PRIVACY STATEMENT

UNDERSTANDING YOUR HEALTH INFORMATION AND MEDICAL RECORD

Each time you come to our office, we document information about you and your visit. Your medical record contains your name, insurance/billing information, health history, symptoms, physical exam findings, test results and a plan for evaluation and treatment. This information has been designated by the federal government as PROTECTED HEALTH INFORMATION (PHI). The Health Insurance Portability and Accountability Act (HIPAA) provides guidelines for the use and disclosure of PHI. Our office has implemented privacy practices which attempt to protect your health information in accordance with the HIPAA guidelines.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your

protected health information.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon request, we will provide you with any revised Notice.

YOUR RIGHTS

The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have a right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in your medical record for as long as we maintain the protected health information.

You have the right to request restrictions on the uses and disclosures of your health information. This means you may ask us not use or disclose any part of your protected health information for the purpose of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care. Your request must be made in writing. Your physician or designated Privacy Officer is not required to agree to a restriction that you may request. If your physician or Privacy Officer believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. If your physician or Privacy Officer does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.  You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will attempt to accommodate reasonable requests. All requests must be made in writing.  You have the right to request to amend your protected health information. This means you may request to amend your PHI in your medical record for as long as we maintain this information. Your physician or Privacy Officer may deny your request for amendment. If your request is denied, you have the right to file a statement of disagreement with us. We reserve the right to make a rebuttal to your statement and will provide you a copy of any such rebuttal. You have the right to receive a list of all the people and companies that have received your PHI through disclosures provided by our office. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to receive a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically or in other formats.

Comprehensive Urologic Care, S.C. reserve the right to charge you a fee to administer these rights and a fee for providing a copy of an individual record or your full medical record. Our fee schedule has been developed in accordance with federal and state laws when such laws exist. This fee is not covered by your health insurance plan.

Comprehensive Urologic Care, S.C. RESPONSIBILITIES ARE TO:

Maintain the privacy of your health information as required by law.

Provide you with a notice our legal duties and privacy practices with respect to information we collect and maintain.

Do what is required by this Notice or a Notice that is in effect at the time that we use or disclose your health information.

Notify you if we are unable to agree to your requested restriction on disclosure of your health information.

Agree to reasonable requests to communicate your health information by an alternative method or at an alternative location.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, other physicians in our office, our office staff and others outside our office that are involved in your health care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to obtain payment for care provided through our office and to support the operation of Comprehensive Urologic Care, S.C. urologic practice.

EXAMPLES OF HOW YOUR HEALTH INFORMATION WILL BE USED OR DISCLOSED FOR TREATMENT, PAYMENT AND OPERATIONS

These examples are not meant to be exhaustive, but illustrative.

We will use your health information to provide treatment

For example: A physician, physician assistant, nurse or other member of our office staff will collect and document information about you in your medical record. This health information will be used to provide, coordinate and manage your health care. While this information will be used primarily within our office, we will at times disclose this information to individuals and/or entities outside our office. We will ensure to the best of ability that all these individuals and/or entities use this information in a manner consist with HIPAA guidelines.

We will use your health information to obtain payment

For example: We will send a bill that includes some of your health information to the person or entity (such as your health insurance company or Medicare) that is responsible for payment of health care services provided to you. Disclosure of information may occur prior to billing in order to determine eligibility or coverage for insurance benefits and/or to determine medical necessity.

We will use your health information for business operations.

For example: We may use or disclose your PHI during routine office operating procedures such as the use of an office sign in sheet or to contact you to remind you of an appointment. We will disclose PHI with third party "business associates" that perform various activities (e.g. billing, transcription etc.) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of PHI, we will have a written contract that contains terms that will protect the privacy of this information. We may use or disclose your PHI, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object

Upon receipt of your written authorization to use and disclose your health information

We will use and/or disclose your health information to those persons or companies for which you give us your written authorization or permission to do so. If you authorize us to use or disclose your information, you must complete our Release of Information Form. You may revoke your authorization in writing at any time except to the extent that we have already used or disclosed your health information as you previously authorized. If you health information includes Highly Confidential Information, we may only use and disclose such information for treatment, payment and operations as described above. Otherwise, unless a disclosure is allowed or required by federal law, you must give us your authorization to disclose Highly Confidential Information. A person who can verify your identity must witness and co-sign an Authorization to Release Health Information form about treatment for mental illness or developmental disability.

We may use and disclose your PHI in the following instances. You have the opportunity to agree or to object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the PHI, then your physician, physician assistant or nurse may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is relevant to your health care will be disclosed.

Others Involved In Your Health Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Emergencies: We may use and disclose your PHI in an emergency treatment situation. If this happens, your physician shall try to obtain your authorization as soon as reasonably practicable after the delivery of treatment. If your physician or another physician in the practice is require by law to treat you and the physician has attempted to obtain your authorization but is unable to your authorization, he or she may still use and disclose your PHI to treat you.

Communication Barriers: We may use and disclose your protected health information if your physician or another physician in the practice attempts to evaluate or provide care to you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intended to authorize to use and disclosure under the circumstances.

Other Permitted and Required Uses and Disclosures that may be made Without your consent, authorization or Opportunity to Object.

We may use and disclose your PHI in the following situations without your consent or authorization. These situations include:

Required by law: We may use and /or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health: We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your PHI, if directed by the public authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse and Neglect: We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In such cases, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your PHI to s person or company required by the FDA to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in response to a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. The law enforcement purposes include (1) legal procedures and otherwise required by law (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.

Coroner, Funeral Directors and Organ Donations: We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death of for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your PHI to researches when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your PHI, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend and individual.

Military Activity and National Security: When the appropriate conditions apply, we may use and disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by the appropriate military command authorities; (2) for the purpose of a determination by the Department of Veteran Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: Your PHI may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Inmates: We may use and disclose your PHI if you are an inmate of a correctional facility and your physician created or received your PHI in the course of providing care to you.

Right to File a Complaint

If you believe your privacy rights have been violated you may file a complaint with our Privacy Officer, the Director of the office of Civil Rights (OCR) or the U.S. Secretary of Health and Human Services (HHS). We will not retaliate against you if you file a complaint with us or with the Directors of OCR or HHS.

If you would like to report a Privacy Problem or want further information, please contact our office manager or Privacy Officer.