Legal and Ethics Oversight and Regulatory Disclosures (Code of Ethics)



It is the intent of this organization to operate within the 
framework of State and Federal law and professional ethics.
To that end, this organization will report adverse incidents 
(including patient death) in accordance with applicable State 
law and with the standards of the accrediting agency.  In 
addition, adverse incidents will be considered as a part of 
the quality assessment/performance improvement process with 
the anticipation of studying elements which contribute to 
such incidents and examined in the paradigm of the risk 
management program.
Legal services are available through corporate legal counsel. 

Voluntary state and national professional associations and 
specialty societies are also a resource for legal/ethical 
Questions of ethics will be presented to the Medical Director 
or Governing Body for judgment regarding those issues which 
need clarification by professional staff.  Private ethics 
counsel is available from the Ethics Departments of the local 
hospitals, medical schools and specialty societies.
Governance will be organized along traditional business 
standards; i.e., a duly appointed or elected governing body 
of the business entity of the clinical provider staff 
organization.  There will be at least one annual meeting of 
each entity; other meetings will be held at the call of the 
president of the business entity or the director of the 
provider staff organization.  When possible, the annual 
meetings will be scheduled so that the meeting of the 

clinical organization precedes the meeting of the business 
entity.  In this manner the recommendations of the clinical 
organization can be acted upon at the business meeting.  The 
major role of the provider staff organization is to make 
recommendations in the area of staff privileges and related 
clinical matters; the organization's bylaws define the issue 
of staff credentialing.


The following disclosures are made pursuant to regulatory 
requirements and accreditation standards.  This information 
is also addressed in appropriate sections of the policy and 
procedure manuals, as applicable. 
1.  Disclosure of ownership
    This organization is owned and operated by Rakesh Gupta, MD.
2.  Confidentiality and Privacy
    Confidentiality and privacy issues relating to the 
    providers, the intellectual property of the organization,
    employee information, and patient records are addressed
    in the appropriate policy and procedure manual.
3.  Marketing
    The following methods are utilized for marketing and 
    these methods accurately represent the organization;
    the care, treatment and services provided. AREA 
4.  Transfer to Acute Care
    Patients requiring acute care are transferred to the 
    acute care facility most capable of rendering appropriate
    care.  Providers at this organization maintain privileges
    at the local hopsital.The decision to transfer may be 
made by the
    surgeon or designee.
5.  Billing Practices
    Staff provides billing practice information, including 
    fees and payment policies, prior to any procedure being 
    performed on a patient.  Patient queries are treated with
A conflict of interest occurs when an individual or 
organization has an interest that might compromise their 
reliability. A conflict of interest exists even if no 
improper act results from it, and can create an appearance of 
impropriety that can undermine confidence in the conflicted 
individual or organization.
Cures for Conflicts of Interest
The best way to handle conflicts of interests is to avoid 
them entirely. There fore any conflict of interest identified 
that can not be cured; will be removed.
Full Disclosure will be given regarding ownership of the 
organization and individuals that may benefit financially 
from the organization.
Those with a conflict of interests are expected to recuse 
themselves from (i.e., abstain from) decisions where such a 
conflict exists. 
The following areas may be conflicts of interest, but when 
addressed in the following manner and disclosed, they are not 
considered conflicts of interest.
Conflicts of Interest:
6.  Relationship with Health Care Providers Credentialed to
    Work in this Organization
7.  Relationship with Referrals and Referral Sources
    There is no contractual relationship between this 
    organization and any external referral sources.
    Providers in this facility do not engage in fee-
8.  Relationship with Third Party Payers
    This organization does not hold any stock nor have any
    relationship which results in financial gain with the
    third party payers save legally-entitled payment for
    services rendered.
  Additionally, decisions are base on the patients care, 
    treatment and service needs, regardless of how the 
    organization compensates or shares financial risk with 
    its leaders, managers, staff, and licensed independent 
    At times indications for such care, treatment, and   
    services can contradict the recommendations of an 
    external entity, i.e. insurance companies, managed care
    reviewers, state payers, etc.  If such a conflict
    arises, care, treatment, service, and discharge 
    decisions are made based on the patient's needs, 
    regardless of the recommendations of the external 
9.  Relationship with Educational Institutions
    This organization does not have relationship with any 
    educational instituti

Approved by Governing Body
Control #25.12