Learn About Strictly Pediatrics Surgery Center

WHO WE ARE: We are partially owned by physicians who desired to provide a safe and comfortable medical facility that would provide efficient and effective services to patients.

WHAT WE ARE: We are an outpatient surgical and procedural facility licensed in the State of Texas

YOUR RIGHTS AS A PATIENT: You have the right to choose the provider and the facility for your health care services. You will not be treated differently by your physician if you obtain health care services at another facility.

YOUR CHOICE: Your physician may have ownership interest in this facility. You have the right to know this, so if you want to know, please ask. Please discuss with your surgeon your questions or concerns, if you may want to have your procedure at an alternative health care facility.

CREDENTIALS: All of the physicians and anesthetists have been credentialed according to regulations and standards. Information is available upon request.

PATIENT GRIEVANCE: If patients have complaints or concerns in regard to care at our facility, they are encouraged to let the manager know. If further review is indicated, patients are urged to fill out a grievance form, which is available upon request at the front desk. Contact information for the Center manager, for the State and for Medicare are available below.

ADVANCE DIRECTIVES: If you have an advance directive or living will and a medical emergency arises, a surgery center will transfer you to the closest hospital. A surgery center will not follow do not resuscitate requests. Please discuss with your physician if you have questions. A hospital will make decisions about following any advance directive or living will or a request to not resuscitate should your heart stop or if you should stop breathing. You have a right to have your living will or advance directive information present in our medical record and to be informed of the facility’s policy prior to the procedure. State information and forms to prepare an advance directive or living will, if you decide to have one, can be found at the following web site: http://www.dads.state.tx.us/news_info/publications/handbooks/advancedirectives.html

Please let us know if you have a complaint or concern by asking for the Administrator.
Consumer Complaints can also be made at state and federal offices:
Write the State: Texas Department of State Health Services PO Box 149347 Austin, Texas 78714-9347
State web site: http://www.dshs.state.tx.us/Licensing-Facilities.shtm
Call the State: Complaint hotline at 888-963-7111
For Medicare: Office of the Medicare Ombudsman at
http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html

Owners

Seton Healthcare Family
ASD Management
James Attra, MD
Megyn Busse, MD
Chantal Lucia Casadonte, M.D.
Bharani Challa, MD
Yue Julia Chen, M.D.
Stacey Clark, MD
Patrick Combs, MD
Jose Cortez, MD
Achal Dhruva, MD
David Easley, MD
Nilda Garcia, MD
Sharon Gnagi, M.D.
Dani Gonzalez, M.D.
Hilton Gottschalk, MD
Erich Grethel, MD
Dyer Heintz, MD
Lan T. Hoang, MD
Jeff Horwitz, MD
Marisa Izaguirre, MD
Kent Jones, MD
Michael Josephs, MD
Patrick Kelley, MD
Joseph Leary, MD
Kathleen McClain, M.D

Leslie McQuiston, MD
Vani Menon, MD
Tory Meyer, MD
Jessica Naiditch, MD
Ankur Rana, MD
Sujal Rangwalla, MD
Daniel Ratcliff, MD
Corrie Roehm, MD
Julie Sanchez, MD
Anees Siddiqui, MD
Drew S. Sawyer, MD
Suzanne Smart, MD
Amber Fenton, MD
Scott Sebastian, MD
George Seremetis, MD
John Caleb Simmons, M.D.
Danielle Smith, MD
Juliana Vaughan, MD
Adam Weinfeld, MD
Kelley Nast, MD
Mary Wang MD
Robert Williamson, MD
Michael Yium, MD
Jeffrey Zapalac, MD
Robert J. Zwiener, MD

Notice Informing Individuals about Nondiscrimination and Accessibility Requirements

This Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Center does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
We

Provide free aid and services to people with disabilities to communicate effectively with
us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic
  formats, other formats)
free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact an employee who will assist you in obtaining the
services.

If you believe that we have 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

Strictly Pediatrics Surgery Center
1301 Barbara Jordan Blvd., Suite 100
Austin, TX 78723
Robert Knox, RN

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance,
the administrator or another manager 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/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
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

The staff of this health care facility recognizes you have rights while a patient receiving medical care. In return, there are responsibilities for certain behavior on your part as the patient. This statement of rights and responsibilities is posted in our facility in at least one location that is used by all patients.

Your rights and responsibilities include:

A patient, patient representative or surrogate has the right to

Receive information about rights, patient conduct and responsibilities in a language and manner the patient, patient representative or surrogate can understand.
Be treated with respect, consideration and dignity.
Be provided appropriate personal privacy.
Have disclosures and records treated confidentially and be given the opportunity to approve or refuse record release except when release is required by law.
Be given the opportunity to participate in decisions involving their health care, except when such participation is contraindicated for medical reasons.
Receive care in a safe setting.
Be free from all forms of abuse, neglect or harassment.
Exercise his or her rights without being subject to discrimination or reprisal with impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical disability, or source of payment.
Voice complaints and grievances, without reprisal.
Be provided, to the degree known, complete information concerning diagnosis, evaluation, treatment and know who is providing services and who is responsible for the care. When the patient’s medical condition makes it inadvisable or impossible, the information is provided to a person designated by the patient or to a legally authorized person.
Exercise of rights and respect for property and persons, including the right to
- Voice grievances regarding treatment or care that is (or fails to be) furnished.
- Be fully informed about a treatment or procedure and the expected outcome before it is performed.
- Have a person appointed under State law to act on the patient’s behalf if the patient is adjudged incompetent under applicable State health and safety laws by a court of proper jurisdiction. If a State court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with State law may exercise the patient’s rights to the extent allowed by State law.
Refuse treatment to extent permitted by law and be informed of medical consequences of this action.
Know if medical treatment is for purposes of experimental research and to give his consent or refusal to participate in such experimental research.
Have the right to change primary or specialty physicians or dentists if other qualified physicians or dentists are available.
A prompt and reasonable response to questions and requests.
Know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
Receive, upon request, prior to treatment, a reasonable estimate of charges for medical care and know, upon request and prior to treatment, whether the facility accepts the Medicare assignment rate.
Receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have charges explained.
Formulate advance directives and to appoint a surrogate to make health care decisions on his/her behalf to the extent permitted by law and provide a copy to the facility for placement in his/her medical record.
Know the facility policy on advance directives.
Be informed of the names of physicians who have ownership in the facility.
Have properly credentialed and qualified healthcare professionals providing patient care.
Know your physician has malpractice insurance, as required by the state.

A patient, patient representative or surrogate is responsible for

Providing a responsible adult to transport him/her home from the facility and remain with him/her for 24 hours, unless specifically exempted from this responsibility by his/her provider.
Providing to the best of his or her knowledge, accurate and complete information about his/her health, present complaints, past illnesses, hospitalizations, any medications, including over-the-counter products and dietary supplements, any allergies or sensitivities, and other matters relating to his or her health.
Accept personal financial responsibility for any charges not covered by his/her insurance.
Following the treatment plan recommended by his health care provider.
Be respectful of all the health providers and staff, as well as other patients.
Providing a copy of information that you desire us to know about a durable power of attorney, health care surrogate, or other advance directive.
His/her actions if he/she refuses treatment or does not follow the health care provider’s instructions.
Reporting unexpected changes in his or her condition to the health care provider.
Reporting to his health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
Keeping appointments.

COMPLAINTS
Please contact us if you have a question or concern about your rights or responsibilities. You can ask any of our staff to help you contact the Administrative Director at the surgery center. Or, you can call 512-904-4450

We want to provide you with excellent service, including answering your questions and responding to your concerns.

You may also choose to contact the licensing agency of the state,
Texas Department of State Health Services
Facility Licensing Group (MC 2835)
P.O. Box 149347
Austin, TX 78714-9347
512-834-6649

If you are covered by Medicare, you may choose to contact the Medicare Ombudsman at 1-800-MEDICARE (1-800-633-4227) or on line at http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html

The role of the Medicare Beneficiary Ombudsman is to ensure that Medicare beneficiaries receive the information and help you need to understand your Medicare options and to apply your Medicare rights and protections.

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

This Privacy Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes permitted or required by law. We must follow the privacy practices described in this Notice while it is in effect. We reserve the right to change the terms of this Notice and to make the new Notice effective for all future protected health information we maintain. We will post the most current Notice and make the new Notice available to anyone. You may request a copy of current Notice at any time. This Privacy Notice also describes your rights to access and control your “protected health information” which is health information that is created or received by your health care provider.We may contract with business associates through the course of our operations such as those companies that process your health care claim, review insurance information, provide coding and billing services. We require the business associate sign an agreement and agree to safeguard the security and privacy of your health information.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATIONWe will use and disclose health information to provide treatment, obtain payment, and conduct health care operations.

Treatment: To provide, coordinate, and manage your health care. For example, we may disclose protected health information to physicians or other health care professionals who may be treating you or consulting with us. Examples include your physicians, anesthesia provider, or pharmacist. We may disclose information to a pharmacy to fill a prescription or to a laboratory to contact a lab test or provide specimen results.
Payment: To obtain payment for the services. This may include contact with your insurance company to get the bill paid and to determine benefits of your health plan. We may also disclose information to another provider involved in your care so the provider can get paid. For example, we may give information to anesthesia providers so they can contact your insurer about payment for their services.
Operations: To perform our own health care activities such as quality assessment and improvement, licensing or credentialing, medical record reviews, and general business administration.
Other Uses and Disclosures: To remind you of appointments or to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, or to notify family or others involved in your care concerning your location or condition. You may object to these disclosures. If you do not or cannot object, we will use our professional judgment to make reasonable assumptions about to whom we can make disclosures.
Other Uses and Disclosures Permitted: to comply with laws and regulations.
A. When Legally Required by any federal, state or local law.

B. When There Are Risks to Public Health such as:
- To prevent, control, or report disease, injury or disability as required or permitted by law.
- To report vital events such as birth or death as required by law.
- To conduct public health surveillance, investigations and interventions as required by law.
- To collect or report adverse events and product defects, track Food and Drug Administration (FDA) regulated products, enable product recalls, repairs or replacements and review.
- To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.
- To report to an employer information about an individual who is a member of the workforce as legally permitted or required.
C. To Report Suspected Abuse, Neglect Or Domestic Violence as required by law.

D.To Conduct Health Oversight Activities such as audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensing or disciplinary actions; or other activities necessary for appropriate oversight as required or authorized by law.

E. In Connection With Judicial and Administrative Proceedings such as in the course of any judicial or administrative proceeding or in response to a subpoena we receive.

F. For Law Enforcement Purposes. Examples are:
- Upon court order, court-ordered warrant, subpoena, summons or similar process.
- For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
- Under certain limited circumstances, when you are the victim of a crime.
- To law enforcement if there is concern that your health condition was the result of criminal conduct.
- In an emergency to report a crime.
G. For Organ Donation or to Coroners or Funeral Directors such as for organ, eye or tissue donations; identification purposes; performing other duties authorized by law.

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

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

J. For Specified Government Functions relating to military and veterans activities, national security and intelligence activities, protective services, medical suitability determinations, correctional institutions, and law enforcement situations.

K. For Worker’s Compensation to comply with worker’s compensation laws or similar programs.

PATIENT RIGHTS
Uses and Disclosures Permitted without Authorization but with Opportunity to ObjectWe may disclose your protected health information to your family member or a close personal friend if it is directly relevant to the person’s involvement in your surgery or payment related to your surgery. We can also disclose your information in connection with trying to locate or notify family members or others involved with your care concerning your location and condition. You may object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to that person’s involvement with your care, we may disclose your protected health information.Other than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action based upon the authorization. At the end of this Privacy Notice is information about how to contact the Privacy Officer to request information, copies, express concerns, complain, or authorize additional uses and disclosure of your health information.

YOU HAVE THE RIGHT TO:

See and copy your medical records and other records used to make treatment and payment decisions about you. There are some limitations, based upon the federal law. You must submit a written request. We may charge you a fee for copying, mailing or incurring other costs in complying with your request. We may deny your request to see or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger life or safety of you or another person. Depending upon circumstances, you may have the right to request a review of this decision.
Request a restriction on uses and disclosures of your protected health information. You may ask us not to use or disclose certain parts of your protected health information for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes. Your request must state the specific restriction requested and to whom you want the restriction to apply. If you request that the Surgery Center not disclose your protected health information to your health plan for purposes of payment or healthcare operations (but not treatment) and if you are paying the full amount from your own money for your treatment, the Surgery Center must honor your requested restriction. Otherwise, the facility is not required to agree to a restriction and we will notify you if we deny your request. If the facility does agree to the requested restriction, we will abide by this agreement unless use or disclose of the information becomes essential to provide emergency treatment. You may request a restriction by contacting the Privacy Officer.
The right to request to receive confidential communications by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will not require you to provide an explanation for your request. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.
The right to request we amend your protected health information. A request for an amendment must be in writing and it must explain why the information should be amended. Under certain circumstances, we may deny your request.
The right to receive an accounting of disclosures. You have the right to request an accounting of certain disclosures for purposes other than treatment, payment or health care operations. We are not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing and specify a time period. We are not required to provide an accounting for disclosures that occurred prior to April 14, 2003 or for periods of time in excess of six years. The first accounting you request during any 12-month period will be without charge. Additional accounting requests may be subject to a reasonable fee. After January 1, 2014 (or a later date as permitted by HIPAA), the list of disclosures will include disclosures made for treatment, payment, or health care operations using an electronic health record, if we have one for you.
The right to obtain a paper copy of this notice at any time.
The right to be informed in writing of a breach where your unsecured protected health information has been accessed, acquired, used or disclosed to an unauthorized person or entity.

OUR DUTIESThe Surgery Center is required by law to maintain the privacy of your health information and to provide you with this Privacy Notice of our duties and privacy practices. We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future protected health information that we maintain. If the Surgery Center changes its Notice, we will provide a copy of the revised Notice at your next visit. In the event there has been a breach of your unsecured protected health information, we will notify you.

COMPLAINTSYou have the right to express complaints to the facility if you believe that your privacy rights have been violated. We encourage you to express any concerns you have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint. You may complain to the facility’s Privacy Officer in person, by phone, or in writing. You also have the right to express complaints to the Secretary of the United States Department of Health and Human Services.

CONTACT PERSON TO MAKE REQUESTS, TO LEARN MORE, TO FILE A COMPLAINT, OR TO EXPRESS CONCERNS, PLEASE CONTACT THE PRIVACY OFFICER. YOU MAY MAKE CONTACT IN PERSON, BY PHONE, OR IN WRITING. CALL TO ASK FOR THE PRIVACY OFFICER OR SEND MAIL ADDRESSED TO THE PRIVACY OFFICER AT THE SURGERY CENTER.

Lynn Hileman – Privacy Officer
1301 Barbara Jordan Blvd.
Austin, Texas 78723
512-474-7337