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 INFORMATON. PLEASE REVIEW IT CAREFULLY.

We are committed to protecting the confidentiality of your medical information, and are required by law to do so. This notice describes how we may use your medical information within the Provider and how we may disclose it to others outside the Provider. This notice also describes the rights you have concerning your own medical information. Please review it carefully and let us know if you have questions.

HOW WILL WE USE AND DISCLOSE YOUR MEDICAL INFORMATION?

Treatment: We may use your medical information to provide you with medical services and supplies. We may also disclose your medical information to others who need that information to treat you, such as doctors, physician assistants, nurses, medical and nursing students, technicians, therapists, emergency service and medical transportation providers, medical equipment providers, and others involved in your care. For example, we may share your medical information with your other physicians to assist in your treatment.

We also may use and disclose your medical information to contact you to remind you of an upcoming appointment, to inform you about possible treatment options or alternatives, or to tell you about health-related services available to you.

Patient Directory: In order to assist family members and other visitors in locating you while you are in the Provider’s facility, the Provider maintains a patient directory. This directory includes your name, room number, your general condition (such as fair, stable, or critical), and your religious affiliation (if any). We will disclose this information to someone who asks for you by name, although we will disclose your religious affiliation only to clergy members. If you do not want to be included in the Provider’s patient directory, please contact our Patient Care Coordinator.

Family Members and Others Involved in Your Care: We may disclose your medical information to a family member or friend who is involved in your medical care, or to someone who helps to pay for your care. We also may disclose your medical information to disaster relief organizations to help locate a family member or friend in a disaster. If you do not want the Provider to disclose your medical information to family members or others who will visit you, please notify the Patient Care Coordinator, Sandy at sandy.brady@cssifm.com.

Payment: We may use and disclose your medical information to get paid for the medical services and supplies we provide to you. For example, your health plan or Health Insurance Company may ask to see parts of your medical record before they will pay us for your treatment.

Provider Operations: We may use and disclose your medical information if it is necessary to improve the quality of care we provide to patients or to run the Provider. We may use your medical information to conduct quality improvement activities, to obtain audit, accounting or legal services, or to conduct business management and planning. For example, we may look at your medical record to evaluate whether Provider personnel, your doctors, or other health care professionals did a good job.

Many of our patients like to make contributions to the Provider. The Provider or its foundation may contact you in the future to raise money for the Provider. You have the right to opt out of receiving such fundraising communications. If you do not want the Provider or its foundation to contact you for fundraising, please notify our clinic in writing.

Research: We may use or disclose your medical information for research projects, such as studying the effectiveness of a treatment you received. These research projects must go through a special process that protects the confidentiality of your medical information.

Required by Law: Federal, state, or local laws sometimes require us to disclose patients’ medical information. For instance, we are required to report child abuse or neglect and must provide certain information to law enforcement officials in domestic violence cases. We also are required to give information to the State Workers’ Compensation Program for work-related injuries.

Public Health: We also may report certain medical information for public health purposes. We also may need to report patient problems with medications or medical products to the FDA, or may notify patients of recalls of products they are using.

Public Safety: We may disclose medical information for public safety purposes in limited circumstances. We may disclose medical information to law enforcement officials in response to a search warrant or a grand jury subpoena. We also may disclose medical information to assist law enforcement officials in identifying or locating a person, to prosecute a crime of violence, to report deaths that may have resulted from criminal conduct, and to report criminal conduct at the Provider’s facility. We also may disclose your medical information to law enforcement officials and others to prevent a serious threat to health or safety.

Health Oversight Activities: We may disclose medical information to a government agency that oversees the Provider or its personnel, such as State Department of Health Services, the federal agencies that oversee Medicare, the Board of Medical Examiners, and the Board of Nursing. These agencies need medical information to monitor the Provider’s compliance with state and federal laws.

Coroners, Medical Examiners and Funeral Directors: We may disclose medical information concerning deceased patients to coroners, medical examiners and funeral directors to assist them in carrying out their duties.

Organ and Tissue Donation: We may disclose medical information to organizations that handle organ, eye or tissue donation or transplantation.

Military, Veterans, National Security and Other Government Purposes: If you are a member of the armed forces, we may release your medical information as required by military command authorities or to the Department of Veterans Affairs. The Provider may also disclose medical information to federal officials for intelligence and national security purposes, or for presidential Protective Services.

Judicial Proceedings: The Provider may disclose medical information if the Provider is ordered to do so by a court or if the Provider receives a subpoena or a search warrant. You will receive advance notice about this disclosure in most situations so that you will have a chance to object to sharing your medical information.

Information with Additional Protection: Certain types of medical information have additional protection under state or federal law. For instance, medical information about communicable disease and HIV/AIDS, genetic testing, and mental health. For those types of information, the Provider is required to get your permission before disclosing that information to others in many circumstances.

Authorization: The Provider must obtain a written authorization from you before it may disclose certain types of notes recorded by mental health professionals, before it may disclose information for certain marketing purposes, and before it sells your information.

Other Uses and Disclosures: If the Provider wishes to use or disclose your medical information for a purpose that is not discussed in this Notice, the Provider will seek

Your permission. If you give your permission to the Provider, you may take back that permission any time, unless we have already relied on your permission to use or disclose the information. If you ever would like to revoke your permission, please notify our Patient Care Coordinator in writing.

WHAT ARE YOUR RIGHTS?

Right to Request Your Medical Information: You have the right to look at your own medical information and to get a copy of that information. (The law requires us to keep the original record.) This includes your medical record, your billing record, and other records we use to make decisions about your care. To request your medical information, write to our Patient Care Coordinator. If you request a copy of your information, we will charge you for our costs to copy the information. We will tell you in advance what this copying will cost. You can look at your record at no cost.

Right to Request Amendment of Medical Information You Believe Is Erroneous or Incomplete: If you examine your medical information and believe that some of the information is wrong or incomplete, you may ask us to amend your record. To ask us to amend your medical information, write to our Patient Care Coordinator.

Right to Get a List of Certain Disclosures of Your Medical Information: You have the right to request a list of many of the disclosures we make of your medical information. If you would like to receive such a list, write to our Patient Care Coordinator. We will provide the first list to you free, but we may charge you for any additional lists you request during the same year. We will tell you in advance what this list will cost.

Right to Request Restrictions on How the Provider Will Use or Disclose Your Medical Information for Treatment, Payment, or Health Care Operations: You have the right to request us not to make uses or disclosures of your medical information to treat you, to seek payment for care, or to operate the Provider. We are required to agree to requests to restrict disclosure of medical information about you to a health plan if the disclosure is for the purpose of carrying out payment or Provider operations, and the medical information pertains solely to a health care item or service for which you (or someone else on your behalf) have paid in full. We are not required to agree to other requests, but if we do agree, we will comply with that agreement. If you want to request a restriction, submit your request in writing to our Patient Care Coordinator and describe your request in detail.

Right to Request Confidential Communications: You have the right to ask us to communicate with you in a way that you feel is more confidential. For example, you can ask us not to call your home, but to communicate only by mail. To do this, write to our Patient Care Coordinator. You can also ask to speak with your health care providers in private outside the presence of other patients—just ask them!

Right to a Paper Copy: If you have received this notice electronically, you have the right to a paper copy at any time. You may download a paper copy of the notice from our website, at www.cssifm.com, or you may obtain a paper copy of the notice by requesting this from our Patient Care Coordinator.

CHANGES TO THIS NOTICE

From time to time, we may change our practices concerning how we use or disclose patient medical information, or how we will implement patient rights concerning their information. We reserve the right to change this Notice and to make the provisions in our new Notice effective for all medical information we maintain. If we change these practices, we will publish a revised Notice of Privacy Practices. You can get a copy of our current notice of Privacy Practices at any time by obtaining from our website. www.cssifm.com

DO YOU HAVE CONCERNS OR COMPLAINTS?

Please tell us about any problems or concerns you have with your privacy rights or how the Provider or its business associates use or disclose your medical information. If you have a concern, please contact our Patient Care Coordinator.

If for some reason the Provider cannot resolve your concern, you may also file a complaint with the federal government. We will not penalize you or retaliate against you in any way for filing a complaint with the federal government.

DO YOU HAVE QUESTIONS?

The Provider is required by law to give you this Notice and to follow the terms of the Notice that is currently in effect. The Provider is also required by law to notify affected individuals following a breach of unsecured protected health information. If you have any questions about this Notice, or have further questions about how the Provider may use and disclose your medical information, please contact our Patient Care Coordinator.

Effective date: May 1, 2017