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 IT CAREFULLY.

Protected health information, about you, is obtained as a record of your contacts or visits for healthcare services with our practice. Specifically, protected health information is information about you, including demographic information (i.e., name, address, phone, etc.) that may identify you and which relates to your past, present or future physical or mental health condition and related healthcare services.

Our practice is required to follow specific rules on how staff uses your information and how we disclose or share this information with other healthcare professionals involved in your care and treatment. This notice describes how we follow those rules and use and disclose your protected health information to provide your treatment, obtain payment for services you receive, manage our healthcare 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.

If you have any questions about this Notice, please contact our Privacy Manager at (812) 477-8808.

Your Rights Under the Privacy Rule Following is a statement of your rights under the Privacy Rule in reference to your protected health information. Please feel free to discuss any questions with out staff.

You have the right to receive, and we are required to provide you, with a copy of this Notice of Privacy Practices. We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. If needed, new versions of this notice will be effective for all protected health information that we maintain at that time. Upon your request we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail, or you may ask for one at the time of your next appointment.

You have the right to authorize other use and disclosure. This means that you have the right to authorize or deny any other use or disclosure of protected health information that is not specified within this notice. You may revoke an authorization, at any time, in writing, except to the extent that your physician or our office has taken an action in reliance on the use or disclosure indicated in the authorization.

You have the right to designate a personal representative. This means that you may designate a person with the delegated authority to consent to or to authorize the use or disclosure of protected health information.

You have the right to inspect and copy your protected health information. This means that you may inspect and obtain a copy of protected health information about you that is contained in your medical chart for as long as we maintain the protected health information. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on he circumstances, you have the right to disagree, in writing, with the denial of access. Please contact our Privacy Manager if you have questions about access to your medical record.

We have the right to charge a reasonable fee for copies as established by professional, state, or federal guidelines.

You have the right to request a restriction of your protected health information. This means that you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must that the specific restriction requested and to whom you want the restriction to apply.

We are not required to agree to a restriction that you may request. If we believe that it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician 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. We have the right to terminate a restriction and will notify you in writing of such termination. You may disagree with our termination of a restriction in written or verbal form. With this in mind, please discuss any requested restriction you wish with your physician.

You may have the right to request an amendment to your protected health information. This means that you may request an amendment of protected health information about you 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. We will provide you with a copy of any such denial and/or rebuttal.

You have the right to request a disclosure accountability. This means that you may request a listing of your protected health information disclosures we have made to entities or persons outside of our practice. It excludes disclosures that we may have made directly to you. You have the right to receive specific information regarding disclosures that occurred after April 14, 2003. You may receive a disclosure accountability on a no-fee basis once every twelve months. We have the right to charge a reasonable administrative fee for multiple disclosures within a twelve-month period and to require payment of such fees prior to delivering additional accounting.

HOW WE MAY USE OR DISCLOSE PROTECTED HEALTH INFORMATION

TREATMENT
We may use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment.

We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information to contact you to remind you of your appointment. We may contact you by phone or by other means to provide results from exams or test and to provide information that describes or recommends treatment alternatives regarding your care.

PAYMENT
Your protected health information will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommended for you, such as, making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

HEALTHCARE OPERATIONS
We may use or disclose, as needed, your protected health information in order to support the business activities of our practice. We will share your protected health information with third party “business associates” that perform various activities (e.g. billing services) for our practice. Whenever an arrangement between our office and a business associate involved the use or disclosure of your protected health information, we will have a written contract with that entity to protect the privacy of your health information. We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke an authorization at any time, in writing, except to the extent that we may have taken an action in reliance on the use or disclosure indicated in the authorization.

OTHERS INVOLVED IN YOUR HEALTHCARE
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person that you identify, your protected health information that directly relates to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for the care of your location, your general condition, or death. We may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.

AS REQUIRED BY LAW
We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

FOR PUBLIC HEALTH
We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for purpose of controlling, disease, injury or disability.

FOR COMMUNICABLE DISEASES
We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

FOR HEALTH OVERSIGHT
W may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the healthcare system, government benefit programs, other government regulatory programs and civil rights laws.

IN CASES OF ABUSE OR NEGLECT
We may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.

TO THE FOOD AND DRUG ADMINISTRATION
We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects, problems and biologic product deviations, to track products, to enable product recalls, or to make repairs or replacements.

FOR LEGAL PROCEEDINGS
We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

TO LAW ENFORCEMENT
We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include: (1) legal processes; (2) limited information requests for identification and location purposes; (3) those pertaining to victims of a crime; (4) suspicion that death has occurred as a result of criminal conduct; (5) in the event that a crime occurs on the premises of the practice; and (6) medical emergency (not on the practice’s premises) when it is likely that a crime has occurred.

TO CORONERS, FUNERAL DIRECTORS, AND FOR ORGAN DONATION
We may disclose protected health information to a coroner or medical examiner for identification purposes, for determining 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 his duties.

FOR RESEARCH
We may disclose your protected health information to researchers when an institutional review board has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

IN CASES OF CRIMINAL ACTIVITY
Consistent with applicable federal and state laws, we may disclose your protected health information if we believe that the use and disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for enforcement authorities to identify or apprehend an individual.

FOR MILITARY ACTIVITY AND NATIONAL SECURITY
When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel; (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits; (3) to foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including the provision of protective services to the Present or others legally authorized.

FOR WORKER’S COMPENSATION
Your protected health information may be disclosed as authorized to comply with worker’s compensation laws and other similar legally established programs.

WHEN AN INMATE
We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

REQUIRED USES AND DISCLOSURES
Under the law, we must make disclosures to you and, when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the Privacy Rule.

You may complain to us or to the Secretary of Health and Human Services if you believe that your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Manager of your complaint. We will not retaliate against you for filing a complaint.