NOTICE OF PRIVACY PRACTICES
GASTROENTEROLOGY SPECIALTIES, PC AND LINCOLN ENDOSCOPY CENTER, LLC
4545 R STREET, STE 100 LINCOLN, NE 68503
EFFECTIVE DATE: APRIL 14, 2003 Revised July 1, 2020
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
If you have any questions about this notice, please contact the Medical Records HIPAA Coordinator at (402) 465-4545.
Our Pledge Regarding Health Information. We understand that health information about you and your health care is personal and are committed to protecting health information about you. We create a record of the care and services you receive from to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor or others working in this office. This notice informs you how we may use and disclose health information about you and your rights to the health information we keep about you. It describes certain obligations we have regarding the use and disclosure of your health information. We are required by law to make sure that health information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to health information about you; and follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. We may use health information about you to provide you with health care treatment or services. We may
disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. We may disclose health information about you to a family member or a personal representative as designated by you, shared with those you allow to accompany you in our service areas, or disclosed to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
For Payment: We may use and disclose health information about you so that the treatment and services you receive from
us may be billed to and payment collected from you, an insurance company, or a third party.
For Health Care Operations: We may use and disclose health information about you for operations of our health care
practice. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive
quality care.
Appointment Reminders: We may use and disclose health information to contact you. We may call your home, work,
cellular or emergency contact number to remind you of an appointment, notify you of a cancellation, or give medical
or billing information. We may leave a message on your answering machine or voice mail of your upcoming appointment
or a request to return our call.
Health-Related Services and Treatment Alternatives: We may use and disclose health information to tell you about
health-related services or recommend possible treatment options or alternatives that may be of interest to you. Please let
us know if you do not wish us to send you this information, or if you wish to have us use a different address to send this
information to you.
Research. Under certain circumstances, we may use and disclose health information about you for research purposes.
For example, a research project may involve comparing the health and recovery of all patients who received one
medication to those who received another, for the same condition. We may help potential researchers look for patients
with specific health needs, so long as the health information they review does not leave our facility. We will ask for your
specific permission if the researcher will have access to your name, address, or other information that reveals who you
are, or will be involved in your care.
Organ and Tissue Donation. If you are an organ donor, we may release health information to organizations that handle
organ procurement or organ eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ
or tissue donation and transplantation.
As Required By Law. We will disclose health information about you when required to do so by federal, state, or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose health information to authorized authorities
about you when necessary to prevent a serious threat to the health and safety of the public, another, or yourself.
Military and Veterans. If you are a member of the armed forces or separated/discharged from military services, we may
release health information about you as required by military command authorities or the Department of Veterans Affairs as
may be applicable.
Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs.
Public Health Risks. We may disclose health information about you for public health activities when authorized by you or
required by law such as: to prevent or control disease, injury or disability; to report births and deaths; to report child abuse
or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may
be using; to notify persons or organizations required to receive information on FDA-regulated products; to notify a person
who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify
the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.
Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by
Law such as audits, investigations, inspections, and licensure.
Lawsuits and Disputes. We may disclose health information about you in response to a subpoena, discovery request,
administrative order or other lawful process.
Law Enforcement. We may release health information if asked to do so by a law enforcement official in reporting certain
injuries, as required by law; gunshot wounds, burns, injuries to perpetrators of crime; to identify or locate a suspect,
fugitive, material witness, or missing person; name and address, date of birth or place of birth, social security number,
Blood type or Rh factor, type of injury, date and time of treatment and/or death, a description of distinguishing physical characteristics about the victim of a crime.
Coroners, Health Examiners and Funeral Directors. We may release health information to a coroner, health examiner
or Funeral director to identify a deceased person or determine the cause of death.
National Security and Intelligence Activities. We may release health information about you to authorized federal
Officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others. We may disclose health information about you to authorized federal
officials to protect the President or conduct special investigations.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may
release health information about you to the correctional institution or law enforcement official. This release would be
necessary for the institution to provide you with health care; to protect your health and safety or the health and safety of
others; or for the safety and security of the correctional institution.
Your Rights Regarding Health Information About You.
Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make
decisions about your care. This may include health and billing records. To inspect and copy your health information,
you must submit your request in writing, (using a HIPAA compliant authorization request) to Gastroenterology Specialties
Medical Records HIPAA Coordinator. If you request a copy of the information, we may charge a fee for the costs of
copying, mailing or other supplies and services associated with your request. We may deny your request to inspect and
copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial
be reviewed.
Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to
amend the information by request in writing and submitting to Gastroenterology Specialties Medical Records HIPAA
Coordinator. A Right to Amend Form may be requested by calling 465-4545, or you may submit your request for
amendment on one page of paper, legibly handwritten or typed in at least 10 point font size, and provide a reason that
supports your request for an amendment. We may deny your request for an amendment if it is not in writing, does not
include a reason to support the request, if you ask to amend information that was not created by us, is not part of the
health information kept by or for our practice; is not part of the information which you would be permitted to inspect and
copy; or is accurate and complete. Any amendment we make to your health information will be disclosed to those with
whom we disclose information as previously specified.
Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosures of your health information we have made. To request this list of disclosures, you must submit your request in writing to Gastroenterology
Specialties Medical Record HIPAA Coordinator.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use
or disclose about you for treatment, payment, or health care operations.
We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance
or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request
unless the information is needed to provide you emergency treatment. To request a restriction, submit your request in
writing to Gastroenterology Specialties Medical Record HIPAA Coordinator. In your request, be specific about what
information you want to limit and to whom you want the limits to apply.
Right to Request Confidential Communications. You have the right to request that we communicate with you about
health matters in a certain way or at a certain location. To request confidential communications, you must make your
request in writing to Gastroenterology Specialties Medical Record HIPAA Coordinator. We will accommodate all
reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. If you request a copy of this notice, please ask the receptionist.
Right to receive notification after a breach of unsecured Patient information. You have the right to receive notification by letter or email after a breach of unsecured PHI.
Changes To This Notice. We reserve the right to change this notice and will post the current notice in the facility.
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, contact Gastroenterology Specialties
Nate Kreifels, Privacy Officer. All complaints must be submitted in writing to the address noted above, if you have questions, call
402-465-4545. You will not be penalized for filing a complaint.
Other Uses Of Health Information. If you provide us permission to use or disclose health information about you, you
may revoke that permission, in writing, at anytime. If you revoke your permission, we will no longer use or disclose health
information about you for the reasons covered by your written authorization. We are unable to take back any disclosures
we have already made with your permission.
Acknowledgement of Receipt of this Notice. We will request that you sign a separate form or notice acknowledging
you have received a copy of this notice. If you choose, or are not able to sign, a staff member will sign their name and
date. This acknowledgement will be kept on file.
