Notice of Privacy Practices

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

This Notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your individually identifiable health information.

PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

• How we may use and disclose your IIHI
• Your privacy rights in your IIHI
• Our obligations concerning the use and disclosure of your IIHI

The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

B. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS:

1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice - including, but not limited to, our doctors and nurses - may use or disclose your IIHI in order to treat you or to assist others in your treatment.

2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. Also, we may use your IIHI to bill you directly for services and items.

3. Health Care Operations. Our practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice.

4. Appointment Reminders.

5. Treatment Options.

6. Health-Related Benefits and Services.

7. Disclosures Required By Law. Our practice will use and disclose your IIHI when we are required to do so by federal, state or local law.

C. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:

• maintaining vital records, such as births and deaths

• reporting child abuse or neglect
• preventing or controlling disease, injury or disability
• notifying a person regarding potential exposure to a communicable disease
• notifying a person regarding a potential risk for spreading or contracting a disease or condition
• reporting reactions to drugs or problems with products or devices
• notifying individuals if a product or device they may be using has been recalled
• notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
• notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:

• Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement
• Concerning a death, we believe has resulted from criminal conduct
• Regarding criminal conduct at our offices
• In response to a warrant, summons, court order, subpoena or similar legal process
• To identify/locate a suspect, material witness, fugitive or missing person
• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

5. Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

6. Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

7. Military. Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

8. National Security. Our practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

9. Inmates. Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

10. Workers' Compensation. Our practice may release your IIHI for workers' compensation and similar programs.

11. Research. Our practice may, under certain circumstances use and disclose IIHI for medical research purposes.

12. Fundraising Activities. Our practice may use your IIHI to contact you in an effort to raise money for the Hospital. Your IIHI may be disclosed to a foundation related to the Hospital. Such disclosure would be limited to contact information, such as your name, address and phone number and the dates you required treatment or services at the Hospital. The money raised in connection with these activities would be used to expand and support the Hospital’s provision of health care and related services to the community. If you do not want to be contacted as part of these fundraising activities, then please let us know.

13. Disclosures to You or for HIPAA Compliance Investigations. Our practice may disclose your IIHI to you or to your personal representative, and is required to do so in certain circumstances described below in connection with your rights of access to your IIHI and to an accounting of certain is closures of your IIHI. Practice must disclose your IIHI to the Secretary of the United States Department of Health and Human Services (the "Secretary") when requested by the Secretary in order to investigate practice’s compliance with privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA").

D. USES AND DISCLOSURES TO WHICH YOU HAVE AN OPPORTUNITY TO OBJECT

Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care. Unless you object, practice may disclose your IIHI to a family member, other relative, friend, or other person you identify as involved in your health care or payment for your health care. Practice may also notify those people about your location or condition.

E. OTHER USES AND DISCLOSURES OF IIHI WHICH AUTHORIZATION IS REQUIRED

Other types of uses and disclosures of your IIHI not described above will be made only with your written authorization, which, except in limited situations, you have the right to revoke in writing.

The practice is required by law to maintain the privacy of your IIHI, to provide individuals with notice of its legal duties and privacy practices with respect to IIHI, and to abide by the terms described in this Notice. The practice reserves the right to change the terms of this Notice and of its privacy policies, and to make the new terms applicable to all of the IIHI it maintains. Before practice makes an important change to its privacy policies, we will promptly revise this Notice and post a new Notice in our patient entrance and on all maintained websites. You have the following rights regarding your IIHI:

1. Right to Restrict Access to Your Health Information. You may request that the practice restrict the use and disclosure of your IIHI. The practice is not required to agree to any restrictions you request, but if it does so, these entities will be bound by the agreed restrictions, except in emergency situations.

2. Right to Confidential Communication. You have the right to request that communications of IIHI to you from the practice be made by particular means or at particular locations. For instance, you might request that communications be made at your work address, or by e-mail rather than regular mail. Your requests must be made in writing and sent to the practice. Practice will accommodate your reasonable requests without requiring you to provide a reason for your request.

3. Right to Inspect and Copy Your Health Information. Generally, you have the right to inspect and copy your IIHI that practice maintains, provided that you make your request in writing to the practice. Within thirty (30) days of receiving your request (unless extended by an additional thirty (30) days), practice will inform you of the extent to which your request has or has not been granted. In some cases, practice may provide you a summary of the IIHI you request if you agree in advance to such a summary and any associated fees. If you request copies of your IIHI or agree to a summary of your IIHI, practice may impose a reasonable fee to cover copying, postage, and related costs. If practice denies access to your IIHI, we will provide an explanation of the basis for denial, as well as of your opportunity to have your request and the denial reviewed by a licensed health care professional (who was not involved in the initial denial decision) designated as a reviewing official. If practice does not maintain the IIHI you request but know where that IIHI is located, you will be told how to redirect your request.

4. Right to Amend Your Records. If you believe that your IIHI maintained by practice contains an error or needs to be updated, you have the right to request that the practice correct or supplement your IIHI. Your request must be made in writing to the practice, and it must explain why you are requesting an amendment to your IIHI. Within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), practice will inform you of the extent to which your request has or has not been granted. Practice generally can deny your request if your request relates to IIHI: (i) not created by the practice; (ii) that is not part of the records practice maintains; (iii) that is not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, practice will provide you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant IIHI be made with a copy of your request and practice denial attached; and (iii) complain about the denial.

5. Right to Receive an Accounting of Disclosures. You generally have the right to request and receive a list of the disclosures of your IIHI that the practice has made at any time during the six (6) years prior to the date of your request. The list will not include disclosure for which you have provided a written authorization, and does not include certain uses and disclosures to which this Notice already applies, such as those: (i) for treatment, payment, and health care operations; (ii) made to you; (iii) for persons involved in your health care; (iv) for national security or intelligence purposes; or (v) to correctional institutions or law enforcement officials. You should submit any such request to the practice, and within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), practice will respond to you regarding the status of your request. Practice will provide the list to you at no charge, but if you make more than one request in a year you will be charged a fee of $75.00 for each additional request.

6. Right to a Copy of This Notice. You have the right to receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically.

7. Right to Complain. If you believe your privacy rights with respect to your IIHI have been violated, you may complain to the practice or the Compliance Office at Southern Regional Health System and submitting a written complaint. Practice will in no manner penalize you or retaliate against you for filing a complaint regarding the practice’s privacy practices. You also have the right to file a complaint with the Department of Health and Human Services Office of Civil Rights.

If you have any questions regarding this notice or our health information privacy policies, please contact:

Debbie Roddenberry, Director

Southern Crescent Physicians’ Group

11 Upper Riverdale Rd. SW

Riverdale, GA 30274

770-897-7093