HIPAA Patient Privacy Notice


Weight Loss Institute of Arizona, LLC DeBarros Surgical, LLC Arizona Surgical Institute, LLC

(480) 829-6100 1855 E Southern Ave – Tempe, AZ 85282 8575 E Princess Drive, #215 – Scottsdale, AZ 85255 9305 W Thomas Rd #489 – Phoenix, AZ 85037 16222 N 59th Ave #D180 – Glendale, AZ 85306

HIPAA Patient Privacy Notice Effective: January 2, 2007

The Health Insurance Portability and Accountability Act (HIPAA) and its privacy rule gives individuals a right to adequate notice of the uses and disclosures of protected health information (PHI) that may be made by this office, and of the individual’s rights and the office’s legal duties with respect to the PHI.


If you have any questions about this notice, please contact our Privacy Officer at the number listed at the end of this notice.

Each time you visit a healthcare provider, a record of your visit is made. Typically this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by your healthcare provider.

Our Responsibilities The Weight Loss Institute of Arizona, LLC, DeBarros Surgical, LLC, and Arizona Surgical Institute, LLC are required by law to maintain the privacy of your health information and to provides you with a description of our legal duties and privacy practices regarding your health information. The current notice will be posted in the reception room or at our website at wliaz.com. The notice will include the effective date. In addition, we will make our best effort to provide you with a copy of this notice that we request you acknowledge with your signature.

We are required by law to abide by the terms of this notice and notify you if we make changes to this notice, which may be at any time. Changes to the notice will apply to your medical information that we already maintain as well as new information received after the change occurs. If we change our notice, it will be posted in the reception room or on our website at wliaz.com. You may also request that a revised notice be sent to you in the mail or you may ask for one at your next appointment or appropriate visit. This notice will also serve to advise you as to our rights with regard to your medical information.

How We May Use and Disclose Medical Information About You The following categories describe examples of the way we use and disclose medical information:

1. For Treatment: We may use medical information about you to provide, coordinate and manage your treatment or services. We may disclose medical information about you to other doctors, nurses, technicians (e.g. clinical laboratories or imaging companies), medical students or other personnel who are involved in your care. We may communicate your information either orally or in writing by mail, electronic mail, or facsimile. We may also provide a subsequent healthcare provider with copies of various reports that should assist him or her in treating you. For example, your medical information may be provided to a physician to whom you have been referred so as to ensure the physician has appropriate treatment information regarding your previous treatment and diagnosis.

2. For Payment: We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information before it approves or pays for the healthcare services we recommend for you.

3. For Health Care Operations: We may use or disclose, as needed, your health information in order to support our business activities, These activities may include, but are not limited to, quality assessment activities, licensing, legal advice, accounting support, information systems support and conducting or arranging for other business activities. In addition, we may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary to contact you to remind you of your appointment by telephone or reminder card.

4. Business Associates: There are some services provided in our organization through business contacts with business associates. Examples include transcription, billing and collections, document shredding, quality assurance, and software support. When these services are contracted, we may disclose your health information to our business associates so they can perform the job we have asked them to do. To protect your health information, however, we require the business associates to appropriately safeguard your information through a written contract.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object We may also use and disclose your health information as set forth below. You have the opportunity to agree or object to the use or disclosure of all or part of your health information in these instances. If you are not present or able to agree or object to the use or disclosure of health information (such as in an emergency situation), your clinician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the information that is relevant to your health care will be disclosed.

1. Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may release medical information about you to a friend or family member who is involved in your medical care or who helps to pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

2. Future Communications: We may communicate to you via newsletters, mailing, or other means regarding treatment options, information on health-related benefits or services; to remind you that you have an appointment for medical care; or other community-based initiatives or activities in which our facility is participating. If you are not interested in receiving these materials, please contact our Privacy Officer.

Other Permitted and Require Uses and Disclosures that May Be Made Without Your Authorization or Opportunity to Object We may use or disclose your health information in the following situations without your authorization or without providing you with an opportunity to object. These situations include:

As Required by Law: We may use and disclose health information to the following types of entities, including, but not limited to:

Food and Drug Administration Public health or legal authorities charged with preventing or controlling disease, injury or disability Correctional institutions Workers’ Compensation agent Organ and tissue donation organizations Military command authorities Health oversight authorities Funeral directors, coroners, and medical directors National security and intelligence agencies Protective services for the President and others Authority that receives reports on abuse and neglect Contacting the Weight Loss Institute of Arizona Privacy Officer: Phone: (480) 829-6100 Address: 1855 E Southern Ave, Tempe, AZ 85282

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