Privacy Notice



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.  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 must follow the privacy practices described in the Notice while it is in effect.  We reserve the right to change the terms of the 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 the current Notice at any time by making a request to our Privacy Officer at the address provided at the end of this Privacy Notice.  You may also direct any questions about this notice to our Privacy Officer. 



We will use and disclose health information to provide treatment, obtain payment and conduct health care operations.  We will limit the use and disclosure of your protected health information to that which is the minimum necessary to accomplish the purpose of the use, disclosure, or request and to meet legal requirements. 

  1. Treatment:  To provide and coordinate your health care.  For example, we may disclose health information to physicians or other health care providers who may be treating you or are otherwise involved in the provision, coordination, or management of your medical care.  Examples include your physicians, anesthesia provider or pharmacist.

  2. 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 receives payment.  For example, we may give information to health care providers so they can contact your insurer about payment for their services.

  3. Operations:  To perform our own health care activities such as quality assessment and improvement, licensing/credentialing and general business administration.

  4. Other Uses and Disclosures:  To remind you of appointments or to contact a family member, friend or other person to the extent necessary to help with your health care, payment for your health care 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.

  5. Other Permitted and Required Uses and Disclosures:  To comply with laws and regulations.

    When legally required by any international, federal, state or local law, or as required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the federal privacy requirements.

    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, replacements or review.
    • To notify a person, when authorized by law, 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.

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

    In connection with Judicial and Administrative Proceedings such as in the course of any judicial or administrative proceedings.

    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; and (5) if crime occurs on our premises.  Examples are:
    • As required by law for reporting of certain types of wounds or other physical injuries.
    • 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 and Tissue Donation to handle organ procurement or other entities engaged in procurement to facilitate organ, eye or tissue donation and transplantation.

    Coroners, Medical Examiners and Funeral Directors.  For coroners and medical examiners,  as necessary for identification purposes, determining cause of death, and performing other duties authorized by law.  For funeral directors, to permit the funeral director to carry out his duties as authorized by law.  We may disclose such information in reasonable anticipation of death. 

    For Research Purposes when the use or discloser 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. 

    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.

    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 situation.

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

    Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

    Data Breach Notification Purposes to provide legally required notices of unauthorized access to or disclosure of your health information. 



● Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care or payment for your health care.  If you are unable to agree of object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. 

●We may 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.  We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

●We may also use your protected health information for fundraising activities.  If we use or disclose your protected health information for fundraising activities, we will provide you the choice to opt out of those activities.  You may also choose to opt back in. 



● Uses and disclosures of protected health information for marketing purposes, except if the communication is in the form of a face-to-face communication made by us to you or a promotional gift from us of nominal value.  If the marketing involves direct or indirect financial remuneration to us from a third party, the authorization will state that such remuneration is involved.

● Uses and disclosures that constitute a sale of your protected health information.  Any authorization will state that the disclosure results in remuneration to us. 

● Other uses and disclosures of protected health information not covered by this Notice or the laws that apply to us will be made only with your written authorization.  If you do give us authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer, and we will no longer disclose protected health information under the authorization. 


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.


  1.  See and copy your medical records and other records used to make treatment and payment decisions about you.  There are some limitations, based upon federal law.   You must submit a written request to see or copy your health information.  We have up to 30 days to make your protected health information available to you.  We may charge a reasonable fee for the costs associated with your request.  If, in our professional judgment, we determine that the access requested is likely to endanger the life or safety of you or another person, your request may be denied.  You have the right to request a review of the denial.  If your protected health information is maintained in an electronic format, you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity.  We will make every effort to provide you your protected health information in the form or format you request, if it is readily producible.

  2. Receive Notice of a Breach of any of your unsecured protected health information.

  3. Request a restriction or limitation on the health information we use or disclose for treatment, payment or health care operations.  You may also request a limit on health information we disclose to someone involved in your care or the payment for your care, like a family member or friend.  You must submit a written request for the restriction or limitation to our Privacy Officer, and such request must state the specific type of restriction or limitation requested, the information to be restricted, and to whom you want the restriction to apply.  We will agree to your request for restriction if (1) the disclosure is for the purpose of carrying out treatment, payment or health care operations and is not otherwise required by law, and (2) the Protected Health Information pertains solely to a health care item or service for which you, or an individual on your behalf, have paid us in full.  We will notify you if we deny your request.  If the facility does agree to the requested restriction or limitation, we will abide by this agreement unless use or discloser of the information becomes essential to provide emergency treatment.

  4. 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 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.  Your request must be made in writing to our Privacy Officer.

  5. 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.  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.  If you have questions about amending your medical record, please contact our Privacy Officer.

  6. The right to receive an accounting of disclosures.  You may have the right to request an accounting of how we or our business associates disclosed your protected health information for purposes other than treatment, payment of health care operations or for which you provided written authorization.  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.  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 (6) years.  The request for an accounting must be made in writing, and your right to receive this information is subject to certain exceptions, restrictions, and limitations.  The exception above for treatment, payment or health care operations may not apply to certain disclosures through an electronic health record in which case you may have a right to receive an accounting of disclosures of such information during only the three years prior to the date on which you request the accounting.  The first accounting you request during any twelve (12) month period will be without charge; additional accounting request may be subject to a reasonable fee. 

  7. The right to obtain a paper copy of this notice at any time.  Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.  You may obtain a copy of this notice at our website;



You 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.







JACKSON, MS  39216







Contact Info:

St. Dominic Ambulatory Surgery Center
Dominican Plaza
1st Floor, Suite 15
970 Lakeland Drive
Jackson, MS 39216


AAAHC Accreditation