Notice of Privacy Practices
94047 v7 (Rev 10/1/2025)
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS
TO YOUR MEDICAL INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY
Effective 4/2010; Revised 8/2025
OUR COMMITMENT TO YOUR PRIVACY
Nebraska Spine Hospital, LLC is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
This notice provides you with the following important information:
• How Nebraska Spine Hospital, LLC may use and disclose your identifiable health information;
• Your privacy rights in your identifiable health information; and
• Nebraska Spine Hospital, LLC’s obligations concerning the use and disclosure of your identifiable health information.
The terms of this notice apply to all records containing your identifiable health information that are created or retained by Nebraska Spine Hospital, LLC. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records Nebraska Spine Hospital, LLC has created or maintained in the past, and for any of your records we may create or maintain in the future. A copy of the current Notice is posted in the admissions area. You will be provided with a copy of the Notice at the time of your initial visit to our hospital. The effective date of our notice will be posted in the upper portion of the notice.
WHO WILL FOLLOW THIS NOTICE
This notice describes the privacy practices of the entities that are part of Nebraska Spine Hospital, LLC, including:
Any health care professional authorized to enter information into your medical records, including members of our medical staff;
All departments, units and offices operated by Nebraska Spine Hospital, LLC;
Any member of a volunteer group that assists you while you are patient of Nebraska Spine Hospital, LLC;
All employees, staff and other personnel of Nebraska Spine Hospital, LLC; and
All other Nebraska Spine Hospital, LLC affiliated entities.
All of these entities, individuals, sites, and locations will follow the terms of this notice. In addition, these entities, individuals, sites, and locations may share health information with each other for treatment, payment, or health care operations purposes as described in this notice. Please realize that your personal doctor may use different notices or policies regarding health information created in his or her office.
HOW WE MAY USE AND DISCLOSE YOUR IDENTIFIABLE HEALTH INFORMATION
The following categories describe different ways in which we may use and disclose your identifiable health information. For each category of uses or disclosures, we will explain what we mean and provide examples. Not every use or disclosure in a category will be listed; however, all of the ways we are permitted to use and disclose information will fall within one of the categories. Please realize, in some instances Nebraska has special laws concerning the use and disclosure of certain types of health information, such as mental health, substance abuse and HIV/AIDS information.
The laws of the state of Nebraska in which you receive treatment from Nebraska Spine Hospital, LLC will apply to uses and disclosures of these types of health information.
Treatment. We may use health information about you to provide you with health treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at one of the Nebraska Spine Hospital, LLC. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell a Nebraska Spine Hospital, LLC dietitian if you have diabetes so that appropriate meals can be arranged.
Coordinating Care. Nebraska Spine Hospital, LLC may share health information about you with others in order to coordinate the different things you need, such as prescriptions, lab work, x-rays and follow-up care. To the extent permitted by law, we also may disclose health information about you to people outside Nebraska Spine Hospital, LLC who may be involved in your health care (such as family members, home health agencies and others that provide services that are part of your care).
Payment. We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about surgery you received so your health plan will pay us or reimburse you for the surgery. We also may 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. We also may disclose your health information to other health care providers and health plans for the payment activities of those providers and plans. For example, we may provide your information to a physician who is not on our medical staff so that the physician may bill you or your insurer for the services you received from that physician.
Health Care Operations. Nebraska Spine Hospital, LLC may use and disclose health information for routine facility operations, such as business planning and development, quality review of service provided, internal auditing, accreditation, certification licensing or credentialing activities (including the licensing or credentialing activities of health care professionals), medical research and education for staff and students, assessing your satisfaction with our services, and to other health care entities that have a relationship with you and need the information for operational purposes. We may use and disclose your health information to the external agencies responsible for oversight of health care activities such as The Joint Commission, external quality assurance and peer review organizations, and credentialing organizations. We may also disclose health information to business associates we have contracted with to perform services for or on our behalf such as patient satisfaction survey organizations. We may also disclose your health information to medical device manufacturers or pharmaceutical companies in order for those companies to carry out their legal obligations to state and federal agencies.
Treatment Options. We may use and disclose your 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 and disclose your health information to tell you about health-related benefits or services that may be of interest to you.
Hospital/Facility Directory. We may include certain limited information about you in our patient/client directory while you are receiving treatment at a Nebraska Spine Hospital, LLC. This information may include your name, location in the facility, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. This is so your family, friends, and clergy can visit you in Nebraska Spine Hospital, LLC and generally know how you are doing. If you do not want your information included in Nebraska Spine Hospital, LLC’s directory, upon your admission you should inform the personnel registering you in to Nebraska Spine Hospital, LLC facility or your caregiver. If you do not want information released in the directory, we cannot tell members of the public such as flower or other delivery services or friends and family that you are here or your general condition.
Release of Information to Family/Friends. We may release your health information to a friend or family member that is helping you pay for your health care, or who assists in taking care of you. We also may tell your family or friends your condition and that you are in the Nebraska Spine Hospital, LLC. If you have specific objections or instructions regarding these communications, you may discuss them with your caregivers.
Food and Drug Administration (“FDA”). We may disclose your PHI to a person or company required by the FDA to report information such as adverse events and product defects, to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance.
Nebraska Health Information Initiative. Nebraska Spine Hospital, LLC participates with CyncHealth, a statewide internet-based health information exchange. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “Opt-Out” and prevent searching of your health information available through CyncHealth, by calling (402) 506-9900, or downloading an “Opt-Out” form and emailing to support@cynchealth.org.
Uses and Disclosures that are Required or Permitted by Law. Subject to requirements of federal, state, and local laws, we are either required or permitted to report your health information for various purposes. Some of these reporting requirements and permissions include:
Public Health Activities: We may disclose your health information to public health officials for activities such as for the prevention or control of communicable disease, bioterrorism, injury or disability; to report deaths; to report suspected child, elder, or spouse abuse or neglect; to report reactions to medications or problems with medical products; to report information to the federal Centers for Disease Control or to authorized national or state cancer registries for their data aggregation.
Disaster Relief Efforts: We may disclose your health information to an entity assisting in a disaster relief effort, such as the American Red Cross, so that your family can be notified about your condition and location.
Health Oversight Activities: We may disclose your health information to a health oversight agency for activities authorized by law. Such agencies include federal Centers for Medicare and Medicaid Services, and state medical or nursing boards. These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor activities such as health care treatment and spending, government programs, and compliance with civil rights laws and the health care system in general.
Judicial or Administration Proceeding: We may disclose your health information in response to a legal court or administrative order, a subpoena, discovery request, civil or criminal proceedings, or other lawful process.
Law Enforcement. We may release health information if asked to do so by a local, state or federal law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar legal process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime in certain limited circumstances;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at Nebraska Spine Hospital, LLC; such as theft, drug diversion, or attempts to obtain drugs illegally.
• In emergency circumstances to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).
Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information to help funeral directors to carry out their duties.
Organ and Tissue Donation. If you are an organ donor, we may release health 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.
Research. We may use and disclose health information to researchers either when you authorize the use and disclosure of your health information or the CHI Health Institutional Review Board of Record and/or Privacy Board approves an authorization waiver for the use and disclosure of your health information for a research study.
Serious Threats to Health or Safety. We may use and disclose health 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. Any disclosure, however, would only be to someone able to help prevent the threat and/or to any specifically identified victims of the threat.
Report Abuse. As permitted or required by law, or as otherwise agreed to by you, we may disclose your PHI when the information relates to a victim of abuse, neglect, or domestic violence.
Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
National Security and Intelligence Activities. We may disclose your health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your health information to federal officials in order to protect the President, other officials, or foreign heads of state, or to conduct investigations.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official. Disclosure for these purposes would be necessary: (1) for the institution to provide health care services to you; (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.
Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
PROHIBITED USES AND DISCLOSURES
We are prohibited from using or disclosing your PHI for any of the following activities:
To conduct a criminal, civil, or administrative investigation into any person for the act of seeking, obtaining, providing, or facilitating reproductive health care.
To impose criminal, civil, or administrative liability on any person for the act of seeking, obtaining, providing, or facilitating reproductive health care.
The identification of any person for the purpose of conducting such investigation or imposing such liability.
Genetic information for underwriting purposes, except as allowed for specified health plans.
Sale of PHI, unless an authorization form is signed by each individual whose PHI is sold prior to the use or disclosure.
YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION
You have the following rights regarding the identifiable health information we maintain about you:
Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we contact you at work or by U.S. Mail. To request that we contact you in a certain way or at a certain location, you must make your request in writing to the Administrator of Nebraska Spine Hospital, LLC, 6901 North 72nd Street, Suite 20300, Omaha, NE 68122. We will not ask you the reason for your request, and we will accommodate reasonable requests.
Your written request must specify how or where you wish to be contacted. You must provide us with a mailing address where you can receive correspondence and other communications from us related to payment for the services you have received from us. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations purposes. You also have the right to request that we limit our disclosure of your health information to individuals involved in your care or the payment for your care, such as family members and friends. Nebraska Spine Hospital, LLC is not required to agree to your request.
NOTE: If we do agree, we will strive to comply with your request unless your information is needed to provide emergency treatment to you. However, Nebraska Spine Hospital, LLC cannot insure complete success. However, if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
To formally request a restriction, you must make your request in writing to Nebraska Spine Hospital, LLC Privacy Office. In your request, you must describe in a clear and concise fashion: (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. Nebraska Spine Hospital, LLC does not have the authority to bind anyone else to any restrictions to which Nebraska Spine Hospital, LLC may agree.
Inspection and Copies. You have the right to inspect and copy health information that may be used to make decisions about your care, including your medical records and billing records, but not including psychotherapy notes. Nebraska Spine Hospital, LLC will respond to your request within 30 days, unless state law requires us to respond earlier.
To formally inspect or obtain a copy of health information that is maintained by or on behalf of Nebraska Spine Hospital, LLC and that may be used to make decisions about you, you must submit your request in writing to the Health Information Management Department of Nebraska Spine Hospital, LLC. Nebraska Spine Hospital, LLC 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 your health information under certain limited circumstances. For example, you may not be provided with your health information if it is determined that providing such information could cause harm to you or another person. In most cases, if you are denied access to health information, you may request that the denial be reviewed. Nebraska Spine Hospital, LLC’s Chief Medical Officer in accordance with applicable law will review your request and the denial. The person conducting the review will not be the person who denied your request. The Nebraska Spine Hospital, LLC organization that originally denied you access will comply with the outcome of the review.
Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Nebraska Spine Hospital, LLC Privacy Office. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
Right to Request an Accounting of Certain Disclosures. You may request a list of our disclosures of your PHI, subject to several exceptions and limitations. For example, this right does not apply to disclosures for purposes other than treatment, payment, or health care operations, and it excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures. To request this list or accounting of disclosures, you must submit your request in writing to Nebraska Spine Hospital, LLC’s Privacy Officer. Your request must state a time period that may not be longer than six years prior to the request date and may not include dates before August 16, 2010. Your request should indicate in what form you want the list (i.e., on paper, electronically). The first list you request within a 12-month period will be free. For additional lists during the same 12-month period, we may charge you for the cost of providing the list. We will notify you of the cost Involved and you may choose to withdraw or modify your request at the time before any costs are incurred.
Right to Receive Notice of a Privacy Breach. You have the right to receive written notification if Nebraska Spine Hospital, LLC discovers a breach of unsecured protected health information involving your health information. Breach means the unauthorized acquisition, access, use, or disclosure of protected health information which compromises the security or privacy of the information.
Right to Request Electronic Copies of Information. You have the right to request your records in an electronic or paper form/media. Please contact Nebraska Spine Hospital, LLC’s Health Information Management Department for further details.
Right to Restrict Disclosure to Insurers. You have the right to request to restrict the disclosure of your information to a health plan regarding a specific health care item or service that you, or someone on your behalf (other than a health plan), has paid for in full. We are required to comply with your request for this specific type of restriction. For example, if you sought counseling services and paid in full for the services rather than submitting the expenses to a health plan, you may request that your health information related to the counseling services not be disclosed to your health plan.
Right to File a Complaint
Our physicians, care providers, staff, and volunteers are committed to providing an excellent care experience to everyone we serve. We welcome your comments and want to be sure we are meeting your needs and expectations.
We do understand, however, that there may be times when you feel your visit did not meet your needs or expectations. When this happens, we recognize your right to express or voice your concerns about your care. We invite you to first voice any concerns with us at the phone numbers provided below. You can be sure that your care will not be affected in a negative way. To express or voice your concerns with Nebraska Spine Hospital, LLC, you may contact the Chief Executive Officer or Chief Nurse Executive at (402) 572-3000.
If you believe your privacy rights have been violated, you may file a complaint with the Administrator of Nebraska Spine Hospital, LLC. Concerns can be directed to Administration at (402) 572-3000.
You may file a written complaint with:
Nebraska Spine Hospital, LLC
6901 North 72nd Street, Suite 20300
Omaha, NE 68122
You may also submit a complaint to:
U.S. Department of Health & Human Services
200 Independence Avenue SW
Washington, DC 20201
(877) 696-6775 (toll free) or
http://www.hhs.gov/hipaa/filing-a-complaint/index.html
Nebraska Spine Hospital, LLC complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, or religion. If you believe your civil rights have been violated, you may file a complaint with the Civil Rights Coordinator of Nebraska Spine Hospital, LLC. Concerns can be directed to Civil Rights Coordinator at (402) 572-3000.
You may file a written complaint with:
Civil Rights Coordinator
Nebraska Spine Hospital, LLC
6901 North 72nd Street, Suite 20300
Omaha, NE 68122
OR
Office for Civil Rights, Region VII
U.S. Department of Health & Human Services
601 E 12th St. – Room 353
Kansas City, MO 64106
Voice Phone: (800) 368-1019 ● Fax: (816) 426-3686 ● TDD: (800) 537-7697
You may also submit a complaint to:
U.S. Department of Health & Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
(800) 368-1019 ● (800) 537-7697 (TDD)
http://www.hhs.gov/ocr/office/file/index.html.
Right to Provide and Authorize for Other Uses and Disclosures
We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note, we are required to retain records of your medical care.
If you have any questions about this notice, please contact Nebraska Spine Hospital, LLC’s Privacy Office at (402) 572-3000.
Outside Resources
While we hope you are satisfied with our response to your concern, you may have concerns that you would like to voice to someone outside of Nebraska Spine Hospital, LLC. If so, you may contact the following without fear of reprisal from Nebraska Spine Hospital, LLC:
For unresolved concerns about general care, safety, and quality:
Nebraska Department of Health and Human Services
Facilities Investigations
PO Box 94986
Lincoln, NE 68509-4669
Phone: (402) 471-0316 ● Fax: (402) 471-1679
On-line complaint form at dhhs.ne.gov/pages/complaints.aspx
Outside Quality Improvement Organizations (Nebraska)
Commence Health BFCC-QIO Program
P.O. Box 2687
Virginia Beach, VA 23450
(888) 755-5580
(TTY) Dial 711
For Nebraska Spine Hospital, LLC accredited by The Joint Commission, patient safety concerns can be reported to The Joint Commission at www.jointcommission.org using the “Report a Patient Safety Concern or Event” link and complete the online form. By mail to:
The Joint Commission
Office of Quality and Patient Safety
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
By phone to: (800) 994-6610
For Medicare concerns:
Medicare Hotline: (800) 633-4227
State Health Insurance Information Program (SHIPS): (800) 234-7119
http://www.doi.nebraska.gov/nebraska-ship-smp