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.

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NOTICE OF PRIVACY PRACTICES PURSUANT TO 45 C.F.R. § 164.520

1. Our Duties
We are required by law to maintain the privacy of your Protected Health Information ("Protected Health Information"). We must also provide you with this notice that describes the ways we may use and share your health information. We are required to abide by the terms of our Notice of Privacy Practices currently in effect. However, we reserve the right to change our privacy practices in regard to Protected Health Information and make new privacy policies effective for all Protected Health Information that we maintain. You may obtain a copy of any notice or a copy of the current privacy policy by contacting our Privacy Officer, at our current address.

2. Your Complaints
You may complain to us and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. You may file a complaint with us by sending a certified letter addressed to "Privacy Officer" at our current address, stating what Protected Health Information you believe has been used or disclosed improperly. You will not be retaliated against for making a complaint. For further information you may contact our Privacy Officer, at telephone number 801-990-1911.

3. Description and Examples of Uses and Disclosures of Protected Health Information
By signing a Consent form regarding the use and disclosure of your Protected Health Information, you agreed that we may use and disclose your Protected Health Information to carry out (i) treatment, (ii) payment, and (iii) health care operations. Here are some examples of our use of your Protected Health Information. In connection with treatment, we will, for example, allow a physician associated with us to use your medical history, symptoms, injuries or diseases to treat your current condition. In connection with payment, we will, for example, send your Protected Health Information to your insurer or to a federal program, such as Medicare, that pays for your treatment. This allows us to obtain payment for the services we rendered on your behalf. In connection with Health Care Operations, we will, for example, allow our auditors, consultants, or attorneys access to your Protected Health Information to determine if we billed you accurately for the services we provided to you.

4. Description of Uses and Disclosures We May Make Without Your Consent
Even without your consent, the privacy regulations, gives us the right to use and disclose your Protected Health Information: (i) for health oversight activities such as investigations, audits, and inspections; (ii) if we have an indirect treatment relationship with you, (iii) if, in an emergency treatment situation, we attempt to obtain consent as soon as reasonably practicable after we delivered such emergency treatment; (iv) if we are required by law to treat you, and we try but are unable to obtain such consent; or (v) if we attempt to obtain consent from an individual who has substantial barriers to communicating, but we determine in our professional judgment, that your consent to receive treatment is clearly inferred from the circumstances. The purposes for which we might use your Protected Health Information would be to carry out treatment, payment, and health care operations similar to those described in Paragraph 1.

5. Other Uses and Disclosures Require Your Authorization
Uses and disclosures other than those allowing us to carry out treatment, payment, and health care operations, and other than those for which you consent is not required by law, will only be made by obtaining a written authorization from you. You may revoke this authorization in writing at any time, except to the extent that we have taken action in reliance of your authorization.

6. Uses of Protected Health Information to Contact You
We may use your Protected Health Information to contact you regarding appointment reminders or to contact you with information about treatment alternatives or other health-related benefits and services that, in our opinion, may be of interest to you. We may use your Protected Health Information to contact you in an effort to raise funds for our operations.

7. Disclosures of Protected Health Information for Billing Purposes
We may disclose your billing information to any person that calls our billing company with billing question after we verify the identity of the person by requesting information such as your social security number or health plan number.

8. Individual Rights
(i) You may request us to restrict the uses and disclosures of your Protected Health Information, but we do not have to agree to your request. (ii) You have the right to request that we communicate with you regarding your Protected Health Information in a confidential manner or pursuant to an alternative means, such as by a sealed envelope rather than a postcard, or by communicating to a specific phone number, or by sending mail to a specific address. (iii) You have the right to request that you be allowed to inspect and copy your Protected Health Information, including medical and billing records. Fees may apply. Under limited circumstances, we may deny you access to a portion of your health information and you may request a review of the denial. (iv) You have the right to request corrections or additions to your health information. (v) You have the right to request and accounting of certain disclosures of your health information made by us. The accounting does not include disclosures made for treatment, payment, and healthcare operations and some disclosures required by law. Your request must state the period of time desired for the accounting, which must be within the six years prior to your request and exclude dates prior to April 14, 2003. The first accounting is free but a fee will apply if more than one request is made in a 12-month period. All requests must be made in writing. Contact the Mountain West Anesthesia Office for the appropriate form for your request.

9. Effective Date
The effective date of this Notice is January 22, 2003; Updated Nov 2009.

10. Provider:

  • Mountain West Anesthesia, L.L.C.
  • 3340 N. Center Street, Suite 800
  • Lehi, UT
  • 84043

  • Phone: 801-990-1911
  • Fax: 801-990-1912