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Required Disclosures























The patient has the right to:

   1.Treatment without regard to race; creed; color; ethnic origin; nationality; sex; handicap; age; affiliation with fraternal or religious        

      organizations; cultural, economic, or educational background; or the source of payment for care.

   2.Considerate and respectful care.

   3.The knowledge of the name of the surgeon who has primary responsibility for coordination, his care, and the names and professional

      relationships of other practitioners who will see him.

   4.Receive information from his surgeon about his illness, his course of treatment, and his prospects for recovery in terms he can

      understand.  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.

   5.Receive the necessary information about any proposed treatment or procedure in order to give informed consent or to refuse this course of

      treatment.  Except in emergencies, this information shall include a description of all the procedure(s) or treatment(s), the medically

      significant risk(s) involved in this treatment, an alternate course of treatment or non-treatment, and the risk(s) involved in each, and the

      name of the person who would carry out the treatment(s) or procedure(s).

   6.Participate actively in decision(s) regarding his medical/surgical care.  To the extent it is permitted by law, includes the right to refuse


   7.Full consideration of privacy concerning his medical/surgical care program.  Case discussion, consultation, examination and treatment are

      confidential and shall be conducted discreetly.  The patient has the right to be advised as to the reason for the presence of any individual.

   8.Confidential treatment of all communications and records pertaining to his care.  His written permission shall be obtained before his

      medical records are made available to anyone not concerned with his care.

   9. Reasonable responses to any reasonable request he makes for services.

   10. Reasonable continuity of care and to know in advance the time and location of appointment(s), as well as, the practitioner providing the


   11.Be advised if the surgeon proposes to engage in or perform human experimentation affecting his care or treatment.  The patient has the

         right to refuse to participate in such research projects.

   12. Be informed by his surgeon, or designee, of his continuing health care requirements.

   13. Examine and receive an explanation of his bill regardless of the source of payment.

   14. Have all patient’s rights explained to the person who has legal responsibility to make decisions regarding medical care on behalf of the


   15. Express any grievances or suggestions verbally or in writing.

   16.Have in effect advanced medical directives concerning such issues as living wills and durable powers of attorney that will be identified to

         the Center and followed as appropriate under State and Federal Regulations.




  • Your reports of pain will be believed.

  • Information about pain and pain relief measures.

  • A concerned staff committed to pain relief measures.

  • Health professionals who respond quickly to reports of pain.

  • Effective pain management.




  • Ask your doctor or nurse what to expect regarding pain and pain management.

  • Discuss pain relief options with your providers and nurses.

  • Work with your provider and nurse to develop a pain management plan.

  • Ask for pain relief when pain first begins.

  • Help your provider and nurses assess your pain.

  • Tell your provider or nurse if your pain is not resolved.

  • Tell your provider or nurse about any other worries you have taking pain medication   




Your physician may have an ownership interest in this facility.  Your doctor also has staff privileges at a local hospital.  You have the right to ask your doctor to have your procedure to be performed at that hospital.




On January 11,1992, a New Jersey law took effect which mandates that all health care facilities ask patients whether they have an Advance Directive or Living Will.  At the Center For Special Surgery we have made this part of our admitting process.  Your doctor should have inquired about this issue at his/her office and instructed you to bring a copy of your Advance Directive or Living Will the day of your procedure. During our pre op call our staff member will also speak to you on this matter.


An Advance Directive or Living Will is used by an individual to indicate their voluntary, informed choice of accepting, rejecting, or choosing among alternative courses of medical treatment. An Advance Directive or Living Will is a document which allows you to give written instruction to those caring for you indicating the type of health care you would wish to receive or reject in the event you become unable to express these decisions yourself.  There are three different types of Advance Directive:


   1. Proxy Directive - This is a document in which a competent adult names a trusted relative or friend to make health care decisions on their

       behalf when they are unable to make these decisions.

   2. An Instruction Directive - In this document, the person writing it provides written instructions concerning the type of medical treatment \

       they want or do not want performed for them and under what circumstances.

   3. A Combined Directive - In this document, a competent adult states their general wishes regarding the kind of health care they wish to

       receive but appoints a trusted friend or relative to carry them out.

       A brochure containing living will information is available from the division of Aging.  If you wish to receive the brochure, please make your          request to:

                    The Division of Aging Services  P.O. Box 715   Trenton, NJ 08625-0715


Advance Directive/Living Will forms will be available at our center. The Center does not directly honor Advance Directive/Living Wills at our facility as we generally care for healthy non-terminal patients. If however, there be any unforeseen complications during the surgery our medical staff will make every effort to stabilize the patient for transfer to a local hospital.  Any Living wills will be forwarded with the complete patient chart for use at the hospital.




This policy takes effect on October 12, 2002 and remains in effect until it is formally changed.

POLICY: The privacy of patient’s medical information is important to us.  We understand that medical information is personal and we are committed to protecting it. A record of the care and services a patient receives at our facility along with any pertinent medical test results or examinations is maintained in a file.  This file is needed to provide quality care and comply with legal requirements.  Patients have the right to know how we use and share medical information.  They also have rights to release the file of their medical information with proper written documentation.



   A. Keep medical files private.

   B. Make this policy available to patients and their representatives describing our legal duties, privacy practices, and patient rights concerning        their medical information.

   C. The Center must follow its posted policies.




   A. The Center has the right to change our privacy policies at any time provided the changes comply with current law.

   B. The Center may change the policies for all files including dates of service before the policies were created.



   A. Before an important change to our privacy practices takes effect, we will post the new policy and its effective date.




The following section describes different ways that the Center uses and discloses medical information.  For each kind of  standard use listed, an explanation and example will be provided. However, not every conceivable use or disclosure will be included.  Both standard uses and other general uses that are permitted by law will be listed.  The Center will not use or disclose medical information in a manner not listed below without specific written authorization.  Moreover, any specific written authorization may be revoked at any time by written notification.


A. FOR TREATMENT - The Center may use medical information that is presented to us to provide medical treatment or services. Medical information may be disclosed to doctors, nurses, technicians, medical students, or other people who are taking care of a patient, also clerical staff who are handling the file in the course of their specific job function.


EXAMPLE- A patient is admitted to our facility for foot surgery and they are a  diabetic.  A number of health care and support staff need to know about the diabetic condition.      

   - The doctor needs to know this because it may slow the healing process.   

   - The nurse(s) and receptionist need to know this because they may offer the patient refreshments after their procedure.

   - The clerical who is entering the patient’s information into our database and creating the patient file needs to know this information to alert

      the medical staff. 

   - Any health care provider who the patient is referred to for additional care or treatment needs to be aware of the condition to assist them in         their activities.


B. FOR PAYMENT - The Center may disclose medical information for payment purposes.


EXAMPLE- A patient is scheduled for a procedure in our facility.

   - Their insurance plan may require notification from our staff about treatment prior to services being rendered to get approval or determine         if the plan will pay  for the treatment.

   - The health insurance plan requires information about diagnosis and care to process all claims for paying the center or reimbursing the

      patient for any payments made to the center.


C. FOR HEALTH CARE OPERATIONS- The Center may disclose medical information for our health care operations.  This may include measuring and improving quality, evaluating the performance of our staff and maintaining our accreditation, certificates or approvals we need to legally provide services.


EXAMPLE- A patient receives treatment at our facility and we are being inspected by the Joint Commission.

   - The on-site professional(s) who are conducting the inspection need to view the chart and entire patient record to ensure we are following

      our policies and procedures.

   - During the inspection, the on-site professional(s) may wish to speak to a patient about the care they are receiving that day to ensure we are

      following our policies and procedures.


D. ADDITIONAL USES AND DISCLOSURES- In addition to using a patient’s medical information for treatment, payment and health care operations, we may also use and disclose medical information for the following purposes:

   1. NOTIFICATION of family member, personal representative or other person(s) who are responsible for a patient’s care.  If requested, we will

       share information  about location or general condition.  If the patient is present and able,  we will ask permission before we share the

       information.  In case of emergency we will only  share the information that is directly necessary for the patient’s care, according to our    

       professional judgment.  We will use our professional judgment to make decisions in the patient’s best interest about allowing someone to

       pick up medicine, medical supplies, or to insure patient compliance with critical post treatment activities (such as keeping bandages dry).

   2. DISASTER RELIEF- Share medical information with public or private organization(s) or person(s) who can legally assist in disaster relief


   3. RESEARCH IN LIMITED CIRCUMSTANCES-  Medical information that can assist research will be shared, but nonessential patient

       information  such as name, address and insurance information will be withheld.

   4. COURT ORDERS, JUDICIAL AND ADMINISTRATIVE PROCEEDINGS- If served, we may disclose medical information in response to a court

       order, subpoena, discovery request, or other lawful process.  Under limited circumstances such as a court order, warrant, or grand jury

       subpoena, we may disclose medical information with law enforcement officials.

   5. PUBLIC HEALTHCARE ACTIVITIES- As required by law, we may disclose medical information to public health or legal authorities charged

       with preventing or controlling diseases, injury or disability, including child abuse or neglect.  We may also contact the FDA for the purposes

       of reporting an adverse reaction to a product.

   6. VICTIMS OF ABUSE, NEGLECT OR DOMESTIC VIOLENCE- We will disclose medical information to the appropriate authorities if we

       reasonably believe there is a crime of this type being committed.

   7. WORKERS COMPENSATION- We may disclose health information when authorized by the patient and necessary to comply with laws

       relating to workers compensation or other similar programs.

   8. HEALTH OVERSIGHT ACTIVITIES- We may disclose medical information to agencies providing health oversight as required by law.

   9. LAW ENFORCEMENT- We may disclose limited information to law enforcement officials concerning the medical information of a suspect,

       fugitive, material witness, crime victim or missing person.




   A. Patients have the right to look at or get copies of their medical information.  Any request for copies must be made in writing and be

       included in the patients chart for future reference.

   B. As per NJAC 8:43G-15.3(d) health care providers must furnish patients and their representatives with copies of their medical records and

       may charge a $10 search fee, $1.00 per page for the first 100 pages, $.25 per page for pages 101-400 and the actual cost of any postage


   C. Patients have the right to receive a list of all the times we shared medical information for purposes other than treatment, payment and

       health care operations and other specified exceptions.

   D. Patients may request that we place additional restrictions on use or disclosure of their medical information.  We will notify the patient if we

       are unable to comply with their request.

   E. Patients may request that we change their medical information.  We may deny that request if we did not create the information that is in

       dispute.  If we deny the request, we must provide the patient a written explanation.  The patient may then provide a written explanation that

       will be included with the disputed information.

   F.  If the patient reads these policies via the internet or via a posted copy and wishes to have a copy, the Center will provide a hard copy.

   G. The patient has the right to have a designated person to write to or ask questions concerning these policies.  The person designated at our

        facility is:   

                              Ania Skorupka, CST., Administrator               973-427-6800


   H. If a patient believes we have violated their privacy rights and does not wish to contact the person listed above, they may submit a written

       complaint to the US Department of Health and Human Services.  We will not retaliate in any way if the patient files a complaint. 

   I. Effective March 26, 2013, the patient has the right to restrict certain disclosures of Protected Health Information to a Health Plan when the

       individual pays out of pocket in full for the healthcare item or service.




POLICY: HIPAA privacy rules give individuals the right to request a restriction of uses and disclosures of their protected health information.  The individual is also provided the right to request confidential communications or that communications be made via alternative means such as sending information to the individuals place of employment instead of their home.  The center shall address and respect patients concerns.



   A. The center has developed a patient disclosure consent form (included at the end of  this section).  This form requests where and how each        patient wishes to be contacted.

   B. Every staff physician’s office will be given a copy of our patient disclosure consent form and will be requested to have the patient fill the

       form out in their office and forward the form to the center at the time the case is being scheduled.

   C. The completed form will be included in the patients chart and will be referred to for any off site patient contact.

   D. Should a staff physician’s office fail to forward a completed patient disclosure consent form :

          1. The initial contact via phone will be a guarded conversation until direct patient conversation is made.

          2. The staff member will ask for a verbal response to the form’s questions  and will include the form in the chart to be signed by the

               patient the day of their procedure. 

   E. The form shall remain in the chart and will be referred to for all post-procedure calls made.




Policy:  The Center has established a  procedure for documenting the existence, submission, investigation, and disposition of a patient’s written or verbal grievance to the Center.

   A. All alleged violations/grievances relating, but not limited to, mistreatment, neglect, abuse (verbal, mental, sexual, or  physical), must be      

       fully documented.  

   B. All allegations must be immediately reported to a person of authority in the Center.

   C. Only substantiated allegations must be reported to the State authority or the local authority, or both.

   D.  The initial review of the grievance and a written response will take place within a 30 day period of the complaint being received.

   E. The Center, in responding to the grievance, will investigate all grievances made by a patient or the patient’s representative regarding

       treatment or care that is (or fails to be) furnished.

   F. The Center will document how the grievance was addressed, as well as provide the patient with written notice of its decision. The decision

       will contain the name of the Center's contact person, the steps taken to investigate the grievance, the results of the grievance process, and

       the date the grievance process was completed.

   G. The person lodging the complaint will also be forwarded the following information as to where they can lodge a formal complaint should

       they not be satisfied with the decision of the investigation.





PO BOX 358

TRENTON, NJ 08625-0358                                                                  609-292-9900





PO BOX 852

TRENTON, NJ 08625-0852                                                                  877-582-6995 




OAKBROOK TERRACE, IL 60181                                                    630-792-5800




OVERVIEW: The Red Flags Rule requires many businesses and organizations to implement a written Identity Theft Prevention Program to detect the warning signs – or “red flags” – of identity theft in their day-to-day operations. By focusing on red flags now, a company will be better able to spot an impostor using someone else’s identity to get products or services from them. As a practical matter, the Rule applies to any company that provides products or services and bill customers later. The FTC, the federal agency that enforces a number of consumer protection laws, has identified the issues that need to be addressed. The Iden­tity Theft Prevention Program has two parts: Part A requires companies to determine whether a business or organization is at low risk, and Part B spell out the requirements for a Identity Theft Prevention Program for businesses in the low risk category.



We have conducted an assessment of The Center for Special Surgery at Hawthorne. Here are the reasons we are at low risk for identity theft:  We have a stable workforce and all patient information is secured on the second floor where there is no patient access. Additionally, all visitors to the second floor must be accompanied by an employee limiting their access to privileged information.  All requests for information are directed to a single individual. Lastly, all patients must submit a government issued picture ID to receive services. Upon entry to our facility the ID must be verified by a staff member.



STEP 1: Red flags we have identified:

   1. Notice from a customer, a victim of identity theft, a law enforcement agency, or someone else that an account has been opened or used


   2. Verbal requests for patient information.

   3. Invoices submitted that do not have details.

   4. Patients arrive without any or improper requested proof of identification or are hesitant about allowing us to see such information claiming

       they fear identity theft.


STEP 2: How we’ll detect the red flags we have identified:

   1. Notices of possible fraud that request information.

   2. Request for information from a company or individual that states there is an urgent need for the information and submitting written

       authorization would delay the process.

   3. An invoice is received that has no purchase order listed.

   4. Picture IDs must be verified by a staff member. Red flags will be raised when pictures do not match or cards presented are bulky due to

       multiple laminations suggesting picture replacement.


STEP 3: Here’s how we’ll respond to the red flags we have identified:

   1. Any notice is verified by the administrator prior to any information being shared.

   2. No patient information is released without proper written authorization.  A record of all written requests and releases are kept in the

       patient's chart.

   3. Prior to payment being issued, all invoices are verified for accuracy by the person who initiated the order.

   4.Any question of false identification being submitted is directed to the administrator prior to services being delivered.


STEP 4: Here's how we'll administer the program:

   1. Our program has been approved by the Board of Directors.

   2. The person who will administer our program is John Tauber, Administrator.

   3. Our Nursing and Clerical staff will be trained during their orientation and yearly in-services.

   4. We don’t use service providers in connection with accounts covered by the Red Flags Rule.

   5. A yearly evaluation will be performed by the Board of Directors requesting feedback from our staff to keep the program up to date with

       current issues.


The Following Is Available As

A Printable Pamphlet


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