As a patient in a Clinic in New York State, you have the right, consistent with law, to:
  1. Receive services(s) without regard to age, race, color, sexual orientation, religion, marital status, sex, national origin or sponsor;
  2. Be treated with consideration, respect and dignity including privacy in treatment;
  3. Be informed of the services available at the center;
  4. Be informed of the provisions for off-hour emergency coverage;
  5. Be informed of the charges for services, eligibility for third-party reimbursements and, when applicable, the availability of free or reduced cost care;
  6. Receive an itemized copy of his/her account statement, upon request;
  7. Obtain from his/her health care practitioner, or the health care practitioner’s delegate, complete and current information concerning his/her diagnosis, treatment and prognosis in terms the patient can be reasonably expected to understand;
  8. Receive from his/her physician information necessary to give informed consent prior to the start of any nonemergency procedure or treatment or both. An informed consent shall include, as a minimum, the provision of information concerning the specific procedure or treatment or both, the reasonably foreseeable risks involved, and alternatives for care or treatment, if any, as a reasonable medical practitioner under similar circumstances would disclose in a manner permitting the patient to make a knowledgeable decision;
  9. Refuse treatment to the extent permitted by law and to be fully informed of the medical consequences of his/her action;
  10. Refuse to participate in experimental research;
  11. Voice grievances and recommend changes in policies and services to the center’s staff, the operator and the New York State Department of Health without fear of reprisal;
  12. Express complaints about the care and services provided and to have the center investigate such complaints. The center is responsible for providing the patient or his/her designee with a written response within 30 days if requested by the patient indicating the findings of the investigation. The center is also responsible for notifying the patient or his/her designee that if the patient is not satisfied by the center response, the patient may complain to the New York State Department of Health’s Office of Health Systems Management;
  13. Privacy and confidentiality of all information and records pertaining to the patient’s treatment;
  14. Approve or refuse the release or disclosure of the contents of his/her medical record to any health-care practitioner and/or health-care facility except as required by law or third-party payment contract;
  15. Access to his/her medical record per Section 18 of the Public Health Law, and Subpart 50-3. For additional information see: Access to Your Medical Records and Do I Have the Right to See My Medical Records?
  16. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors; and
  17. Make known your wishes in regard to anatomical gifts. You may document your wishes in your health care proxy or on a donor card, available from the center.

Your health record is the physical property of the WestsideGI. The information contained in the record however belongs to you. You have the right to:

  1. Request a restriction or limitation on the medical information we use or disclose about you for your 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, such as a family member or friend. We are not required to agree to your requested restrictions. If we do not agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
  2. Obtain a copy of this notice by requesting it from the Administrator of the Center.
  3. Inspect and obtain a copy of your health care record by submitting a request in writing to the Medical Record Department of the Center.
  4. Amend your healthcare record if you feel that medical information that we have about you is incorrect or incomplete by requesting in writing that the amendment be made. You must provide a reason that supports your request.
  5. Obtain a report of all the disclosures of your health information that we have made.
  6. Request that we communicate with you about your medical information in a certain way or at a certain location.
  7. Revoke our authorization to use and disclose medial information about you, except to the extent that we have already used or disclosed your medical information.

Our responsibilities regarding your medical information.

We are required by law to:

  1. Maintain the privacy of your health information.
  2. Provide you with this notice, which describes our legal duties and privacy practices with respect to information we collect about you.
  3. Abide by the terms of this notice.
  4. Notify you if we are unable to agree to a requested restriction.
  5. Accommodate reasonable requests that you have made to have us communicate your health information to you in a certain way or a certain location.

We reserve the right to change this notice. We reserve the right to make the revised and changed notice effective for medical information that we already have about you, as well as any information that we receive in the future. We will post a copy of the current notice in the Center. The notice will contain the effective date on the first page. Each time that you register at the Center, we will offer you a copy of the current notice in effect.

How we may use and disclose medical information about you.

Each time that you visit us a record of your visit is made. We may use or disclose the health information contained in this record. The following categories describe the different ways that we may use and disclose your medical information.


We may use medical information about you to provide you with medical treatment and services. We may disclose medical information about you to doctors, nurses, technicians, or other Center personnel who are involved in taking care of you at the Center. For example, information obtained by a nurse, physician, or other member of your health care team will be recorded in your medical records and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health team. Members of your healthcare team will then record the actions that they took and their observations. By reading your medical record, the physician will know how you are responding to treatment.


We may use and disclose medical information about you so that the treatment and services you receive at the Center may be billed to and payment may be collected from you, an insurance company or third party.

Health care operations.

We may use and disclose medical information about you for the operations of the Center. For example, members of the medical staff, the risk or quality management committee may use information in your health record to assess the care and outcomes in your case and others like it. This information will be used in a way to improve the quality and effectiveness of the healthcare and the services that we provide.

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 the 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.

Individuals involved in your care or payment of your care.

We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care.

As required by law.

We will disclose medical information about you when required to do so by federal, state or local law.

Health related benefits and services.

We may use and disclose medical information to inform you about health related benefits or services that may be of interest to you.


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. The Center would only disclose the information to someone able to help prevent the threat.

Business associates.

Some of the services provided at the Center are provided by business associates. For example, we contract with certain laboratories to perform lab tests. When we contract for these services, we may disclose your health information to our business associates so that they can perform the job we have hired them to do. To protect your health information, we require our business associates to appropriately safeguard your information.

Worker’s compensation.

We may release medical information about you to the extent authorized by and to the extent necessary to comply with the laws relating to workers compensation or other similar programs established by law.

Public health risks.

As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

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 health care system, government programs and compliance with civil rights laws.

Lawsuits and disputes.

If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or an 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 a dispute but only if efforts have been made to tell you about the request or to obtain an order protecting the information required.

Law enforcement.

We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Coroners, medical examiners and funeral directors.

We may release medical information to a coroner or medical examiner. We may also disclose health information to a funeral directors consistent with applicable law to carry out the duties.

Food and Drug Administration (“FDA”).

We may disclose to the FDA health information related to adverse events with respect to food, supplements, products and product defects or post marketing surveillance information to enable product recalls, repairs or replacement.


If you are an inmate of a correctional institution or under the custody of a law enforcement agent, we may release medical information about you to the correctional institution or law enforcement official.

Marketing Purposes.

As required by law, the Center will not disclose medical information for marketing purposes that constitute the sale of PHI without an authorization from the patient(s).

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 upon written authorization you provide to us. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization in writing at any time. If you revoke your authorization we will no longer use or disclose medical information about you for the reasons covered by your written authorization. The revocation however will not have any effect on any action the Center took before it received the revocation.

Questions or complaints.

If you have any questions and would like additional information, you may contact the office. If you believe that your privacy rights have been violated, you can submit a written complaint describing the circumstances surrounding the violation Attn: Medical director at the facility or to the Secretary of Health and Human Services, State of NY. You will not be penalized for filing any complaint.


We are giving you this summary of Advance Directives to help you understand the ways in which our staff will support your rights as an adult patient to make decisions about your health care treatment and to have those wishes honored in the event you are not able to make or communicate your decisions.

Advance Directives are written or oral instructions relating regarding the provision of healthcare in the event an adult over 18 becomes incapacitated. The most common types of Advance Directives are the following.

During the registration process you will be asked if you have Advance Directives. If you do, we will ask you to give us a copy, which will become a part of your medical record. Your physician will discuss with you whether any existing orders you may have regarding withholding life sustaining treatment are appropriate for your care at the Center

If you currently do not have any advance directives and if you wish to complete an Advance Directive, copies of the official State forms are available at our facility or you can got to the following website for more information


Reference :Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual, Appendix L-Guidance for Surveyors: Ambulatory Surgical Centers. March 15, 2013:416.50(c).