Provided By HCSI – Revised March 2013 USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500. Under the law, we must make disclosures to you upon your request. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. We may use or disclose your protected health information in the following situations without your authorization. If we use or disclose your protected health information for fundraising activities, we will provide you the choice to opt out of those activities. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also call you by name in the waiting room when your physician is ready to see you. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. For example, we may disclose your protected health information to medical school students that see patients at our office. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. This includes the coordination or management of your health care with a third party. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. It also describes your rights to access and control your protected health information. This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. This Notice of Privacy Practices is NOT an authorization.

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

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