If you have any questions about this notice, please contact our office at 219.866.7555 123 McKinley Avenue, Renssalaer, IN 47978

WHO WILL FOLLOW THIS NOTICE

This notice describes information about privacy practices followed by our employees, staff and other office personal.

YOUR HEALTH INFORMATION

This notice applies to the information and records we have about your health, health status, and the healthcare services you receive at this office.

We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your right regarding the use and disclosure of that information.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We must have your written, signed consent to use and disclose health information for the following purpose:

For Treatment: We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurse technicians' office staff and other personnel who are involved in taking care of you and your health.

For example, your doctor my be treating you for a kidney condition and may need to know if you have any other health problems that could complicate your treatment, the doctor may use your medical history to decide what treatment is best for you. The doctor may consult with another physician about your condition so that they can help determine the most appropriate care for you.

Different personnel in our office may share information about you and disclose information to people that do not work in our office, such as phoning in prescriptions to your pharmacy, scheduling lab work and ordering X-rays. Family members and other healthcare providers may be part of your medical care outside this office and require information that we may have.

For Payment: We may use and disclose health treatment about you so that treatment and services you receive at this office may be billed and payment may be collected from you, your insurance, or a third party. For example, we may need to give your health plan information about a service you received so that we will be reimbursed for the service. We may also contact your insurance about treatment you are going to receive to obtain prior approval or to find out whether your plan will cover the services.

For Healthcare Operations: We may use and disclose health information about you in order to run the office and make sure that you and other patients receive quality care. For example, we may use you health information to evaluate the performance of our staff in caring for you.

Appointment Reminders: We may contact you as a reminder that you have an appointment for treatment or medical care at our office.

You may revoke your consent at any time by giving us written notice. If you do revoke your consent your consent we will not be permitted to use or disclose information for purpose of the treatment payment or healthcare options. We can choose to discontinue providing you with healthcare treatment and services.

SPECIAL SITUATIONS

We may use or disclose health information about you without your permission for the following:

Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent serious threat to your health and safety and or the health and safety of the public or another person.

Required By Law: We will disclose health information about you when required to do so by federal, state or local law.

Workers' compensation: We may release health information about you for workers' compensation claims.

Public Health Risks: We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability, death, suspected abuse or neglect, non accidental physical injuries, reaction to medications or problems with products.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court order. We may also disclose health information about you in response to a subpoena.

Family and Friends: We may disclose health information about you to your family members or friends if we obtain your verbal or written agreement to do so. We may also disclose health information to your family or friends based on our professional judgment that you would not object. For example: when you bring your friend or spouse with you into the exam room during treatment or while treatment is being discussed.

OTHER USES AND DISCLOSERS OF HEALTH INFORMATION

We will not use or disclose your health information for any other then those identified in the previous sections without your written authorization. We must obtain your authorization separate from any consent.

If we have HIV or substance abuse information about you, we cannot release that information without written authorization different than the consent mentioned above.

YOUR RIGHT REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding health information we maintain about you.

Right to Inspect and Copy: You have the right to inspect and copy your health information, such as medical and billing records that we use to make decisions about your care. You must submit a written request in order to inspect or copy your health information. If you request a copy of the information, we have the rights to charge a fee for the costs of copying and mailing.

Patient Signature____________________________Date______________