סערװיסעס פרײ פון אפצאל. רופט1-212-606-1760, TTY: 1-800-676-3777.

দৃষ্টি আকর্ষণ: যদি আপনি বাংলায় কথা বলেন, তাহলে আপনি বিনামূল্যে ভাষাগত সহায়তা পরিষেবা পেতে পারেন৷ ফোন করুন: 1-212-606-1760, TTY:  1-800-676-3777

UWAGA: Jeżeli mówi Pan/Pani po polsku, dostępne są dla Państwa bezpłatne usługi pomocy językowej. Proszę zadzwonić pod numer 1-212-606-1760, TTY:  1-800-676-3777.

ملاحظة: إذا كنت تتحدث اللغة العربية، فإننا نوفر لك خدمات مساعدة لغوية بالمجان. اتصل على<1-212-606-1760، هاتف نصي (TTY): 1-800-676-3777.

VEUILLEZ NOTER: Si vous parlez français, des services d’assistance linguistique gratuits, sont à votre disposition. Appelez le 1-212-606-1760, TTY: 1-800-676-3777.

وجہ فرمائیں: اگر آپ کی زبان اردو ہے تو آپ کے لیے زبان میں معاونت فراہم کرنے والی سروسز (لینگوئج اسسٹنس سروسز) بلامعاوضہ دستیاب ہیں کال کریں 1-212-606-1760 TTY: 1-800-676-3777۔

PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuha kang mga libreng serbisyo ng tulong sa wika. Tumawag sa 1-212-606-1760, TTY: 1-800-676-3777.

ΠΡΟΣΟΧΗ: Εάν μιλάτε ελληνικά, διατίθενται δωρεάν υπηρεσίες γλωσσικής βοήθειας για εσάς. Καλέστε το 1-212-606-1760. TTY: 1-800-676-3777.

VINI RE: Nëse flisni shqip, keni në dispozicion shërbime ndihme për gjuhën pa pagesë. Telefononi 1-212-606-1760, TTY: 1-800-676-3777.

As a patient in Connecticut, you have the right to:

1. Be involved in all aspects of care, including the plan of care. To the extent authorized by you, or permitted by law, your family shall participate in decisions concerning care and treatment.
2. Have your physician and/or personal of your choice notified of your admission to the hospital.
3. Care that is provided in a manner that supports a patient’s privacy, confidentiality, safety, dignity, individuality, cultural, emotional, spiritual and personal values and that is considerate and respectful regardless of age, sex, sexual orientation, gender identity or expression, physical or mental disability, religion, race, national origin, ethnicity or culture, language, socio-economic or financial status.
4. Make informed decisions.
5. Refuse treatment as allowed by law.
6. Be provided with free interpreter services as needed.
7. Be informed of the names and functions of all healthcare professionals providing personal care, except where the healthcare professional’s safety may be jeopardized.
8. Right to request a second opinion about your care.
9. Review and obtain copies of your medical records.
10. Receive information about and an explanation of costs related to care provided.
11. Create an advanced directive.
12. Proper assessment and management of your pain or discomfort.

The Statement of Patient’s Responsibilities, designed as a companion to the Patient’s Bill of Rights, encourages patients to participate in their own health care and treatment. Hospital for Special Surgery believes that a mutual understanding of the Patient’s Bill of Rights and Responsibilities will result in more effective delivery of health care services.

The Statement of Patient Responsibilities reads as follows:

To the extent possible, Hospital for Special Surgery requests that you, as our patient:

1. Provide accurate and complete information about your past illnesses, hospitalizations, medications and other matters relating to your health, and answer any questions concerning these matters.
2. Participate in your health care planning by talking openly and honestly about your concerns with your physician and other health care professionals.
   Understand your health problems, treatment course and care decisions to your own satisfaction and ask questions if you do not understand.
3. Cooperate with your physician and other health care professionals in carrying out your health care plan both as an inpatient and after discharge.
4. Participate and cooperate with our health care professionals in creating a discharge plan that meets your medical and social needs.
5. Inform the hospital or any of its professionals of the existence of any advanced directive (proxy, DNR, living will) you have created.
6. Take responsibility for the consequences and outcomes if you do not follow the care, service or treatment plan.
7. Provide accurate information related to insurance or other sources of payment. You are responsible for ensuring payment of your bills and you may be responsible for charges not covered by your insurance.
8. Treat other patients, visitors and staff with respect and consideration. Support mutual consideration and respect by maintaining civil language and conduct in interactions with staff and providers.
9. Support our commitment to a diverse and inclusive environment in which racist and/or discriminatory behaviors and acts of intolerance towards others are not tolerated.
10. Follow instructions, policies, rules, and regulations in place to support quality care for patients and a safe environment for all individuals in the hospital.
11. Be considerate of your fellow patients, respecting their need for privacy and a quiet environment.

Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider’s or health care facility's right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your health care provider or health care facility. A summary of your rights and responsibilities follows:

A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.

1. A patient has the right to a prompt and reasonable response to questions and requests.
2. A patient has the right to know who is providing medical services and who is responsible for his or her care.
3. A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
4. A patient has the right to bring any person of his or her choosing to the patient-accessible areas of the health care facility or provider’s office to accompany the patient while the patient is receiving inpatient or outpatient treatment or is consulting with his or her health care provider, unless doing so would risk the safety or health of the patient, other patients, or staff of the facility or office or cannot be reasonably accommodated by the facility or provider.
5. A patient has the right to know what rules and regulations apply to his or her conduct.
6. A patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
7. A patient has the right to refuse any treatment, except as otherwise provided by law.
8. A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care.
9. A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.
10. A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
11. A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.
12. A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.
13. A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
14. A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research.
15. A patient has the right to express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency.
16. A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
17. A patient is responsible for reporting unexpected changes in his or her condition to the health care provider.
18. A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
19. A patient is responsible for following the treatment plan recommended by the health care provider.
20. A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility.
21. A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider’s instructions.
22. A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.
23. A patient is responsible for following health care facility rules and regulations affecting patient care and conduct.

Contact Information for Questions or Concerns

Should you have questions about any of these rights, or wish to express a recommendation or concern, you may contact one or more of the following:

• To report a complaint or grievance, you can contact the facility administrator by phone at 561.725.4300 or by mail at: HSS Palm Beach ASC, 300 Palm Beach Lakes Blvd. West Palm Beach, FL 33401.
• You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services: 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 or by phone 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html;
• Joint Commission at 800.994.6610, or by letter sent to Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181, or e-mail to complaint@jointcommission.org
• Centers for Medicare and Medicaid Services: Toll-free: 877.267.2323 TTY Toll-free: 866-226-1819. Medicare Only: Toll-free: 800-MEDICARE (800-633-4227); TTY Toll-free: 877-486-2048. 7500 Security Boulevard, Baltimore, MD 21244
• New York State Department of Health by phone at: 800.804.5447 or letter sent to NYS Department of Health, Centralized Hospital Intake Program, Mailstop: CA/DCS, Empire State Plaza, Albany, NY 12237
• Florida State Department of Health by phone at: 850.245.4323; 850.245.4444 or letter sent to Florida DOH 4052 Bald Cypress Way, Tallahassee Fl, 32399

The Statement of Patient’s Responsibilities, designed as a companion to the Patient’s Bill of Rights, encourages patients to participate in their own health care and treatment. Hospital for Special Surgery believes that a mutual understanding of the Patient’s Bill of Rights and Responsibilities will result in more effective delivery of health care services.

The Statement of Patient Responsibilities reads as follows:

To the extent possible, Hospital for Special Surgery requests that you, as our patient:

• Provide accurate and complete information about your past illnesses, hospitalizations, medications and other matters relating to your health, and answer any questions concerning these matters.
• Participate in your health care planning by talking openly and honestly about your concerns with your physician and other health care professionals.
• Understand your health problems, treatment course and care decisions to your own satisfaction and ask questions if you do not understand.
• Cooperate with your physician and other health care professionals in carrying out your health care plan both as an inpatient and after discharge.
• Participate and cooperate with our health care professionals in creating a discharge plan that meets your medical and social needs.
• Inform the hospital or any of its professionals of the existence of any advanced directive (proxy, DNR, living will) you have created.
• Take responsibility for the consequences and outcomes if you do not follow the care, service or treatment plan.
• Provide accurate information related to insurance or other sources of payment. You are responsible for ensuring payment of your bills and you may be responsible for charges not covered by your insurance.
• Treat other patients, visitors and staff with respect and consideration. Support mutual consideration and respect by maintaining civil language and conduct in interactions with staff and providers.
• Support our commitment to a diverse and inclusive environment in which racist and/or discriminatory behaviors and acts of intolerance towards others are not tolerated.
• Follow instructions, policies, rules, and regulations in place to support quality care for patients and a safe environment for all individuals in the hospital.
• Be considerate of your fellow patients, respecting their need for privacy and a quiet environment.

If you are concerned that you may not be able to pay for your care, we may be able to help. Hospital for Special Surgery provides financial aid for medically necessary services based on a patient's financial need and includes a sliding scale discount for patients who qualify. Aid may be available for patients who do not have insurance and for those who are underinsured. We may be able to work with you to arrange a manageable payment plan.

Our financial assistance policy applies to services provided by the Hospital, and some services provided by certain HSS physicians and other clinical staff.

On the webpages below, you can access the full policy, an application and additional information, including a full list of providers who participate in the Hospital's financial assistance policy. You can also call the Financial Advisory Department at 212.606.1505, and we would be glad to provide information to you and answer any questions you may have.

• Financial Assistance – HSS Florida
• Financial Assistance – HSS Palm Beach Ambulatory Surgery Center, LLC

Effective Date: October 24, 2019
Revision Date: October 30, 2025

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

HSS Florida Physicians, LLC (HSSFP) values respect for our patients’ privacy. Not only is it what our patients expect, it is the right way to conduct health care. As required by law, we will protect the privacy of health information that may reveal your identity, and we will provide you a copy of this Notice, which describes the health information privacy practices of HSSFP and its medical staff and affiliated health care providers when providing health care services for HSSFP. If you have any questions about this Notice or would like further information, please contact the HSSFP’s Executive Director, who serves as the HSSFP Privacy Officer, at (561) 657-4600.

WHO WILL FOLLOW THE PRACTICES IN THIS NOTICE?

We provide health care to our patients together with physicians and other health care professionals and organizations. The privacy practices described in this Notice will be followed by:

• Health care professionals who provide direct services to treat you at HSSFP;
• Employees, medical staff, trainees, students, and volunteers who provide direct services to you at HSSFP; and
• HSSFP business associates and their subcontractors.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

For information about how we use and disclose information collected through the MyHSS patient portal, please refer to our MyHSS Privacy Policy and MyHSS Terms of Use. If there is a conflict between this Notice and the MyHSS Privacy Policy or MyHSS Terms of Use, this Notice will apply to the extent that Protected Health Information (as defined by the Department of Health and Human Services) is involved.

We will generally obtain your written authorization before using your health information or sharing it with others outside of HSSFP. There are some situations, described below, when we do not need your written authorization before using your health information or sharing it with others. If your health information is disclosed to a recipient pursuant to any of the applicable purposes described in this Notice, it is possible that such health information may be subject to further redisclosure by the recipient and no longer protected by the requirements of this Notice.

1.    Treatment, Payment, and Health Care Operations

We may use your health information or share it with others to treat you, obtain payment for that treatment, and run our health care operations. In some cases, we may also disclose your health information for payment activities and certain health care operations of another health care provider or payor.

Treatment. We may share your health information with HSSFP doctors, nurses and other health care providers who are involved in taking care of you, and they may in turn use that information to diagnose or treat you. Your HSSFP doctor may also share your health information with another doctor or provider to whom you have been referred for further health care.

Payment. We may use your health information or share it with others so that we may obtain payment for your health care services. For example, we may share information about you with your health insurance company to obtain reimbursement after we have treated you, or to determine whether it will cover your treatment. We might also need to inform your health insurance company about your health condition to obtain pre-approval for your treatment, such as admitting you for a particular type of surgery. Finally, we may share your information with other health care providers and payors for their payment activities.

Health Care Operations. We may use your health information or share it with others to conduct our health care operations. For example, we may use your health information to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care they provide. In addition, we may share your health information with other health care providers and payors for certain health care operations if the information is related to a relationship the provider or payor currently has or previously had with you, and if the provider or payor is required by federal law to protect the privacy of your health information.
 
Recording and Transcription of Clinical Encounters. To help our health care providers document and manage your care, we may use voice recording technology that records and transcribes conversations between you and your HSSFP health care provider during your visit. This technology allows your provider to focus more on you and less on note taking, helping ensure you receive the highest quality care. Your recorded protected health information may only be used in accordance with this notice.

Health Information Exchanges. We may participate in health information exchanges, enabling us to share your health information electronically with other health care providers in the course of providing care for you, as permitted by state and federal law. If you are interested in opting out or changing your health information exchange choice, please contact HSSFP at (561) 657-4600.

Appointment Reminders, Treatment Alternatives, or Distribution of Health-Related Benefits and Services. In the course of providing treatment to you, we may use your health information to contact you with a reminder that you have an appointment for treatment or services. We may also use your health information to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you. However, to the extent a third party provides financial remuneration to us so that we make these treatment-related or health care operations-related communications to you, we will secure your authorization in advance as we would with any other marketing communication (as described later in this Notice).

Fundraising. Fundraising is a communication from HSSFP or one of its business associates, or by HSSFP’s affiliated support organization, The Hospital for Special Surgery Fund, Inc. (the Fund”) for the purpose of raising funds to further HSSFP’s and its affiliates’ missions of patient care, research, and education, including appeals for money or sponsorship of events. We may use certain information about you for fundraising, including demographic information (such as your age, date of birth, and gender, and where you live or work), your insurance status, the dates when you received services from us, and information about the HSSFP department where you received services, the identity of your treating physician(s), and the outcome of your treatment. You have the right to opt-out of future fundraising communications and can do so by following the opt-out instructions provided as part of the fundraising communication.

Business Associates. We may disclose your health information to contractors, agents and other business associates who need the information to assist us with obtaining payment or carrying out our health care operations. For example, we may share your health information with a billing company that helps us to obtain payment from your insurance company. Another example is that we may share your health information with an accounting firm or law firm that provides professional advice to us about how to improve our health care services and comply with the law. If we do disclose your health information to a business associate, we will have a written contract that requires our business associate to protect the privacy of your health information. We may also allow for our business associates to de-identify your health information to be used for the benefit of HSS or the benefit of the business associate, or to create, use and disclose limited data sets as described below in the section titled “Completely De-identified or Partially De-identified Information.”

2.    Patient Directory and Family and Friends Involved in Your Care

We may use your health information in, and disclose it from, our patient directory, or share it with family and friends involved in your care, without your written authorization. You will have an opportunity to object to these uses and disclosures of your health information, unless there is insufficient time because of a medical emergency (in which case we will discuss your preferences with you as soon as the emergency is over). We will follow your wishes, unless we are required by law to do otherwise.

Patient Directory. We generate and maintain a daily list of patients currently admitted (e.g., for inpatient care or outpatient procedures) while you are a patient in HSSFP. If you do not object, we will include your name and your location in this list. This information may be released to people who ask for you by name (e.g., family members looking to visit you or flower shops attempting to deliver flowers to you). We also generate and maintain a daily list of patients currently admitted to HSSFP that includes patients’ religious affiliations, in addition to patients’ names and locations. These religious affiliations may be given to a member of the clergy, such as a priest or rabbi, even if the clergy doesn’t ask for a patient by name. These lists essentially act as a patient directory. If you would prefer that we not include your information in one or either of these lists, you may contact the HSSFP Privacy Officer, at (561) 657-4600.

Family and Friends Involved in Your Care. If you do not object, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for that care. We may also notify a family member, personal representative, or another person responsible for your care about your location and general condition within HSSFP. In some cases, we may need to share your information with a disaster relief organization that will help us notify these persons.

3.    Emergencies or Public Need

We may use your health information, and share it with others, to treat you in an emergency or to meet important public needs. We will not be required to obtain your written authorization or to provide you with an opportunity to object before we use or disclose your health information for these reasons. We will, however, obtain your written authorization for, or provide you with an opportunity to object to, the use and disclosure of your health information in these situations when state law specifically requires that we do so.

Emergencies. We may use or disclose your health information if you need emergency treatment or if we are required by law to treat you.

As Required by Law. We may use or disclose your health information if we are required by law to do so. In certain situations, we may notify you of disclosures we make that were required by law.

Public Health Activities. We may disclose your health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities. For example, we may share your health information with government officials that are responsible for controlling disease, injury, or disability. We may also disclose your health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if the law requires or permits us to do so. Further, we may release some health information about you to your employer if your employer hires us to provide you with a physical exam and we discover you have a work-related injury or disease that your employer must know about to comply with employment laws.

Victims of Abuse, Neglect, or Domestic Violence. We may release your health information to a public health authority that is authorized to receive reports of abuse, neglect, or domestic violence. For example, we may report your information to government officials if we reasonably believe you have been a victim of abuse, neglect, or domestic violence. We will make efforts to obtain your permission before releasing this information, but in some cases, we may be required or authorized to act without your permission.

Health Oversight Activities. We may release your health information to government agencies authorized to conduct audits, investigations, and inspections of our facilities. These government agencies monitor the operation of the health care system, government benefit programs such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws.

Product Monitoring, Repair, and Recall. We may disclose your health information to a person or company regulated by the Food and Drug Administration for the purpose of: (1) reporting or tracking product defects or problems; (2) repairing, replacing, or recalling defective or dangerous products; or (3) monitoring the performance of a product after it has been approved for use by the general public.

Lawsuits and Disputes. We may disclose your health information if we are ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute.

Law Enforcement, & Judicial and Administrative Proceedings. We may disclose your health information to law enforcement officials for the following reasons:

• To comply with court orders or laws we are required to follow;
• To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person;
• If you have been the victim of a crime and we determine: (1) we have been unable to obtain your agreement because of an emergency or your incapacity; (2) law enforcement officials need this information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these officers is in your best interests;
• If we suspect your death resulted from criminal conduct;
• If necessary to report a crime that occurred on our property; or
• If necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical personnel at the scene of a crime).

To Avert a Serious and Imminent Threat to Health or Safety. We may use your health information or share it with others when necessary to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public. In such cases, we will share your information only with someone able to help prevent the threat. We may also disclose your health information to law enforcement officers if you tell us that you participated in a violent crime that may have caused serious physical harm to another person (unless you admitted that fact while in counseling), or if we determine you escaped from lawful custody (such as a prison or mental health institution).

National Security and Intelligence Activities or Protective Services. We may disclose your health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials.

Military and Veterans. If you are in the Armed Forces, we may disclose health information about you to appropriate military command authorities for activities they deem necessary to carry out their military mission. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Inmates and Correctional Institutions. If you are an inmate or you are detained by a law enforcement officer, we may disclose your health information to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security, and good order at the place where you are confined. This includes sharing information that is necessary to protect the health and safety of other inmates or persons involved in supervising or transporting inmates.

Workers’ Compensation. We may disclose your health information for workers’ compensation or similar programs that provide benefits for work-related injuries.

Coroners, Medical Examiners, and Funeral Directors. In the unfortunate event of your death, we may disclose your health information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release your health information to funeral directors as necessary to carry out their duties.
 
Organ and Tissue Donation. In the unfortunate event of your death, we may disclose your health information to organizations that procure or store organs, eyes, or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws.

Research. In most cases, we will ask for your written authorization before using your health information or sharing it with others to conduct research. However, under some circumstances, we may use and disclose your health information without your written authorization if we obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. We may also disclose your health information without your written authorization to people who are preparing a future research project, or to allow researchers to determine if you might be eligible for a particular research study provided that such a disclosure is made solely within our secure records, databases, electronic systems or facilities. In the unfortunate event of your death, we may share your health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facilities any information that identifies you.
We may allow researchers to use specimens or tissues removed from your body during a diagnostic procedure, survey, or medical treatment that would otherwise be discarded. Those specimens or tissues may be used together with your health information to conduct medical research in the same manner as other health information.

4.    Completely De-identified or Partially De-identified Information

We and our business associates may use and disclose your health information if we or our business associates have removed any information that has the potential to identify you so that the health information is “completely de-identified.” Such de-identified information is no longer subject to the terms of this Notice. We and our business associates may also use and disclose “partially de-identified” health information, known as a “limited data set,” about you for research, public health, or health care operations purposes if the person who will receive the limited data set signs an agreement to protect the privacy of the information, as required by federal and state law. Limited data sets will not contain any information that would directly identify you (such as your name, street address, SSN, phone number, fax number, electronic mail address, website address, or license number).

5.    Incidental Disclosures

While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during, or as an unavoidable result of, our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION REQUIRING AUTHORIZATION

As stated above, we cannot and will not use or disclose your health information without your written authorization for any reason except those described in this Notice. For example, we require your written authorization for most uses or disclosures of your health information for certain marketing purposes, for the sale of health information, or with respect to psychotherapy notes.

If you provide us with written authorization, you may revoke, or cancel, that written authorization at any time, except to the extent that we have already relied upon it. If you revoke the authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization. Your revocation will not affect any uses or disclosures we have already made prior to the date we receive notice of the revocation. To revoke a written authorization, please write to HSS Florida Physicians, LLC, Attn. Privacy Officer, 300 Palm Lakes Boulevard West Palm Beach, FL 33401 ROIrequest@hss.edu.

Special Protections for Certain Types of Health Information. Special privacy protections apply to HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information. Some parts of this Notice may not apply to these types of information. If your treatment involves this information, you may be provided with special authorization forms in connection with the disclosure of such information by HSSFP. To request copies of these forms, please contact HSSFP at (561) 657-4600.

YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION

We want you to know that you have the following rights to access and control your health information. These rights are important because they will help you make sure that the health information we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you about your medical matters. To inspect or obtain a copy of your health information, please submit your request in writing to HSS Florida Physicians, LLC, Attn. Privacy Officer, 300 Palm Lakes Boulevard West Palm Beach, FL 33401 or to ROIrequest@hss.edu.

1.    Right to Inspect and Copy Records

You have the right to inspect and obtain a copy, including an electronic copy, from us in a timely manner of any of your health information that may be used to make decisions about you and your treatment, for as long as we maintain this information in our records. This includes medical and billing records. You can also access your health information directly using the MyHSS patient portal, available at https://myhss.hss.edu/myhss or through the Apple App Store or Google Play.

• A request to inspect or obtain a copy of your health information must include: (1) the desired form or format of access; (2) a description of the health information to which the request applies; and (3) appropriate contact information.
• If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies we use to fulfill your request, which must generally be paid before or at the time we give the copies to you.
• If the information you request is stored electronically, we will provide the information in the form and format you request if the information is readily producible in that format, or, if not, we will reach an agreement with you as to alternative readable electronic format.
• We will respond to your request for inspection of records within 10 days. We ordinarily will respond to requests for copies within 30 days. If we need additional time to respond to a request for copies, we will notify you in writing within the time frame above to explain the reason for the delay and when you can expect to have a final answer to your request.
• Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If we do, we may provide you with a summary of the information instead. We will also provide a written notice that explains our reasons for providing only a summary, and a complete description of your rights to have that decision reviewed and how you can exercise those rights. The notice will also include information on how to file a complaint about these issues with us or with the Secretary of the Department of Health and Human Services. If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we will not let you inspect or copy.

2.    Right to Transfer Records

You have a right to initiate a transfer of your records to another person or organization by completing a written authorization form. Your request must include the person(s) authorized to use and/or receive the information, and a description of the information that will be used or disclosed. Ordinarily, we respond to your request within 30 days. To request or revoke a written authorization, please write to HSS Florida Physicians, LLC, Attn. Privacy Officer, 300 Palm Lakes Boulevard West Palm Beach, FL 33401 or ROIrequest@hss.edu.

3.    Right to Amend Records

If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept in our records. Your request must include a description of the amendment requested and should include the reasons why you think we should make the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request.

Your request for an amendment may be denied if you request an amendment of health information that we determine: (1) was not created by HSSFP, unless the originator of the health information is no longer available to make the amendment; (2) is not part of HSSFP’s records; (3) is not health information you would be permitted to inspect or copy; or (4) is accurate and complete. If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement, which we will include in your records. We will also provide you with information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.

4.    Right to an Accounting of Disclosures

You have a right to request an accounting of certain disclosures of your health information we have made in the previous six years, such as for research, public health, health oversight and other specific purposes that are not for treatment, payment or health care operations.

An accounting of disclosures does not describe the ways that your health information has been shared within HSSFP, as long as all other protections described in this Notice have been followed. An accounting of disclosures also does not include information about the following disclosures: disclosures we made to you or your personal representative; disclosures we made pursuant to your written authorization; disclosures we made for treatment, payment or health care operations; disclosures made from the patient directory; disclosures made to your friends and family involved in your care or payment for your care; disclosures that were incidental to permissible uses and disclosures of your health information (for example, when information is overheard by another patient passing by); disclosures for purposes of research, public health or our health care operations of limited portions of your health information that do not directly identify you; disclosures made to federal officials for national security and intelligence activities; and disclosures about inmates to correctional institutions or law enforcement officers.

Your request must state a time period within the past six years for the disclosures you want us to include. For example, you may request a list of the disclosures that we made between January 1 of a given year to December 31 of that same year, so long as the dates are within the past six years. You have a right to receive one free accounting within every 12-month period. However, we may charge you for the cost of providing any additional accounting in that same 12-month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred. The scope of your right to request an accounting may be modified from time to time to comply with changes in federal law or state law.

Ordinarily we will respond to your request for an accounting within 60 days. If we need additional time to prepare the accounting you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting. In rare cases, we may have to delay providing you with the accounting without notifying you because a law enforcement official or government agency has asked us to do so.

5.    Right to Request Additional Privacy Protections, Including Restriction on Disclosures to Health Plans

You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, or run our health care operations. You may also request that we limit how we disclose information about you to family or friends involved in your care. For example, you could request that we not disclose information about a surgery you had. In addition, you have the right to restrict certain disclosures of your health information to a health plan when you pay, or another person on your behalf pays, out-of- pocket in full for the health care item or service. Your request should include: (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.

We are not always required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. We do not need to agree to the restriction unless: (1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and (2) the health information relates only to a health care item or service that you or someone on your behalf has paid for out-of-pocket and in full. However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.

6.    Right to Request Confidential Communications

You have the right to request that we communicate with you about your medical matters in a more confidential way by requesting that we communicate with you by alternative means or at alternative locations. For example, you may ask that we contact you at home instead of at work. Your request should specify how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests.

7.    Right to Notice of Breach of Unsecured Health Information

We are required by law to maintain the privacy of your health information, to provide you with this Notice containing our legal duties and privacy practices with respect to your health information, and to abide by the terms of this Notice. It is HSSFP's policy to safeguard your health information so as to protect the information from those who should not have access to it. If, however, for some reason we experience a breach of your unsecured health information, we will notify you of the breach.

8.    Right to Obtain a Copy of This Notice

You have the right to a paper copy of this Notice. You may request a paper copy at any time, even if you have previously agreed to receive this Notice electronically. To do so, please call HSSFP at (561) 657-4600. You may also obtain a copy of this Notice from our website at https://www.hss.edu/locations/florida or by requesting a copy at your next visit.

9.    Right to Have Someone Act on Your Behalf

You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control the privacy of health information about minors, unless the minors are permitted by law to act on their own behalf. To name a personal representative, please contact your treating provider’s office.

CHANGES TO THIS NOTICE

We may change our privacy practices from time to time. If we do, we will revise this Notice so you will have an accurate summary of our practices, and the revised Notice will apply to all of your health information. We will post any revised Notice in our admitting areas and other locations in HSSFP. You will also be able to obtain your own copy of the revised Notice by accessing our website at https://www.hss.edu/locations/florida calling the HSSFP at (516) 657-4600 , or asking for a Notice at the time of your next visit. The effective date of the Notice will always be noted in the cover page. We are required to abide by the terms of the Notice that is currently in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact the HSSFP’s Privacy Officer at (516) 657-4600 or send a letter to HSS Florida Physicians, LLC, Attn. Privacy Officer, 300 Palm Lakes Boulevard West Palm Beach, FL 33401. To file a complaint with the Department of Health and Human Services you may send a letter to the Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201, or call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. No one will retaliate or take action against you for filing a complaint.

HSS Palm Beach Ambulatory Surgery Center, LLC (HSS Palm Beach ASC) complies with applicable Federal civil rights laws and does not discriminate on the basis of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression. HSS Palm Beach ASC does not exclude people or treat them differently because of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression.

HSS Palm Beach ASC:

• Provides free auxiliary aids and services to people with disabilities to communicate effectively with us, such as:
  • qualified sign language interpreters, video remote interpreting or other aids for hearing impaired individuals or written information in multiple formats, including large print, audio, accessible electronic formats, or other formats for visually impaired individuals
• Provides free language services to people whose primary language is not English, such as:
  • qualified interpreters or a language line of information written in other languages If you need these services, contact HSS Palm Beach ASC’s ADA Coordinator at 561.725.4300.
• If you believe that HSS Palm Beach ASC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with:

ADA Coordinator
HSS Palm Beach Ambulatory Surgery Center
300 Palm Beach Lakes Blvd
West Palm Beach, FL 33401
Phone: 561.725.4300
Fax: 561.725.4310

You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, HSS Palm Beach ASC’s ADA Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html

ATENCIÓN: Si usted habla español, le avisamos que tenemos servicios lingüísticos gratuitos a su disposición. Llame al: 1-561-725-4300, TTY: 1-800-368-1019, 800-537-7697.

注意：如果您講中文，可向您提供免費語言服務。致電 1-561-725-4300，TTY: 1-800-368-1019, 800-537-7697.

Внимание: Если Вы говорите по русски, примите к сведению, что Вы можете воспользоваться бесплатными услугами переводчика. Звоните по номеру: 1-561-725-4300, TTY: 1-800-368-1019, 800-537-7697.

ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis asistans nan lang ki disponib pou ou gratis. Rele nan 1-561-725-4300, TTY: 1-800-368-1019, 800-537-7697.

알려드립니다: 귀하께서 한국어를 하시는 경우, 무료로 언어 도움 서비스를 이용하실 수 있습니다. 1-561-725-4300 (TTY: 1-800-368-1019, 800-537-7697) 번으로 전화하십시오.

ATTENZIONE: se parli italiano sono disponibili servizi di assistenza linguistica gratuiti. Chiama il numero 1-561-725-4300, TTY: 1-800-368-1019, 800-537-7697.

אכטונג׃ אױב איר רעדט אידיש, זענען פאר אײך דא צו באקומען שפראך הילף סערװיסעס פרײ פון אפצאל. רופט 1-561-725-4300, TTY: 1-800-368-1019, 800-537-7697.

দৃষ্টি আকর্ষণ: যদি আপনি বাংলায় কথা বলেন, তাহলে আপনি বিনামূল্যে ভাষাগত সহায়তা পরিষেবা পেতে পারেন৷ ফোন করুন: 1-561-725-4300, TTY: 1-800-368-1019, 800-537-7697.

UWAGA: Jeżeli mówi Pan/Pani po polsku, dostępne są dla Państwa bezpłatne usługi pomocy językowej. Proszę zadzwonić pod numer 1-561-725-4300, TTY:  1-800-368-1019, 800-537-7697.

ملاحظة: إذا كنت تتحدث اللغة العربية، فإننا نوفر لك خدمات مساعدة لغوية بالمجان. اتصل على 
1-561-725-4300، هاتف نصي (TTY): 1-800-368-1019, 800-537-7697.

VEUILLEZ NOTER: Si vous parlez français, des services d’assistance linguistique gratuits, sont à votre disposition. Appelez le 1-561-725-4300, TTY: 1-800-368-1019, 800-537-7697.

توجہ فرمائیں: اگر آپ کی زبان اردو ہے تو آپ کے لیے زبان میں معاونت فراہم کرنے والی سروسز (لینگوئج اسسٹنس سروسز) بلامعاوضہ دستیاب ہیں کال کریں 1-561-725-4300 TTY: 1-800-368-1019, 800-537-7697.

PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuha kang mga libreng serbisyo ng tulong sa wika. Tumawag sa 1-561-725-4300, TTY: 1-800-368-1019, 800-537-7697.

ΠΡΟΣΟΧΗ: Εάν μιλάτε ελληνικά, διατίθενται δωρεάν υπηρεσίες γλωσσικής βοήθειας για εσάς. Καλέστε το 1-561-725-4300. TTY: 1-800-368-1019, 800-537-7697.

VINI RE: Nëse flisni shqip, keni në dispozicion shërbime ndihme për gjuhën pa pagesë. Telefononi 1-561-725-4300, TTY: 1-800-368-1019, 800-537-7697.