Heart Center Medical Group Notice of Privacy Practices

Effective April 14, 2003

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.

We will supply a written copy of this Notice to any person requesting it, whether or not they are a current patient. All patients will be given a copy of this Notice at the time of the first service provided to them following the effective date listed above. This Notice will be posted prominently and copies will be made available in our office.

OUR COMMITMENT TO YOUR PRIVACY

In compliance with the federal law known as the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), Heart Center Medical Group has established privacy policies and procedures relating to the protected health information of our patients. Protected health information (“PHI”) is information related to your past, present, or future physical or mental health or condition, or payment for such, in which you personally could be identified. HIPAA requires that providers must maintain the privacy of protected health information, provide a notice of their legal duties and privacy practices, and abide by the terms of the privacy notice currently in effect.

Your Rights as a Patient

With respect to your protected health information (“PHI”), you have certain rights:

Right to Inspect and Copy. You have a right to inspect and copy PHI that may be used to make decisions about your care or payment for your care. This includes medical and billing records but does not include psychotherapy notes. To inspect and copy this PHI, you must make your request in writing to Heart Center Privacy Officer, Heart Center Medical Group, 7836 West Jefferson Blvd, Fort Wayne, IN 46804.

Right to Amend. If you feel that PHI we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request in writing to Heart Center Privacy Officer, Heart Center Medical Group, 7836 West Jefferson Blvd, Fort Wayne, IN 46804. In addition, you must provide a reason to support any amendments you request to your medical records.

We may deny your request to amend your medical records if it is not in writing, or does not include a reason to support the request. We may deny your request if:

We did not create the PHI, and you do not provide us with a reasonable basis for us to believe that the originator of this information is no longer able to act on the requested amendment;

The information you have asked to amend is not used to make individual healthcare decisions about you;

You are not entitled to access the PHI under HIPAA

The information you are requesting to amend is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request in writing to Heart Center Privacy Officer, Heart Center Medical Group, 7836 West Jefferson Blvd, Fort Wayne, IN 46804. Your request must state a time period, which may not be longer than six (6) years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. For additional lists we may charge you for the costs of providing the list.

Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. We are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request a restriction, you must make your request in writing to Heart Center Privacy Officer, Heart Center Medical Group, 7836 West Jefferson Blvd, Fort Wayne, IN 46804

Right to Request Confidential Communication. 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 by mail or at work. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests. To request confidential communication, you must make your request in writing to Heart Center Privacy Officer, Heart Center Medical Group, 7836 West Jefferson Blvd, Fort Wayne, IN 46804

Right to a Paper Copy of This Notice. You may request a paper copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, you may come in and pick up a copy, or contact our office at 260-432-2297.

How We May Use Or Disclose Your Protected Health Information (“PHI”)

Under HIPAA, we are permitted to carry out the following activities involving the use of your PHI. (Examples listed are meant to be illustrative, not inclusive.)

Treatment - things we do to provide for your healthcare

Document your history, physical findings, observations, and test results in your medical record.

Record diagnoses and planned treatment or further evaluations.

Communicate this information to other health providers as required to provide for your healthcare.

Payment - things we do to receive payment from third parties for the services we render to you

Send a bill to a third party payer, such as your insurance company or health plan.

Include information about your health that is required for us to receive payment.

Operations - things we do to conduct our business, and to evaluate the quality and efficiency of these processes

Contract with copy and transcription services.

Contract with legal, actuarial, secretarial, accounting, consulting, management, administrative accreditation, data aggregation, or financial services.

Assess patient outcomes.

Transfer, sell, consolidate, or merge our practice.

Evaluate provider performance.

We are also permitted to use or disclose your protected health information for treatment activities by any healthcare provider. We may disclose such information to another covered entity or any healthcare provider for their payment purposes. We may disclose relevant information to another covered entity, with whom you currently have or previously had a relationship, for healthcare operations such as quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, case management and care coordination, conducting training programs, and accreditation, licensing, or credentialing activities, or for the purpose of health care fraud and abuse detection or compliance. Such use, as described in this paragraph, is governed by minimum necessary disclosure standards.

We will institute appropriate administrative, technical, and physical safeguards to protect the privacy of your protected health information from intentional or unintentional use and disclosure that is not authorized under HIPAA. During permitted activities related to treatment, payment, and operations, certain unavoidable, limited, and incidental disclosures of protected health information may occur, such as overhearing a conversation. Under HIPAA, such disclosures are permissible, and are not subject to reporting in any accounting of disclosures.

Disclosures of Protected Health Information Not Requiring Your Authorization

We follow HIPAA regulations with respect to the scope and context in which disclosures of your protected health information can be made without your authorization. The following list summarizes the individuals or entities to which disclosures of your protected health information can be made, under certain specific circumstances described in detail by HIPAA, without your written consent or authorization:

As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement; banking or transportation of organs, eyes, or tissues to facilitate organ, eye or tissue donation; and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Workers’ Compensation. We may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.

In addition, protected health information may be released by a "whistleblower" to an approved health oversight agency, public health authority, or attorney, provided that the "whistleblower" believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Disclosures of Protected Health Information Requiring Your Authorization

Most disclosures of your protected health information that are not part of treatment, payment, or operations require specific authorization by you or your personal representative. Such authorizations must include a description of the information to be disclosed, who is authorized to make the disclosure, who is authorized to receive the disclosure, the purpose of the disclosure, an expiration date or event related to the disclosure, a dated signature by the subject of the disclosure or a personal representative, and, if signed by a representative, a description of his or her authority to act on your behalf. If you request the disclosure, you may indicate "at the request of the individual" as the reason for the disclosure. Any authorizations we initiate will be written in plain language, will list the specific reason for the request, and will inform you that you can revoke the authorization in writing. You will be provided with a copy of any disclosures we initiate. Protected health information that is disclosed to a third party potentially may lose its protection against redisclosure. Authorizations lacking essential elements are considered invalid under HIPAA.

You may refuse to provide an authorization that we request, and treatment or payment generally cannot be conditioned on signing such authorizations, with a few exceptions:

If you wish to participate in research-related treatment as part of a clinical trial, care can be conditioned on your agreeing to the disclosure of protected health information required for the conduct of the trial.

If we will be providing treatment for the sole purpose of creating protected health information for the benefit of a third party, such as an employee fitness evaluation under contract with an employer, we may refuse to conduct the exam if you do not authorize us to disclose the results of the exam to this third party.

COMPLAINTS

If you have any questions about our privacy practices or any of the information contained in this Notice of Privacy Practices for Protected Health Information ("Notice"), or wish to register any complaints related to our privacy practices, you should contact:

Heart Center Privacy Officer

Heart Center Medical Group

7836 West Jefferson Blvd

Fort Wayne, IN 46804

(260) 432-2297

OR

Department of Health and Human Services

Office of Civil Rights

Room 509F HHH Building

200 Independence Ave. SW

Washington, DC 20201

We reserve the right to makes changes to our Notice and have any new provisions become effective for all protected health information we maintain. If we make any material changes to the uses or disclosures of protected health information, the individual's rights, our legal duties, or other privacy practices stated in this Notice, this Notice will be revised. The revised Notice will be posted prominently in our office, and we will make the revised Notice available to anyone who requests a copy.