Patient Information

This Notice Describes How Medical Information About You May Be Used And Disclosed And How You Can Get Access To This Information. Please Review It Carefully.

Effective Date: September 1, 2013

Our goal is to take appropriate steps to safeguard any medical or other personal information that is provided to us. We are required to: (1) maintain the privacy of medical information provided to us; (2) provide notice of our legal duties and privacy practices; (3) abide by the terms of our Notice of Privacy Practices (“Notice”) currently in effect; and (4) notify affected individuals following a breach of unsecured protected health information.

Who Will Follow This Notice. This Notice describes the practices of our employees and staff as well as all employees and affiliates of Bristol Anesthesia Services, P.C., all of whom will follow the terms of this Notice. In addition, these individuals and affiliates may share protected health information with each other for the purpose of treatment, payment, or health care operations as described in this Notice.

Information Collected About You. In the ordinary course of receiving treatment and health care services from us, you will be providing us with personal information such as:
    • Your name, address, and phone number
    • Information relating to your medical history
    • Your insurance information and coverage
    • Information concerning your doctor, nurse, or other medical providers

Some information also may be provided to us by other individuals or organizations that are part of your “circle of care” such as the referring physician, your other doctors, your health plan, and close friends or family members.

How We May Use And Disclose Information About You. We may use and disclose personal and identifiable health information about you in different ways. All of the ways in which we may use and disclose information will fall within one of the following categories, but not every use or disclosure in a category will be listed.

For Treatment. We will use protected health information about you to furnish services and supplies to you for treatment purposes in accordance with our policies and procedures. For example, a doctor treating you for a particular condition may need to obtain and use information from your health plan about prior treatment of a similar or different condition.

For Payment. We will use and disclose protected health information about you to bill for our services and to collect payment from you or your insurance company. For example, we may need to give a payer information about your current medical condition so that the payer will pay us for the services that we have furnished to you. We may also need to inform your payer of the procedure(s) that you are going to receive in order to obtain prior approval or to determine whether the service is covered.

For Health Care Operations. We may use and disclose protected health information about you for the general operation of our business. For example, sometimes we arrange for accreditation organizations, auditors, or other consultants to review our practice, to evaluate our operations, and to tell us how to improve our services.

Public Policy Uses and Disclosures. There are a number of public policy reasons why we may disclose protected health information about you. We may disclose protected health information about you when we are required to do so by federal, state, or local law. We may disclose protected health information about you in connection with certain public health reporting activities. For instance, we may disclose such information to a public health authority authorized to collect or to receive protected health information for the purpose of preventing or controlling disease, injury, or disability, or, at the direction of a public health authority, to an official of a foreign government agency that is acting in collaboration with a public health authority. Public health authorities include state health departments, the Centers for Disease Control and Prevention, the Food and Drug Administration, the Occupational Safety and Health Administration, and the Environmental Protection Agency, to name a few.

We are also required to disclose protected health information to a public health authority or to other government authorities authorized by law to receive reports of child abuse or neglect.

We may disclose your protected health information in situations of domestic abuse or elder abuse. We may disclose protected health information in connection with certain health oversight activities of licensing and other agencies.

Health oversight activities include audit, investigation, inspection, licensure or disciplinary actions, and civil, criminal, or administrative proceedings or actions or any other activity necessary for the oversight of the health care system governmental benefit programs for which protected health information is relevant to:

• determining beneficiary eligibility entities subject to governmental regulatory programs for which protected health information is necessary for determining compliance with program standards;
• entities subject to civil rights laws for which protected health information is necessary for determining compliance.

We may disclose information in response to a warrant, subpoena, or other order of a court or administrative hearing body, and in connection with certain government investigations and law enforcement activities. We may release protected health information to a coroner or to a medical examiner to identify a deceased person or to determine the cause of death.

We also may release protected health information to organ procurement organizations, transplant centers, and eye or tissue banks. We may release your protected health information to workers’ compensation or similar programs. Information about you also may be disclosed when necessary to prevent a serious threat to your health and safety or the health and safety of others. If you are a member of the Armed Forces, we may release protected health information about you as required by military command authorities. We also may release protected health information about foreign military personnel to the appropriate foreign military authority. We may disclose your protected health information for legal or administrative proceedings that involve you. We may release such information upon order of a court or administrative tribunal. We may also release protected health information in the absence of such an order and in response to a discovery or other lawful request, if efforts have been made to notify you or to secure a protective order.

If you are an inmate, we may release protected health information about you to a correctional institution where you are incarcerated or to law enforcement officials. Finally, we may disclose protected health information for national security and intelligence activities and for the provision of protective services to the President of the United States and other officials or foreign heads of state.

Our Business Associates. We sometimes work with outside individuals and businesses that help us to operate our practice successfully. We may disclose your protected health information to these business associates so that they can perform the tasks that we hire them to do. Our business associates must guarantee to us that they will respect the confidentiality of your personal and identifiable health information.

Individuals Involved in Your Care or Payment for Your Care. We may disclose information to your personal representative involved in your care or in the payment for your care. Although we must be able to speak with your other physicians or health care providers, you can let us know if we should not speak with other individuals, such as your spouse or family.

Treatment Alternatives. We may use and disclose your protected health information in order to tell you about or recommend possible treatment options, alternatives, or health-related services that may be of interest to you.

Other Uses and Disclosures of Personal Information. We are required to obtain written authorization from you for any other uses and disclosures of protected health information other than those described above, including, but not limited to, uses and disclosures of any protected health information for marketing purposes (except in certain circumstances) and disclosures that constitute the sale of protected health information. If you provide us with such permission, you may revoke that permission in writing at any time. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. We will be unable to take back any disclosures already made based upon your original permission.

Individual Rights. You have the right to ask for restrictions on the ways in which we use and disclose your protected health information beyond those imposed by law. We will consider your request, but we are not required to accept it unless the request is to restrict disclosure of protected health information about you to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the protected health information pertains solely to a health care item or service for which you, or a person other than the health plan on your behalf, have paid in full. You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail. Except under certain circumstances, you have the right to inspect and copy medical and billing records about you. If you ask for copies of this information, we may charge you a fee for copying and mailing.

If you believe that information in your records is incorrect or incomplete, you have the right to ask us to correct the existing information, correct the missing information, or otherwise amend the protected health information. Under certain circumstances, we may deny your request.

You have a right to ask for a list of instances when we have used or disclosed your protected health information for reasons other than your treatment, payment for services furnished to you, our health care operations, or disclosures you give us authorization to make.

Changes to This Notice. We reserve the right to make changes to this Notice at any time. We reserve the right to make the revised Notice effective for protected health information we have about you as well as any information we receive in the future. In the event that there is a material change to this Notice, the revised Notice will be posted on our website. In addition, you may request a copy of the revised Notice at any time.

Complaints/Comments. If you have any complaints concerning our Privacy Policy, including if you believe that your privacy rights have been violated, you may contact us at the address or telephone number listed below or the Secretary of the Department of Health and Human Services at 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201 (e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.). We will not retaliate against you for filing a complaint.


• You have the right to a copy of this Notice in paper form.
• You may ask us for a copy at any time.
• You may also obtain a copy of this form on our web site: www.bas100.com
• To exercise any of your rights, or for further information about this Notice, please contact us in writing at Privacy Officer, 350 Blountville Hwy #207, Bristol, Tennessee 37620. You may also contact the Privacy Officer at (423) 968-2313.

Notice of Nondiscrimination

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