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

PLEASE REVIEW IT CAREFULLY

The practice provides this Notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create paper and electronic medical records about your health, our care for you, and the services and/or items we provide to you as our patient. We need this record to provide for your care and to comply with certain legal requirements.

We are required by law to:

• make sure that the protected health information about you is kept active;
• provide you with a Notice of our Privacy Practices and your legal rights with respect to protected health information about you; and
• follow the conditions of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose protected health information that we have and share with others. Not every use or disclosure in a category is either listed or actually in place. The explanation is provided for your general information only.

Treatment. We use previously given medical information about you to provide you with current or prospective medical treatment or services. Therefore we may, and most likely will, disclose medical information about you to doctors, nurses, technicians, medical students, or hospital personnel who are involved in taking care of you. For example, it may be necessary to share your medical information with another health care provider whom we need to consult with respect to your care. Different areas of the Practice also may share medical information about you including your record(s), prescriptions, requests of lab work and x-rays. We also may disclose medical information about you to people outside the Practice who may be involved in your medical care after you leave the Practice; this may include your family members, or other personal representatives authorized by you or be a legal mandate (a guardian or other person who has been named to handle your medical decisions, should you become incompetent).

In addition, we may disclose medical information about you in an emergency situation so that your family can be notified about your condition, status and location. We may use and disclose medical information about you when necessary to prevent a serious threat either to your specific health and safety or the health and safety of the public or another person.

Payment. We may use and disclose medical information about you for services and procedures so they may be billed and collected from you, an insurance company, or any other third party. For example, we may need to give your health care information about treatment you received at the Practice, to obtain payment or reimbursement for care. This may also include determinations of eligibility or coverage under the appropriate health plan, pre-certification and pre-authorization of services or review of services for purposes of reimbursement.

Health Care Operations. We may use and disclose medical information about you so that we can run our Practice more efficiently and make sure that all of our patients receive quality care. These uses may include reviewing our treatment and services to evaluate the performance of our staff, deciding what additional services to offer and where, deciding what services are needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may remove information that identifies you so others may use the information to study health care and health care delivery without learning who the specific patients are.

We may also use or disclose information about you for internal or external utilization review and/or quality assurance, to business associates for purposes of helping us to comply with our legal requirements, to auditors to verify our records. We may use and disclose medical information to contact you and/or another healthcare provider participating in your care as a reminder that you have an appointment for medical care with the Practice or that you are to receive periodic care from the Practice. This contact may be by phone, in writing, or otherwise and may involve leaving a message that could (potentially) be received or interpreted by others.

Under certain circumstances, we may use and disclose medical information about you for research purposes regarding medications, efficiency of treatment protocols and the like. We will obtain an Authorization from you before using or disclosing any individually identifiable health information unless the authorization requirement has been waived. If the information has been sufficiently de-identified, an authorization for the use or disclosure is not required.

We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

CHANGES TO THIS NOTICE

We reserve the right to change this notice at any time. We reserve the right to make this changed notice effective for all medical information we already have about you as well as any information we may receive from you in the future. We will post a copy of the current notice in the Practice receiving area.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission, unless those uses can be reasonably inferred from the intended uses above. If you have provided us with your permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission.

PATIENT RIGHTS

THIS SECTION DESCRIBES YOUR RIGHTS AND THE OBLIGATIONS OF THIS PRACTICE REGARDING THE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION.

You have the following rights regarding medical information we maintain about you:

• Right to inspect and copy. You have the right to inspect, copy and request amendment to your medical records. Access to your medical records will not include psychotherapy notes contained in them, or information compiled in anticipation of or for use in a civil, criminal or administrative action or proceeding or for which your access is otherwise restricted by law. Upon proof of an appropriate legal relationship, records of others related to you or under your care (guardian or custodial) may also be disclosed.

To inspect and copy your medical record, you must submit your request in writing. We will charge a reasonable fee for providing a copy of your medical records, or a summary of those records, at your request, which includes the cost of copying, postage, or preparation of an explanation or summary of the information.

• Right to Amend. If you feel that the medical information we have about you in your record is incorrect or incomplete, then you may ask us to amend the information, following the procedure below. You have the right to request an amendment for as long as the Practice maintains your medical record.

Your request for amendment must be submitted in writing, along with your intended amendment and a reason that supports your request to amend. The amendment request must be dated and signed by you and notarized.

We may deny the request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by us for the Practice;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is inaccurate and incomplete.
• Right to an Accounting of Disclosures. You have a limited right to receive an accounting of all disclosures we make to other persons or entities of your medical information except for disclosures required for treatment, payment and health care operations, disclosures that require an Authorization, disclosures incidental to another permissible user or disclosure, and otherwise as allowed by law.
• Your request for disclosure must be in writing and must state a time period not longer than six (6) years back and may not include dates before April 14, 2003. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care (a family member or friend).

We are not required to agree to your request and we may not be able to comply with your request. If we do agree, we will comply with your request except that we shall not comply, even with a request, if the information is excepted from the consent requirement or we are otherwise required to disclose the information by law.

Your request for restriction must be in writing and indicate the following:

• what information you want to limit;
• whether you want to limit our use, disclosure or both; and
• to whom you want the limits to apply, (example: disclosures to your children, parents, spouse, etc.)
• Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, that we not leave voice mail messages or the like.
• To request confidential communications, you must make your request in writing. We will not ask the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish us to contact you.
• Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our office manager, who will direct you on how to file an office complaint. All complaints must be submitted in writing, and all complaints shall be investigated, without repercussion to you.

CONTACTS

All questions and/or correspondence concerning this Notice should be addressed to:

Confidential: Privacy Practice Concerns

Lancaster Surgical Group, P.C.

P.O. Box 3200

Lancaster, PA 17604-3200