As a patient, you have the right:

  • To have access to the patient rights and responsibilities established by this center.
  • To see posted written notice of the patient rights in a place or places within the facility likely to be noticed by patients (or their representative, if applicable) waiting for treatment. The written poster will include name, address, and telephone number of a representative of the state agency to whom the patient can report complaints, as well as the website for the
    Office of the Medicare Beneficiary Ombudsman.
  • To be treated with respect, consideration and dignity.
  • To be respected for your cultural and personal
    values, beliefs and preferences.
  • To effective communication. The center communicates with the patient who has vision, speech, hearing, or cognitive impairments in a manner that fits the patient’s need.
  • To receive information in a manner tailored to the patient’s age, language, and ability to understand. The center provides interpreting and translation services.
  • To be provided appropriate privacy. Patient disclosures and records are treated confidentially, and patients are given the opportunity to approve or refuse their release, except when release is required by law.
  • To access, request amendment to, and obtain information on disclosures of his or her health information, in accordance with law and regulation.
  • To receive care in a safe setting.
  • To refuse participation in experimental research.
  • To pain management.
  • To be free from all forms of abuse or harassment.
  • To be fully informed about a treatment or procedure and the expected outcome before the procedure is performed.

Patients are provided, to the degree known, complete 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 a legally authorized person.

The center provides the patient or surrogate decision-maker with the information about the outcomes of care, treatment, or services that the patient needs in order to participate in current and future health care decisions.

The center informs the patient or surrogate decision-maker about unanticipated outcomes of care, treatment.

  • To have the opportunity to participate in decisions involving your healthcare, treatment, or services, except when such participation is contraindicated for medical reasons. The center involves the patient’s family in care, treatment, or services decisions, to the extent permitted by the patient or surrogate decision-maker, in accordance with law and regulation.
  • To be informed of your right to change your provider if other qualified providers are available.
  • To have appropriate information regarding the absence of malpractice insurance coverage.
  • To truthful marketing and advertising regarding the competence and capabilities of the organization.
  • To exercise your rights without being subject to coercion, discrimination, reprisal, or interruption of care that could adversely affect you.
  • To information about procedures for expressing suggestions, complaints, and grievances, including those required by state and federal regulations.
  • To receive in advance of the date of the procedure the center’s policies on advance directives, including a description of applicable state health and safety laws and if requested, official state advance directive information forms.
  • To receive written information about your physician’s possible ownership in Executive Surgery Center. Patients are informed about physician ownership prior to the procedure.
  • To information regarding fee for services and payment policies.
  • To information regarding the services available at the organization, provisions for after-hour emergency care, and the credentials of healthcare professionals.
  • If a patient is adjudged incompetent under applicable state health and safety laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under state law to act on the patient’s behalf.
  • If a state court has not adjudged a patient incompetent, any legal representative designated by the patient, in accordance with the state law, may exercise the patient’s rights to the extend allowed by state law.

The patient has the right to receive verbal and written notice in advance of the date of the procedure, in a language and manner that the patient or the patient’s representative understands.  The center gives brochures to each patient being admitted with the center’s written policies and the nurse making the preoperative call informs the patient verbally.

As a patient, you have the responsibility

  • To provide complete and accurate information to the best of your ability about your health, any medications, including over the counter products and dietary supplements and any allergies or sensitivities.
  • To follow the treatment plan prescribed by your provider.
  • To provide a responsible adult to transport you home from the facility and remain with you for 24 hours, if required by your provider.
  • To inform your provider about any living will, medical power of attorney, or other directive that could affect your care.
  • To accept personal financial responsibility for any charges not covered by your insurance.
  • To be respectful of the health care providers and staff, as well as other patients.

The Executive Surgery Center is a Limited Liability Corporation (LLC), which is owned by: 

Tarek Fahl, M.D., Matthew Hammit, M.D., Michael Leahy, M.D., James Mathis, M.D., Jeffrey K. Smith, M.D., Travis Hanson, M.D  and Jason Brannen M.D. Kourosh Jafarnia  M.D.

The center strives to provide high quality of care and achieve patient satisfaction.  Patient grievances/complaints provide a means to measure achievement of this goal and to identify a need for performance improvement.


Grievance/Complaint:  Grievances are defined as care that the ASC provided or allegedly failed to provide.

Neglect – Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness (42 CFR 488.301).


Abuse – The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish (42 CFR 488.301).


All complaints received by the center personnel shall be forwarded to the clinical director or his/her designee immediately, at least the same day.  The clinical director will respond in writing to the grievance within 3 days of receiving it.


For a full copy of the grievance procedure, please ask any center personnel.


To report a grievance:

Clinical Director: Rachel Perry, RN

Phone (832)698-3720


To Report a Concern:

Office of Quality Monitoring 

Texas Department of Health

.P.O. Box 149347

Austin, TX  78714-9347

Phone (512) 776-7111 or (888) 963-7111


Executive Surgery Center





This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.   It also describes your rights to access and control your protected health information in some cases. Your "protected health information" means any written and oral health information about you, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.


I.          Uses and Disclosures of Protected Health Information


Executive Surgery Center 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 Executive Surgery Center as obtained your authorization, or 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 (fax).


  1. Treatment. We will 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 a third party for treatment purposes. For example, we may disclose your protected health information to a pharmacy to fill a prescription or to a laboratory to order a blood test. We may also disclose protected health information to physicians who may be treating you or consulting with the with respect to your Executive Surgery Center care. In some cases, we may also disclose your protected health information to an outside treatment provider for purposes of the treatment activities of the other provider.


  1. 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. If you pay for a service or health care item out-of-pocket In full, you can ask us not to share that information for the purpose of payment or our operation with your health insurer.


  1. Operations. We may use or disclose your protected health information, as necessary, for our own health care operations to facilitate the function of 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. Because the surgery center does not engage in any fundraising activities, protected health information is not used for fundraising communications.


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


  1. Other Uses and Disclosures. As part of treatment, payment and health care operations, we may also use or disclose your protected health information for the following purposes: to remind you of your surgery date, to inform you of potential treatment alternatives or options, or to inform you of health-related benefits or services that may be of interest to you.


  1. Uses and Disclosures Beyond Treatment, Payment, and Health Care Operations Permitted Without Authorization or Opportunity to Object


Federal privacy rules allow us to use or disclose your protected health information without your permission or authorization for a number of reasons including the following:


  1. When Legally Required. We will disclose your protected health information when we are required to do so by any federal, state or local law.


  1. When There Are Risks to Public Health. We may disclose your protected 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 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 (Safe Medical Devices Act).
  • 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.


  1. To Report Suspected Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe that a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.


  1. To Conduct Health Oversight Activities. We may disclose your protected health information to a health oversight agency 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.


  1. 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.


  1. 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 law enforcement official if Executive Surgery Center has a suspicion that your health condition was the result of criminal conduct.
    • In an emergency to report a crime.


  1. 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.


  1. For Research Purposes. We may use or disclose your protected health information for research when the use or disclosure for research has been approved by an institutional review board that has reviewed the research proposal and research protocols to address the privacy of your protected health information.


  1. In the Event of a Serious Threat to Health or Safety. We may, consistent with applicable law and ethical standards of conduct, use or disclose your protected health information if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.


  1. For Specified Government Functions. In certain circumstances, federal regulations authorize the Executive Surgery Center 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.


  1. For Worker's Compensation. Executive Surgery Center may release your health information to comply with worker's compensation laws or similar programs.


  • Uses and Disclosures Permitted without Authorization but with Opportunity to Object


We may disclose your protected health information to your family member or a close personal friend if it is directly relevant to the person’s involvement in your surgery or payment related to your surgery. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.  


You may object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to the person’s involvement with your care, we may disclose your protected health information as described.


  1. Uses and Disclosures which you Authorize


We will not disclose your health information for marketing purposes or in a manner that would constitute a sale without your authorization. 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 the authorization.


V.         Your Rights


You have the following rights regarding your health information:


  1. The 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 surgeon and the Executive Surgery Center uses 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 Director of Nursing whose contact information is listed on the last 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 Director of Nursing if you have questions about access to your medical record.

  1. The 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.

Executive Surgery Center 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 Executive Surgery Center 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 Director of Nursing.

  1. The 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 specification of 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 Director of Nursing.
  2. The right to request amendments to your protected health information. You may request an amendment of protected health information about you in a designated record set 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. Requests for amendment must be in writing and must be directed to our Director of Nursing. In this written request, you must also provide a reason to support the requested amendments.
  3. The right to receive an accounting. You have the right to request an accounting of certain disclosures of your protected health information made by Executive Surgery Center. 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 Executive Surgery Center 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 Director of Nursing. The request should specify the time period sought for the accounting. 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.
  4. The right to be notified of a breach of your protected health information. In the event of a breach that affects your unsecured protected health information, we will notify you in accordance with the guidelines and time frame provide by law.
  5. The 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.
  6. Our Duties

Executive Surgery Center is required by law to maintain the privacy of your health information and to provide you with this Privacy Notice of our duties and privacy practices. 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 Executive Surgery Center changes its Notice, we will provide a copy of the revised Notice by providing a copy of the revised Notice at the time of your next scheduled procedure through in-person contact.

VII.       Complaints

You have the right to express complaints to Executive Surgery Center and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the Executive Surgery Center by contacting Executive Surgery Center’s Privacy Officer verbally or in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

VIII.         Contact Person


Executive Surgery Center’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 Executive Surgery Center you may submit a complaint to our Privacy Officer by sending it to:


Executive Surgery Center

13603 Michel Road

Tomball, TX   77375

ATTN: Rachel Perry


Director of Nursing can be contacted by telephone at 832-698-3720.

IX.        Effective Date


This Notice is effective December 16, 2013


Executive Surgery Center

• Complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

• Does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Executive Surgery Center

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: ○ Quali ed sign language interpreters

○ Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as:

○ Quali ed interpreters
○ Information written in other languages

If you need these services, contact Debra Love
If you believe that you have been denied any of these services or discriminated against in another way, on the basis

of race, color, national origin, age, disability, or sex, you can le a grievance with:

Debra Love
13603 Michel Rd.
Suite 100

You can le a grievance in person or by mail, fax, or email. If you need help ling a grievance, the following person is available to help you:

Debra Love

You can also le a civil rights complaint with the U.S. Department of Health and Human Services, Of ce for Civil Rights, electronically through the Of ce for Civil Rights Complaint Portal, available at, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at ce/ le/index.html