Please click on any of the following Notices to read.
Fountains Surgical Center complies with applicable Federal civil rights laws and does not discriminate based on race, color, national origin, age, disability, or sex.
Fountains Surgical Center does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
If you need these services, contact our Civil Rights Coordinator,
at (769) 300-0720.
If you believe that Fountains Surgical Center has failed to provide these services or discriminated in another way based on race, color, national origin, age, disability, or sex, you can file a grievance with:
Fountains Surgical Center
ATTN: Civil Rights Coordinator
129 Fountains Boulevard, Suite 301
Madison, Mississippi 39110
O: (769) 300-0720
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights Coordinator 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.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 769-300-0720.
CHÚ Ý: Nếu bạn nói Tiếng Viet, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 769-300-0720.
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika
nang walang bayad. Tumawag sa 769-300-0720.
رقم 0270-003-967 ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان.
اتصل برقم
ھاتف الصم والبكم
ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 769-300-0720 (ATS: 769-300-0720).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 769-300-0720.
ACHTUNG: Wenn Sie Deutschsprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 769-300-0720.
توجھ:اگربھزبانفارسیگفتگومی کنید،تسھیلاتزبانی بصورترایگانبرای شمافراھممی باشد.با. 769-300-
0720.
ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝Եթեխոսումեքհայերեն, ապաձեզանվճարկարողենտրամադրվելլեզվականաջակցությանծառայություններ: Զանգահարեք 769-300-0720.
LUS CEEV: Yogtiaskojhais lusHmoob, covkevpabtxog lus,muajkevpabdawbraukoj.Hurau1-769-300-0720.
ল�য্করনঃযিদআপিনবাংলা, কথাবলেতপােরন, তাহেলিনঃখরচায়ভাষাসহায়তাপিরেষবাউপল�আেছ।েফানকরন১769-300-0720.
ማስታወሻ: የሚናገሩትቋንቋኣማርኛከሆነየትርጉምእርዳታድርጅቶች፣በነጻሊያግዝዎትተዘጋጀተዋል፡ወደሚከተለውቁጥርይደውሉ1-769-300-0720.
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-769-300-0720.
주의: 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-769-300-0720.
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-769-300-0720.
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-769-300-0720.
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-769-300-0720.
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-769-300-0720
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il umero 1-769-300-0720.
ध्यानद�: य�दआप �हदीबोलते ह �तो आपके िलए मुफ्त म� भाषा सहायता सेवाएं उपलब्ध ह।� 1-769-300-0720
AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel 1-769-300-0720
PERHATIAN: Jika Anda berbicara dalam Bahasa Indonesia, layanan bantuan bahasa akan tersedia secara gratis. Hubungi 1-769-300-0720
DİKKAT: Eğer Türkçe konuşuyor iseniz, dil yardımı hizmetlerinden ücretsiz olarak yararlanabilirsiniz. 1-769-300-0720
ΠΡΟΣΟΧΗ:Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν.Καλέστε 1-769-300-0720
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 the Privacy Officer at (769) 300-07230.
OUR PLEDGE REGARDING YOUR INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at Fountains Surgical Center. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all the records of your care generated by our practice. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
We use and disclose medical information in many ways. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to our doctors, nurses, technicians, nursing or medical students, or hospital personnel who are involved in taking care of you. We may also share medical information about you in order to coordinate the different things you need such as prescriptions, lab work or diagnostic testing. We may also disclose medical information about you to people who may be involved in your medical care such as family members, clergy, rehabilitation centers, etc. For Payment: We may use and disclose medical information about you so that the treatment and services you receive at Fountains Surgical Center, may be billed and payment may be collected from you or on your behalf from an insurance company or a third party. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Healthcare Operations: we may use and disclose medical information about you for our Fountains Surgical Center operations. These uses and disclosures are necessary to run our organization and make sure that all our patients receive quality care.
Appointment Reminders: we may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at Fountains Surgical Center.
Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health Related Benefits and Services: we may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
As Required by Law: we will disclose medical information about you when required to do so by federal, state, or local law.
To Avert a Serious Threat to Health or Safety: we may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
For All Other Uses and Disclosures: All other uses and disclosures of information not contained in this Notice of Privacy Practices will not be disclosed without your authorization.
SPECIAL SITUATIONS FOR USES AND DISCLOSURE
Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs.
Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following:
Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil right laws.
Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement: We may release medical information if asked to do so by a law enforcement officer:
crime or victims; or the identity, description or location of the person
who committed the crime.
Coroners, Medical Examiners, and Funeral Directors: We may release medical information to a coroner or a medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law
Protective Services for the President and others: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services.To file a complaint with CPC for Surgery, write to the Privacy Officer at Comprehensive Pain Center for Surgery, 129 Fountains Boulevard, Madison, Mississippi, 39110.
All complaints must be submitted in writing. YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:
Right to inspect and copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Tim Nichols, Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request, in writing, that the denial be reviewed. Another licensed health care professional chosen by Fountains Surgical Center, will review your request and the denial. The person conducting the review will not be the person who previously denied your request. We will comply with the outcome of the review.
Right to Amend: If you feel that medical information we have about you is incomplete or incorrect, you may ask us to include additional information in your medical record. You have the right to request an amendment for as long as all the information, both old and new, is kept by Fountains Surgical Center. To request an amendment, your request must be made in writing and submitted to our privacy officer. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of disclosures we made of medical information about you, excluding disclosures for the purpose of treatment, payment, and healthcare operation. To request this list or accounting of disclosures, you must submit your request in writing to the Administrator. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to our Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to our Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must tell us how or where you wish to be contacted. If you do not tell us how or where you wish to be contacted, we do not have to follow your request.
Right to Restrict Release of Information for Certain Services: You have the right to restrict the disclosure of information regarding services for which you have paid in full or on an out-of-pocket basis. This information can be released only upon your written authorization.
Right to a Paper Copy of this Notice: You have the right to a paper copy of this notice. You may ask us to give you a 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. To obtain a paper copy of this notice, ask any of our office staff or our Privacy Officer or you may write to our Practice at Fountains Surgical Center at 129 Fountains Boulevard, Madison, Mississippi, 39110.
Right to Breach Notification: You have the right to be notified of any breach of your unsecured healthcare information.
We may change the terms of this Notice in the future. We reserve the right to make changes and to make the new Notice effective for all medical information that we maintain. If we make changes to the Notice, we will:
PATIENT RIGHTS
Access to Care
You have the right to access healthcare.
Safety
You have the right to receive safe and high quality care.
Respect
You have the right to be treated with respect, consideration, and dignity.
Communication
You have a right to be informed by your doctor/provider about your diagnosis, evaluation, treatment, and prognosis in a way you can understand. This includes provisions of interpreting or translation services provided free of charge.
Participation
You have a right to be included in decisions and choices about your care and discharge plan. You may change providers if other qualified providers are available. You may refuse treatment.
Privacy & Confidentiality
You have a right to privacy and confidentiality of your personal matters, including while checking in, and in evaluation and treatment areas.
Comment
You have a right to comment on your care and have your concerns addressed. You have a right to ask questions and receive a timely response.
Support Person
You have the right to select someone to participate in your healthcare decisions when it is medically inadvisable for you to receiive tthe iinfforrmattiion yourrselflf.
Advance Directives
You have the right to be provided written information concerning policies on advance directives, and if requested, official State advanced directive forms.
Complaints/Concerns
We want you to have a positive experience. You should direct any problem, complaint or concern to a staff member or the manager so that immediate and appropriate action can be taken to address the concern.
PATIENT RESPONSIBILITIES
Respect
Consider the rights and well being of others. Behave respectfully toward all health care professionals and staff, as well as other patients and visitors.
Communication
Provide complete and accurate information about your identity and to the best of your ability about your health, any medications taken, including over-the-counter products and dietary supplements, and any allergies and/ or sensitivities.
Participation
Follow the agreed-upon treatment plan prescribed by your provider, cooperate and participate in your care when able. Ask questions if information is not understood.
Pay Fees
Accept personal financial responsibility for any charges not covered by insurance.
Transportation
Provide a responsible adult to provide transportation home and remain with you as directed by your provider or as HindoicwatetdoonMyoaukr edisachCarogeminpstlraucintiotnso. r
How to Make a Complaint or Compliment:
You should contact the manager or person in charge for
problems experienced during your stay. For any written complaints, you may use this address;
Fountains Surgical Center
ATTN: Compliance Director
129 Fountains Boulevard
Madison, Mississippi 39110
OR
If your issue is not resolved to your satisfaction, other external groups you may contact include:
MS State Department of Health & Hospitals
ATTN: Vicki Lynn Risher
PO Box 1700
Jackson, Mississippi 39216-1700 601-576-7400
Contact the Medicare Ombudsman 1-800- 633-4227
http://www.medicare.gov/claims-and-appeals/ medicare- rights/get-help/ombudsman.html
Under the Federal Patient Self Determination Act, we as healthcare providers are obliged to inform you that, as a competent adult or as the parent/legal guardian/patient representative, you have the right to make advance decisions regarding your healthcare.
In the event of a life-threatening emergency, it is the policy of Fountains Surgical Center to perform Cardiopulmonary Resuscitation (CPR) as necessary to stabilize patients for transfer to an acute healthcare facility.
If you have a Living Will or any form of Advance Directives, please inform Comprehensive Pain Center For Surgery of the same, and provide them with a copy.
Copyright © 2018 Fountains Specialty Surgical Center - All Rights Reserved.