Notice of Privacy Practices

NOTICE of PRIVACY PRACTICES for FORIS SURGICAL GROUP, LLP

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.

Under the Federal (HIPAA) Health Insurance Portability and Accountability Act of 1996, the Office for Civil Rights,

U.S. Department of Health & Human Services has developed Standards of Privacy. In accordance with these Regulations (45 CFR Parts 160 & 164), Foris Surgical Group, LLP provides this notice. It is effective April 14, 2003.

PROTECED HEALTH INFORMATION (hereinafter referred to as “PHI”) is the health information, including demographic information, transmitted or maintained, which we have collected, created, or received about an individual which relates to the past, present, or future physical or mental health or condition; provision of health care; or past, present, or future payment for the provision of health care; to an individual and identifies the individual.

UNDER THIS LAW, WE ARE PERMITTED OR REQUIRED TO USE OR DISCLOSE YOUR PHI WITH YOUR CONSENT FOR THESE PURPOSES WITHOUT YOUR WRITTEN AUTHORIZATION:

1) TREATMENT – Providing, coordinating, and managing your health care and related services within our practice, and with third parties outside our practice; consulting with and referring you to other health care providers, etc. For example, information obtained by a nurse, surgeon, or other member of our team will be recorded in your medical record. We use your medical record to communicate within and to provide information to your family physician, primary care provider, and other specialists. We provide information about you to the hospital, surgery center, and other facilities and providers when we arrange for testing, procedures or consultations to be performed for you. We use information we request form other providers and facilities to ensure that your medical record is complete for medical decision-making.

2) PAYMENT – To obtain reimbursement for the services we provide you. For example, a bill or insurance claim may be sent to you or a third party. This will contain personal information about you including your diagnosis, and a description of services provided to you. We will also provide information to your health plan to determine if we must obtain prior authorization for services.

3) HEALTHCARE OPERATIONS – In order to evaluate our office operations and monitor the quality of our care. For example, we may use your information to evaluate the performance of our staff in servicing your needs, to respond to your requests, and to respond to carrier record audits and credentialing or licensing activities.

4) OTHER PURPOSES AS PROVIDED FOR UNDER SECTION CFR 164.512 – As necessary to comply with laws, relating to Workers’ Compensation programs; As required by other laws; For public health activities; Relative to abuse, neglect, or domestic violence; For health oversight activities; For judicial and administrative proceedings; To law enforcement; To coroners and medical examiners, and funeral directors for certain reasons; For organ donation purposes; For research purposes meeting specific requirements; To avert a serious threat to health or safety; and For specialized government functions related to the military, national security, correctional institutions.

OTHER USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR VALID WRITTEN AUTHORIZATION. YOU MAY REVOKE SUCH AN AUTHORIZATION [as provided by CFR 164.508 (b)(5).] You may request an Authorization to Disclose Protected Health Information Form from our office. For example, you may want us to disclose PHI to your employer for a disability claim or FMLA request, or to send copies of your records to an insurance company to apply for life insurance. For security and documentation, we may ask you to provide written authorization to provide copies of some or all of your records to another medical provider.

APPOINTMENT REMINDERS: We may contact you by phone (using home, work or mobile numbers you have provided us) and/or by U.S. mail to provide an appointment reminder or to change an appointment or surgery due to a change in the surgeon’s schedule. Please notify us if you do not wish to be contacted in this manner for this purpose.

FAMILY AND CLOSE FRIENDS: We are permitted to disclose PHI directly relevant to their involvement with your care, or payment related to your care:

1) With your agreement, OR

2) If you are provided an opportunity to object and do not, OR

3) If based on the exercise of our professional judgment and inference from the circumstances we believe do not object. For example, if you bring your spouse with you into the exam room we may assume you agree to our disclosure of your PHI to your spouse during treatment or while treatment is discussed.

As it is difficult for us to know your wishes when your are not present, we request that you provide the names and other identifying information for those persons with whom you wish us to be able to communicate if needed (family member, other relative, or close personal friend or other person identified by you).

YOUR RIGHTS:

1) Right to Restrictions (CFR 164.522) – You have the right to request restrictions on the way we use and disclose your PHI to carry out treatment, payment or health care operations. We are not required to agree to a restriction. If we do agree, we must adhere to it except if you are in need of emergency treatment and the information is needed to provide it. You will need to complete a Request for Restriction Form and submit it to our Privacy Officer.

2) Right to Receive Confidential Communications (CFR 164.522 (b)) – You may request to receive communications of PHI in a certain way (for example, only by mail) or at an alternative location (for example, at your work address). We must accommodate reasonable requests and will not ask you for a reason for this request. You will need to complete a Request for Confidential Communication Form and submit it to our Privacy Officer.

3) Right to Inspect and Copy (CFR 164.524) – You have the right to inspect and obtain a copy of your PHI. We must comply within 30 days of your request. If you request a copy we may charge a fee for the costs of copying (including labor and supplies), and postage, if you request it be mailed.

4) Right to Amend (CDR 164.526) – You have the right to request we amend your PHI. We may deny the request under certain circumstances, for example, if we did not create it, or if it is accurate and complete. You must complete a Request for Amendment to PHI Form and submit it to our Privacy Officer. We must respond within 60 days.

5) Right to Accounting of Disclosures (CFR 164.528) – You have the right to receive a list of the disclosures of your PHI which we made except for disclosures: to carry out treatment, payment and health care operations; made to you; made pursuant to an authorization; or that occurred prior to April 14, 2003. You must submit your request in writing, to our Privacy Officer. We must act on your request within 60 days and we may impose a reasonable fee if you make a request more than once in a 12-month period.

6) Right to a Paper Copy of this Notice – You have the right to obtain a paper copy of this notice from us upon request (even if you agreed to receive it electronically). Contact our Privacy Office to obtain such copy.


OUR DUTIES:

1) We are required by law to maintain the privacy of PHI and to provide individuals with notice of our legal duties and privacy practices with respect to PHI.

2) We are required to abide by the terms of the Notice of Privacy Practices currently in effect.

3) We reserve the right to change the terms of this Notice of Privacy Practices and to make the new provisions effective for all PHI that we maintain. If we revise this Notice, we will make the revised notice available to you upon request.

4) If you believe your privacy rights have been violated, you may file a complaint to our Privacy Officer and/or to the Secretary of the Department of Health and Human Services. There will be no retaliation for filing a complaint.

5) For further information, contact our Privacy Officer, Susan M. Jones, Foris Surgical Group LLP, 74 Thomas Johnson Drive, Frederick, MD 21702—(301) 694-3200.