HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THISINFORMATION. PLEASE REVIEW IT CAREFULLY.

OBLIGATION OF CENTENNIAL FOOT AND ANKLE:

We are required by law to:

Maintain the privacy of protected health information (PHI)

Give you this notice of our legal duties and privacy practices regarding health information on the patient

Follow the terms of our notice that is currently in effect

This notice explains your rights and our legal obligations regarding the privacy of PHI. Protected Health information (PHI) is information that individually identifies you. It may be used and disclosed by your physician, our office staff, another health care provider, your health plan, your employer, or a healthcare clearing house that relates to (1) your past, present, or future physical conditions, (2) the provisions of health care to you, or (3) the past, present, or future payment for your health care.

HOW CENTENNIAL FOOT AND ANKLE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION:

FOR TREATMENT: We may use and disclose you PHI to provide, coordinate, or manage your health care any relate4d services. This included the coordination or management of your health care with a third party. For example we may disclose your PHI to doctors, nurses, technicians, or the personnel, including people outside our office who are involved in your medical care and need the information to provide you with medical care.

FOR PAYMENT: We may use and disclose you PHI to enable us or others to bill and receive payment from you, and insurance company or a third party for the treatments and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.

FOR HEALTH CARE OPERATIONS: We may use your PHI for health care operation purposes. These uses and disclosures are necessary to make sure all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the podiatry care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

APPOINTMENT REMINDERS, TREATMENT ALTERNATIVES, HEALTH RELATED BENEFITS AND SERVICES: We may use and disclose you PHI to contact you to remind you that you have a scheduled medical appointment with us. We also may use and disclose PHI to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

INDIVIDUALS INVOLVED IN YOUR CARE OF IN PAYMENT FOR YOUR CARE: When appropriated we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

AS REQUIRED BY LAW: We will disclose PHI about you when required to do so in the following situations without authorization. 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. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose you PHI 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.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law. Without your authorization, we are expressly prohibited to use or disclose your PHI for marketing purpose. We may not sell your PHI without your authorization. We may not disclose most psychotherapy notes contained in your PHI. We will not use or disclose any of your PHI that contains genetic information that will be used for underwriting purposes. You may revoke the authorization at any time by submitting a written revocation and we will no longer disclose your PHI, except to the extent that your physician or the physicians practice has taken an action in reliance on the uses or disclosure indicated in the authorization.

YOUR RIGHTS REGARDING YOUR PROTECTION HEALTH INFORMATION:

The following are statements of your rights with respect to you PHI.

You have the right to inspect and copy you PHI (fees may apply): Pursuant to your written request, you have the right to inspect or copy the PHI for the purposes of treatment, payment or healthcare operations. You have right to request a summary of your PHI instead of the entire record, or an explanation of your Phi which has been provided to you so long as you agree to this alternative form and agree to pay the associated fees.

You have the right to an electronic copy of electronic medical records (fees may apply): You have the right to request be given to you or have transmitted to another individual or entity, an electronic copy of your PHI, if they are maintained in an electronic format. We will make every effort to provide the electronic copy in the format you request however if it is not readily producible by us we will provide it in either our standard format or in the format or in hard copy form.

You have the right to request restrictions of your PHI: This means you may ask us not to use or disclose any part of your PHI for the purpose of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for the notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to your requested restriction except if you request that the physician not disclose your PHI to your health plan with the respect to healthcare for which you have paid in full out of pocket.

You have the right to receive confidential communications: this means you may request that we communicate with you only in certain ways to reserve your privacy. For example, you may request that we contact you by mail at a specific address or call you on a specific telephone number. You request must be made in writing with specific instructions on how and where we contact you. We will accommodate all reasonable requests and will not ask the reason for the request.

You have the right to request an amendment to you PHI: If you feel that your PHI is incorrect or incomplete, you may ask us to amend the information. A request and the reason for the requested amendment must be made in writing to the HIPAA Compliance Officer. In certain cases we may deny your request. If we deny your request you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you a copy.

You have the right to get a notice of a breach: you have the right to be notified upon a breach of any of your unsecure OHI> You have the right to receive as accounting of disclosures: You have the right to receive an accounting of all disclosures paper or electronic, except for disclosure: pursuant to an authorization, for the purpose of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request. Your request must be made in writing and you must indicate in what form you want the list, for example on paper or electronically.

COMPLAINTS:

You may file a complaint with us or with the Secretary of the US Department of Health and Human Services if you believe you privacy right have been violated. To file a complaint with us you must make it in writing to our HIPAA Compliance Officer. Complaints must be submitted within 180 days of when you knew of or suspected the violation. There will be no retaliation against you for filing a complaint. To file a complaint with the Secretary, mail to: Secretary of the US Dept. of Health and Human Service4s, 200 Independence Ave. SW Washington, DC 20201. Call 202-619-0257 or toll free 877-696-6775 or go to their website.

I acknowledge that I have been provided the Centennial Foot and Ankle Notice of Privacy Practices:

• It tells me how Centennial Foot and Ankle will use my health information for the purpose of my treatment, payment for my treatment, and Centennial Foot and Ankle health operations.
• The Notice of Privacy Practices explains in more detail how Centennial Foot and Ankle may use and share my health information for other than treatment, payment and health care operations.
• Centennial Foot and Ankle will also use and share my health information as required/permitted by law

Centennial Foot and Ankle may release or disclose my Protected Health Information to the following:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.