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 company may use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.


How Your Health Information May be Used or Disclosed:

For Treatment- The company may use your health information to provide you with medical treatment or services. For example, information obtained by a health care provider, such as a physician, nurse, or other person providing health services to you, will be recorded as it relates to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions taken by them in the course of your treatment and note how you will respond to the actions.

For Payment- The company may use and disclose your health information to others for purposes of receiving payment and services that you receive. For example, a bill may be sent to you or a third-party payor, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis and treatment, and supplies used in the course of treatment.

For Health Care Operations- The company may use and disclose health information about you for operational procedures. For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to:
  -evaluate the performance of staff;
  -assess the quality of care and outcomes in yourcase    and similar cases;
  -learn how to improve facilities and services; and
   determine how to improve the quality and          effectiveness of the provided healthcare.

Appointments- The company may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest.

Required by Law- The company may use and disclose information about you as required by law. For example, the company may disclose any information for the following purposes:
  -for judicial and administrative proceedings pursuant    to legal authority;
  -to report information related to victims of abuse,    neglect or domestic violence;
  -to assist law enforcement officials in their official    duties.

Public Health- Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.

Decedents- Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.

Organ/Tissue Donation- Your health information may be used or disclosed for cadaveric organ, eye or tissue donation purposes.

Research- The company may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Health and Safety- Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

Government Functions- Specialized government functions, such as protection of public officials or reporting to various branches of the armed services, may require use or disclosure of your health information.

Workers’ Compensation- Your health information may be used or disclosed in order to comply with laws and regulations related to workers’ compensation.

Your Health Information Rights

You have the right to:
  -request a restriction on certain uses and disclosures of your information; however, the company is not required to agree to a requested restriction;
  -obtain a paper copy of the Notice of Privacy Practices upon request;
  -inspect and obtain a copy of your health record;
  -amend your health record;
  -request communications of your health information by alternative means or at alternative locations;
  -revoke your authorization to use or disclose health information  except to the extent that action has already been taken; and   
  –receive an accounting of disclosures made of your health information.

Complaints
You may make a formal complaint to Human Resources and/or to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint.

Obligations of the Plan

The company is required to:
  -maintain the privacy of protected health information;
  -provide you with this notice of its legal duties and privacy practices with respect to your health information;
  -abide by the terms of this Notice;
  -notify you if the company is unable to agree to a requested restriction on how your information is used or disclosed;
  -accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations; and
  -obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law.

The company reserves the right to change its information practices and to make the new provisions effective for all protected health information it maintains. Revised notices will be made available to you by e-mail and/or in hard copy within 60 days of any change.

Contact Information
If you have any questions or complaints, please contact (company contact and location).