Surgeon’s Incorporated and / or Hamilton Surgical Arts Notice of Privacy Practices

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;

Our Privacy Contact is Lissa, Kelly, and/or Dr. Jackson or Dr. Lowery

This Notice of Privacy Practice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected Health Information is information about you, including demographic information that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices . We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. A revised copy of the Notice of Privacy Practice will be available in the offices at 801 West Gardner Drive, MARION and/or 9660 EAST 146th STREET, NOBLESVILLE, INDIANA, at any time during office hours.

Users and Disclosures of Protected Health Information.

Uses and disclosures or Protected Health Information Based on Your Written Consent

You will be asked by your physicians office to sign a consent form. Once you have consented to use and disclose of your protected health information for treatment, payment and health care operations by signing a consent form, your physician will use or disclose your protected health information as described. Your protected health information may be used and disclosed by your physician, his office staff and others outside of the physicians office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the physicians office.

Following are examples of the types of uses and disclosures of your protected health care information that our office is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to our protected health information. For example , we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physician who may be treating you when we have the necessary permission from you to disclose your protected health information. For example , your protected health information may be provided to a physician/s to whom you have referred to ensure that the physician has the necessary information to diagnose to treat you.

In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertake utilization review activities. For example , obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physicians practice. These activities include, but are not limited to quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conduction or arranging for other business activities.

For example , we may disclose your protected health information to health professional students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We will share your protected health information with third party business associates that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involved the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect privacy of your protected health information.

Facility Directions: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Members of the clergy will be told your religious affiliation.

Others Involved in your Healthcare: We will only disclose to a member of your family, a relative, a close friend or any other person that you have identified on our permission to give medical information form inserted in your medical chart, your protected health information that directly relates to that persons involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in best interest based on our professional judgment.

We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Emergencies: We may use or disclosed your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonable practicable after the delivery of treatment. If your physician or other physician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclosed your protected health information to treat you.

Communication Barriers: We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclose under the circumstances.

Other Permitted and Required Used and Disclosures That May be Made Without Your Consent, Authorization or Opportunity to Object.

We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:

Required by Law : We may disclose your protected information to the extent that law requires the use or disclosure. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of such uses or disclosures.

Public Health : We may disclose your protected information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority.

Communicable Disease : We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight : We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect : We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirement of applicable federal and state laws.

Food and Drug Administration : We may also disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products, to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings : We many also disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of the court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement : We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the even that a crime occurs on the premises of the practice, and (6) medical emergency (not on that Practices premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation : We may disclose protected health information to a coroner or medial examiner for identification purposes, determining 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 carryout their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.

Research : We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security : When the appropriate conditions apply, we may use or disclose protected health information or individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of the foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protected services to the President or others legally authorized.

Workers Compensation : Your protected health information may be disclosed by us as to comply with workers compensation laws and other similar legally established programs.

Inmates : We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Required Uses and Disclosures : Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. Seq.

Your Rights : Following is a statement of your rights with respect to you protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information : This means you may inspect and obtain a copy of your protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A designed record set contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. Please be advised that if you are requesting copies of your records that there will be a charge for those copies .

Under federal law, however, you may not inspect copies of the following records; psychotherapy notes; information compiled in a reasonable anticipation of, or use in, a civil, or administrative action or proceeding, and protected healing information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical records.

You have a right to request a restriction of your protected health information:This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by requesting a form from the offices of Robert F. Jackson, M.D., Chris Lowery, D.O., Hamilton Surgical Arts in Noblesville, Indiana and/or Surgeon’s incorporated in Marion, Indiana.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location: We will accommodate reasonable requests. We may also 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 request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.

You may have the right to have your physician amend your protected health information: This means you may request an amendment of protected health information about you in a designated record set for as along 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. Please contact our Privacy Contact to determine if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information: This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices . It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain expectations, restrictions and limitations.

You have the right to obtain paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

You may contact our Privacy Contact, Lissa, Kelly, and/or Dr. Jackson or Dr. Lowery, at 765-662-8303, 317-773-6677, or 800-708-2462, for further information about the complaint process.

This notice was published and becomes effective on or before April 14, 2003.

Amended 11/5/14

For further informationphn_icon 317-773-6677 Or Email

Get in touch today!

Take the next step by scheduling your consultation online.

Name: *

Phone: *

Email: *

Preferred Location: *

How can we help you?

Sign me up for news & specials!

Get a Free Breast Enhancement Consultation

The first step in achieving your ideal figure with breast enhancement is scheduling your complimentary consultation with Dr. Andan. Contact us today to schedule your free consultation. We look forward to helping you achieve your ideal figure.
Book an Appointment