Patient Information

Important Note: If you request your medical records, there will be a $35 fee

We are in network with most commercial insurances!

The goal of our doctors, nurses, and staff...

Is make your visit as pleasant and comfortable as possible. To make your surgery a successful experience, we believe it is helpful that you, the patient, have access to educational material pertaining to your surgery.

Although your physician remains the best source for information, we hope you find the material presented to be of assistance as you prepare for your surgery.

Procedure Descriptions

Your Rights as a Patient

The following list of patient rights is not intended to be all inclusive. Patients receiving care at our center have a right to:

  • Be treated with respect, consideration and dignity. 
  • Exercise these rights and treated without regard to gender, race, cultural, economic, educational or religious background and without fear of discrimination or reprisal. 
  • Be treated in a safe environment that is free of physical or psychological threats. 
  • Expect that any architectural barriers identified will be addresses, and, whenever feasible, such barriers will be modified or corrected. 
  • Access communication aids (i.e., interpreters, sign language, etc.).  
  • Be provided appropriate privacy and confidentiality concerning their medical care – the patient has the right to be advised as to the reason for the presence of any individual directly involved or observing their care 
  • Be free of restraint except when indicated to protect the patient or others from injury. 
  • Have their questions, concerns or complaints addressed in good faith. 
  • Expect continuity of care. The patient will not be discharged or transferred to another facility without prior notice, except in the case of a medical emergency and within the limits of legal regulations. 
  • Provisions for after-hour and emergency care. 
  • Access necessary surgical and/or procedural interventions that are medically indicated. 
  • Obtain any information they need to give informed consent before any treatment or procedure. 
  • Be provided, to the degree known, complete and timely information concerning their diagnosis, evaluation, treatment and prognosis. When it is medically inadvisable to give such information to a patient, the information is provided to a person designated by the patient or to a legally authorized person.
  • Make choices and decisions regarding their medical care to the extent permitted by law – this includes the right to refuse treatment.
  • Formulate advance directives and appoint a surrogate to make health care decisions on their behalf to the extent permitted by law. The provision of the patient?s care shall not be conditioned on the existence of an advance directive. (please see the center’s policy on advanced directives below).  
  • Have their disclosures and records treated confidentially, and given the opportunity to approve or refuse their release, except when release is required by law. 
  • Receive, on request, and at a reasonable fee established by the Health Information Management Department, a copy of their medical record. 
  • Know the services available at the organization. 
  • Know the facility fees for services. 
  • Request an itemized statement of all services provided to them through the facility, along with the right to be informed of the payment methodology utilized. 
  • At their own expense, to consult with another physician or specialist if other qualified physicians or dentists are requested and available. 
  • Be informed of patient conduct and responsibilities rules. 
  • Refuse to participate in experimental research. 
  • Know the identity, professional status, institutional affiliation and credentials of health care professionals providing their care, and be assured these individuals have been appropriately credentialed according to the policies of the center. 
  • Be informed of their right to change their provider if other qualified providers are available. 
  • Be provided with appropriate information regarding the absence of malpractice insurance coverage. 
  • Be informed about procedures for expressing suggestions, complaints and grievances, including those required by state and federal regulations

Your Responsibilities as a Patient

The care a patient receives depends partially on the patient. Therefore, in addition to these rights, a patient has certain responsibilities that are presented to the patient in the spirit of mutual trust and respect. Patient Responsibilities require the patient to:

  • Provide complete and accurate information to the best of his/her ability about his/her health, any medications, including over-the-counter products and dietary supplements and any allergies or sensitivities.
  • Make it known whether he/she clearly comprehends the course of his/her medical treatment and what is expected of him/her.
  • Follow the treatment plan prescribed by his/her provider.
  • Keep appointments and notify surgery center or physician when unable to do so.
  • Provide a responsible adult to transport him/her home from the facility and remain with him/her for 24 hours, if required by his/her provider.
  • Accept responsibility for his/her actions should he/she refuse treatment or not follow his/her physician’s orders.
  • Accept personal financial responsibility for any charges not covered by his/her insurance.
  • Follow our facility’s policies and procedures.
  • Be respectful of all the health care providers and staff, as well as other patients.

Legal Information:

Ownership Disclosure

The physician who referred you to this facility may have an ownership interest in this facility. You are free to choose another facility in which to receive the services that have been ordered by your physician.

Nondiscrimination Policy

This facility does not discriminate against any person on the basis of age, sex, race, color, religion, national origin, or disability in admission, treatment, or participation in its programs, services and activities or in employment.

Patient Grievances

The patient and family are encouraged to help the facility improve its understanding of the patient?s environment by providing feedback, suggestions, comments and/or complaints regarding the service needs, and expectations.

A complaint or grievance should be registered by contacting the center and/or a patient advocate at the Ohio Department of Health or Medicare (numbers listed below).

The surgery center will respond in writing with notice of how the grievance has been addressed.


Cori Grice, RN, Administrator
6520 West Campus Oval
New Albany, OH 43054

Ohio Department of Health Complaint Unit
246 N. High Street, 2nd FL, Columbus 43215

Medicare Beneficiary Ombudsman
1-800-MEDICARE (1-800-633-4227) (ombudsman link is on left hand column)

The Joint Commission
One Renaissance Blvd.
Oakbrook Terrace, IL 60181

Advance Directives

In accordance with Ohio law, this center must inform you that we are not required to honor and do not honor DNR directives. A healthcare power of attorney will be honored.

If a patient should provide his/her advance directive a copy will be placed on the patient?s medical record and transferred with the patient should a hospital transfer be ordered by his/her physician.

At all times the patient or his/her representative will be able to obtain any information they need to give informed consent before any treatment or procedure.

In order to assure that the community is served by this facility, information concerning advance directives is available at the facility. While the state of Ohio does not have required a specific form for an advanced directive, sample forms are available at the center?s office. To obtain this form and information, please call (614)413-2233.

Patient Guardian

The patient’s guardian, next of kin, or legally authorized responsible person has the right to exercise the rights delineated on the patient’s behalf, to the extent permitted by law, if the patient:

    • Has been adjudicated incompetent in accordance with the law. 
    • Has designated a legal representative to act on their behalf. (Must bring copy of legal documentation).  
    • Is a minor.

HIPAA Patient Privacy


Federal Law (the Health Insurance Portability and Accountability Act or ?HIPAA?) requires that health care providers inform patients of their rights regarding how ?protected health information? (or ?PHI?) may be used and disclosed to complete treatment, payment, health care operations and other purposes that are permitted or required by law. This Privacy Notice describes our privacy practices as they relate to your ?PHI? and as allowed by law. It also describes your rights in regard to accessing and controlling your ?protected health information? in some cases. ?Protected health information? means any written or verbal health information about you that includes individually identifiable data that can be used to identify the health information directly as yours. (For example, your social security number or birthdate with your name.) ?PHI? refers to any and all information created or received by your health care providers that relates to your past, present or future physical or mental health care and treatment.

Contact Person

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

Your Health Record and ?protected health information?
Each time you receive medical care from a physician, surgical center, hospital, or other healthcare provider, a record of your visit is created. This record typically includes, but is not limited to, information such as your name, age, address, a history of your illness, injury or symptoms, any test results, x-rays and laboratory work, the treatment provided to you and treatment plans devised for your care, and notes on follow-up care to be performed. How your health care information may be used and what control you may exercise over the use of your healthcare information is described in this Privacy Notice. Any changes that you wish to make must be put in writing and sent directly to the person listed above.

Uses and Disclosures of ?protected health information?
The Facility may use your ?protected health information? 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 the Facility has obtained your authorization for the use or disclosure is otherwise permitted by the HIPAA privacy regulations or state law. Disclosures of your ?protected health information? for the purposes described in this Privacy Notice may be made in writing, orally, or by facsimile.

Treatment. We may 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 anesthesia providers, nurses, technicians, lab personnel, radiology personnel, Facility staff involved in your care or a third party for treatment purposes. For example, we may disclose your ?protected health information? to a laboratory to order pre-operative tests or to a pharmacy to fill a prescription. We may also disclose ?protected health information? to health care providers who may be treating you or consulting with the Facility with respect to your care. In some cases, we may also disclose your ?protected health information? to people outside the Facility who may be involved in your medical care while you are in the Facility, such as your personal or referring physician; or after you leave the Facility, such as other physicians, health care workers, family members, or others who care for you or who may provide services that are part of your care.

Payment. Your ?protected health information? will be used, as needed, to obtain payment for the services that we provide. This may include certain communications to your health insurance company to get approval for the procedure that we have scheduled. For example, we may need to disclose information to your health insurance company to get prior approval for the surgery. We may also disclose ?protected health information? to your health insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. In order to get payment for the services we provide to you, we may also need to disclose your ?protected health information? to your health insurance company to demonstrate the medical necessity of the services or, as required by your insurance company, for utilization review. We may also disclose patient information to another provider involved in your care for the other provider?s payment activities. This may include disclosure of demographic information to anesthesia care providers for payment of their services.

Operations. We may use or disclose your ?protected health information?, as necessary, for our own health care operations to facilitate the function of the Facility and to provide quality care to all patients. Health care operations include such activities as: quality assessment and improvement activities, employee review activities, training programs including those in which students, trainees, or practitioners in health care learn under supervision, accreditation, certification, licensing or credentialing activities, review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs, and business management and general administrative activities.

In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.

Other uses and disclosures for health care operations may include:

  • Care management
  • Protocol Development
  • Training, accreditation, certification, licensing, credentialing or other related activities
  • Activities related to improving health care or reducing health care costs
  • Underwriting and other insurance related activities
  • Medical review and auditing
  • Business planning and/or development
  • Internal grievance resolution

Appointment Reminders. We may use or disclose your ?protected health information? to contact you, a family member or friend involved in your health care or as authorized by you as a reminder that you have an appointment for treatment or medical care at our Facility. We may also leave a message on your answering machine / voicemail system or send you mail unless you tell us not to.

Treatment Alternatives. We may use or disclose your ?protected health 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 or disclose your ?protected health information? to tell you about health related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment of Your Care. We may use or disclose your ?protected health information? to a friend or family member who is involved in your medical care and/or present during your medical care and treatment in our Facility. We may also give information to someone assisting you in the payment for your care. We may also tell your family or friends that you are in the Facility at the time of your care, or that information may be communicated to an entity assisting in a disaster relief effort in order to communicate your condition status and location to your family. If you want any of this information restricted you must communicate that to us using the appropriate procedure which can be explained to you by Facility staff.

Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one procedure to those who received another procedure for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with the patients? need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process, but we may, however, disclose health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific health needs, so long as the health information they review does not leave the hospital. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the Facility.

As Required By Law. We will disclose health information about you when required to do so by federal, state, or local law. This may include reporting of communicable diseases, wounds, abuse, disease/trauma registries, health oversight matters and other public policy requirements. We may be required to report this information without your permission.

To Avert a Serious Threat to Health or Safety. We may use and disclose health information 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 Conduct Health Oversight Activities. We may disclose your ?protected health information? to a health oversight agency (i.e. State Health Department) 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 ?protected health information? in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order. In certain circumstances, we may disclose your ?protected health information? 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 ?protected health information? 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 a 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.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

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. 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.

For Specified Government Functions. In certain circumstances, federal regulations authorize the Facility to use or disclose your ?protected health information? 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. The Facility may release your health information to comply with worker’s compensation laws or similar programs. Many HIPAA Privacy provisions do not apply to health care delivered under Workers? Compensation coverage or to the health information generated as part of that care and treatment.

Employers. We may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.

Uses and Disclosures which you Authorize. 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 in reliance upon authorization and have already released your ?PHI?.

Your Rights
Although your health record is the physical property of the healthcare practitioner or Facility that compiled it, the information belongs to you. You have the following rights regarding your health information:

Right to Inspect and copy your ?protected health information?. You may inspect and obtain a copy of your ?protected health information? that is contained in a designated record set for as long as we maintain the ?protected health information?. A “designated record set” contains medical and billing records and any other records that your physician and the Facility use for making decisions about you. 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 action or proceeding; and ?protected 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 ?protected health information? 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 Privacy Officer whose contact information is listed on the first 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 Privacy Officer if you have questions about access to your medical record.

Right to Request amendments to your ?protected health information?. If you feel the health information we have in your record is incorrect or incomplete, you may request an amendment of the information 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. In addition, we may deny your request if you ask us to amend information that:

  • Was not created by this Facility, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the health information kept by or prepared for our Facility;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.

Requests for amendment must be in writing and must be directed to our Privacy Officer. In this written request, you must also provide a reason to support the requested amendments.

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 ?protected health information? for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in this Privacy Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply. For example, you could ask that (1) we not use or disclose information about a surgery you had or (2) that certain people are not told certain information.

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 ?protected health information? 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 Privacy Officer.

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 for 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 Privacy Officer.

Right to Receive an accounting. You have the right to request an accounting of certain disclosures of your ?protected health information? made by the Facility. This right applies to disclosures for purposes other than 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 Privacy Officer. 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 April 14, 2003. 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.

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 of the notice or have agreed to accept this notice electronically.

Our Responsibilities
The Facility is required by law to maintain the privacy of your health information and to provide you with this Privacy Notice that outlines our duties and privacy practices. We are required to:

  • Keep your health information private and only disclose it when required to do so by law;
  • Explain our legal duties and privacy practices in connection with your health records;
  • Obey the rules found in the law and this notice;
  • Accommodate your reasonable request for an alternative means of delivery or destination when sending your health information; and,
  • Inform you when we are unable to agree to a requested restriction that you have given us.

We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future ?protected health information? that we maintain. If the Facility changes its Notice, we will provide a copy of the revised Notice to current patients by sending a copy of the revised Notice via regular mail or through in-person contact at the next patient visit.

You have the right to express complaints to the Facility 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 the Facility?s Privacy Officer verbally or in writing, using the contact information provided on the first page of this Privacy Notice. We encourage you to express any concerns you may have regarding the privacy of your information.


Copyright 2023 – Central Ohio Surgical Institute

6520 West Campus Oval, New Albany, Ohio 43054