Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

THIS NOTICE WIL TAKE EFFECT ON APRIL 14, 2003 AND WILL REMAIN IN EFFECT UNTIL REPLACED.

Our Pledge Regarding Your Medical Information

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. This notice will tell you about the ways we may use and share medical information about you. We also will describe your rights and certain duties we have regarding the use and disclosure of medical information.

Our Legal Responsibility

Law Requires Us To:

1. Keep your medical information private.
2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
3. Follow the terms of the notice that is now in effect.

We Have The Right To:

1. Change our privacy practices and terms of this notice at any time, provided those changes are permitted by law.
2. Make changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including previously created or received before the changes.

Notice Of Change To Privacy Practices:

Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

Use and Disclosure of Your Medical Information

There are different ways in which we use and disclose medical information. Not every use or disclosure will be listed; however, we have listed the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide us may be revoked at any time by submitting that request in writing to us.

For Treatment

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to physicians, nurses, technologist, medical students or other people who are taking care of you. We may also share medical information with other health care providers to assist them in treating you.

For Payment

We may use and disclose your medical information for payment purposes. If an insurance company requests a copy in writing of your medical records in order to process or play a claim, a copy only relevant to that date of service will be provided to your carrier.

For Health Care Operations

We may use and disclose your medical information for our health care operations. This may include measuring and improving quality, evaluation of personnel, conducting training programs, facility accreditation, certificates, licenses and other credentials we need to fully serve you.

Additional Uses and Disclosures

• Emergency Notification
• Disaster Relief
• Research in Limited Circumstances
• Court Orders and Judicial and Administrative Proceedings
• Public Health Activities
• Victims of Abuse, Neglect or Domestic Violence
• Workers Compensation
• Health Oversight Activities
• Law Enforcement

Your Individual Rights

You Have A Right To:

1. Look or get copies of your medical information. You must make a request for this in writing. If requesting copies, we will charge $2.00 per page (with a $15.00 minimum) and postage – if you want copies mailed.
2. Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment, health care operations and other specified exceptions.
3. Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions.
4. Request that we communicate with you about your medical information by different means or to different locations. This request must be made in writing.
5. Request that we change your medical information. We may deny your request if we did not create the information you want changed. If we deny your request we will provide you with a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted to change.

Questions and Complaints

If you have any questions about this notice or if you think we may have violated your privacy rights, please contact us:

Phone: 614-766-0773

You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.