Privacy Policy

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA).

Each time you visit a hospital, physician, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination, test results, diagnoses, treatment, and a plan for future care or treatment. This health information often referred to as your medical record, serves as a basis for planning your care and treatment. Your medical record is an essential means of communication between the many health care professionals who contribute to your care. Understanding what is in your record and how your health information is used and may be disclosed allows you to be an informed health care consumer.

This Privacy Notice describes how we may use and disclose your protected health information (PHI). Your “protected health information” (PHI) refers to the information contained in your medical record regarding your physical or mental health. This also includes demographic information used to identify you. This privacy notice also describes your rights to access and control your protected health information.

Ankeny Medical Park Surgery Center (AMPSC) may use your protected health information (PHI) for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless we have obtained your written authorization or the use or disclosure is otherwise permitted by the HIPAA privacy regulations or state law. Disclosures of your PHI for the purposes described in this Privacy Notice may be made in writing, electronically, orally, or by facsimile.

We will use or disclose your health information to provide treatment. We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the management of your health care with a third party for treatment purposes. For example, we may disclose your PHI to a pharmacy to fill a prescription or to a laboratory to perform a blood test. We may also disclose PHI to physicians who may be treating you or consulting with AMPSC or your surgeon with respect to your care. In some cases, we may also disclose your PHI to an outside treatment provider for purposes of the treatment activities of the other provider.

We will use or disclose your health information to obtain payment for the services we provide. For example, we may need to disclose health information to your health insurance company to get prior approval for the surgery, to determine whether you are eligible for benefits, or to determine if a particular service is covered under your health plan. We may also need to disclose your PHI to your health insurance company, in order to obtain payment for the services we provide to you. In addition, your health insurance company may require information so they can confirm the services we provided were medically necessary. We may also disclose health information and demographic information to another provider involved in your care for the other provider’s payment activities. An example of this would be the anesthesiologist providing anesthesia care for your surgery.

We will use or disclose your health information, as necessary, for our own health care operations. For example, members of the quality improvement committee may use information in your medical record to assess the care and outcomes in your case and other like it. This information will then be used in an effort to continually improve the quality of the care and service we provide. Other examples of health care operations include: accreditation, certification, licensing or credentialing activities, employee review activities, legal services, maintaining compliance programs, business management and general administrative activities. This also includes programs in which students, trainees, or practitioners in health care learn under supervision.
In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.

As part of treatment, payment and health care operations, we may also use or disclose your PHI for the following purposes: to remind you of your surgery date, to inform you of potential treatment alternatives or options, to inform you of health-related benefits or services that may be of interest to you,

Federal privacy rules allow us to use or disclose your PHI without your permission or authorization for a number of reasons including the following:

When Legally Required. We will disclose your PHI when we are required to do so by any federal, state or local law.

When There Are Risks to Public Health. We may disclose your PHI for the following public activities and purposes:

  • To prevent, control, or report disease, injury or disability as permitted by law.
  • To report vital events such as birth or death as permitted or required by law.
  • To conduct public health surveillance, investigations and interventions as permitted or required by law.
  • To collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.
  • 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.

To Report Suspected Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe that a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.

To Conduct Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law. We will not disclose your health information under this authority if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.

In Connection With Judicial And Administrative Proceedings. We may disclose your PHI in the course of any judicial or administrative proceeding in response to a court order as expressly authorized by such order. In certain circumstances, we may disclose your PHI in response to a subpoena to the extent authorized by state law if we receive satisfactory assurances that you have been notified of the request or that an effort was made to secure a protective order.

For Law Enforcement Purposes. We may disclose your PHI to a law enforcement official for law enforcement purposes as follows:

  • As required by law for reporting of certain types of wounds or other physical injuries.
  • Pursuant to 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 official if the facility has a suspicion that your health condition was the result of criminal conduct.
  • In an emergency to report a crime.

To Coroners, Funeral Directors, and for Organ Donation. We may disclose protected health information to a coroner or medical examiner for identification purposes; to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. Protected health information may be used and disclosed for organ, eye or tissue donation purposes.

For Research Purposes. We may use or disclose your protected health information for research when the use or disclosure for research has been approved by an institutional review board that has reviewed the research proposal to ensure the privacy of your protected health information.

In the Event of a Serious Threat to Health or Safety. We may, consistent with applicable law and ethical standards of conduct, use or disclose your PHI 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.

For Specified Government Functions. In certain circumstances, federal regulations authorize the facility to use or disclose your PHI to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.

For Worker’s Compensation. AMPSC may release your health information to comply with worker’s compensation laws or similar programs.

Communication with Family/Friend. We may disclose your PHI 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 in your care concerning your location, or condition. However, you may object to these disclosures. If you do not object, or we determine it is in your best interest for us to make a disclosure of information that is directly related to the person’s involvement with your care, we may disclose your PHI as described.

We will not disclose your (PHI) without your permission). We will not disclose your (PHI) without your permission for disclosures for marketing purposes or disclosures that constitute a sale of protected health information.

If the Orthopaedic Outpatient Surgery Center would intend to use your (PHI) for fund-raising purposes, we would inform you of such intent and give you the right to opt out of receiving the fundraising communications.

Any other uses and disclosures not described in our Notice of Privacy Practice will not be made unless you are provided an authorization. The authorization you provide may be revoked prospectively at any time by written revocation.

Your Rights –You have the following rights regarding your health information:

The right to inspect and copy your protected health information. You may inspect and obtain a copy of your PHI that is contained in the medical record for as long as we maintain the record.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative proceeding; and any health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.

We may deny your request to inspect or copy your PHI if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.

To inspect and copy your medical information, you must submit a written request to the Administrator whose contact information is listed on the last page of this Privacy Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request.

Please contact our Administrator if you have questions about access to your medical record.

The right to request a restriction on uses and disclosures of your protected health information. You may ask us not to use or disclose certain parts of your PHI for the purposes of treatment, payment or health care operations. You may ask us not to disclose PHI to a health care plan for payment for items or services which you have paid for in full and out-of-pocket. You may also request that we not disclose your health information to family members or friends who may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply.

The facility is not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If the facility does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Administrator.

The right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanation for your request. Requests must be made in writing to our Administrator.

The right to request amendments to your protected health information. You may request an amendment of your health information contained in the medical record for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be in writing and must be directed to our Administrator. In this written request, you must also provide a reason to support the requested amendments.

The right to receive an accounting. You have the right to request an accounting of certain disclosures of your PHI made by the facility. This does not apply to disclosures made for the purpose of treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Administrator. The request should specify the time period sought for the accounting. We are not required to provide an accounting for disclosures that take place prior to November 1, 2018. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

The right to obtain a paper copy of this notice. Upon request, we will provide a separate paper copy of this notice even if you have already received a copy.

The right to be notified of a breach of PHI. You have the right to receive notice of an access, acquisition, use or disclosure of your health information that is not permitted by HIPAA. If such access, acquisition, use or disclosure compromises the security or privacy of your PHI (we refer to this as a breach), we will provide such notice to you without unreasonable delay but in no case later than 60 days (in writing) after we discover the breach.

Organized Health Care Arrangement (OHCA)

Physicians and certain other practitioners who are not employed by AMPSC but who have clinical privileges at this facility need to share medical information freely with this facility’ personnel in order to effectively provide for your care. Therefore, AMPSC and these practitioners have agreed to follow uniform privacy practices outlined in this privacy notice. This arrangement is called an “organized health care arrangement” and only covers privacy practices for services rendered through AMPSC. It does not cover the information practices of the practitioners in their offices or other care settings. It does not alter the independent status of AMPSC and the practitioners or make them jointly responsible for the clinical services provided by them.

Our Duties

Ankeny Medical Park Surgery Center is required by law to maintain the privacy of your health information and to provide you with this Privacy Notice outlining our privacy practices. We are required to abide by terms of this Notice. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future PHI that we maintain. If we change the content of our Privacy Notice, we will provide a copy of the revised Notice at the time of readmission to our facility.


You have the right to express complaints to AMPSC and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the facility by contacting our Administrator verbally or in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

Contact Person

The facility’s contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Administrator. Information regarding matters covered by this Notice can be requested by contacting the Administrator. If you feel that your privacy rights have been violated by this facility you may submit a complaint to our Administrator by sending it to:

Ankeny Medical Park Surgery Center, L.C.
3625 N. Ankeny Blvd. Ste. J
Ankeny, IA 50023
ATTN: Administrator

The Administrator can be contacted by telephone at 515-965-2200

This Notice is effective February 1, 2019