PRIVACY POLICY (IN ACCORDANCE WITH HIPAA)

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1 PRIVACY POLICY (IN ACCORDANCE WITH HIPAA) The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. This notice will tell you about the ways that we may use and share medical information about you. It also describes your rights and certain duties we have regarding the use and disclosure of your medical information. The law requires us to: 1. Keep your medical information private. 2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information. 3. Follow the terms of this notice. Notice of Change to Privacy Practices: In the event that we make an important change in our privacy practices, we will change this notice and make the new notice available upon request. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION The following section describes different ways that we use and disclose personal health information. We will not use or disclose your medical information for any purpose not listed below without your specific written authorization. Any specific written authorization you provide may be revoked by you at any time by writing to us. If any practices are unacceptable to you, please see our front office staff. We will ask that you make any amendments you would like and then sign the amended version of the privacy policy. FOR COMMUNICATION: We may, from time to time, contact you to provide appointment reminders or information about treatment, treatment alternatives, or other health-related benefits and services that may be of interest to you. We may communicate with you in the following manner: By telephoning your home and leaving a message on your answering machine, or leaving a message with the individual answering the phone. By telephoning your place of employment and/or leaving a message on your voice mail or leaving a message with the individual answering the phone. By writing to your home or place of employment. By fax. By . FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you with your other health care providers to assist them in treating you. FOR PAYMENT: We may disclose your medical information to your insurance provider for payment purposes. 1

2 FOR HEALTHCARE OPERATIONS: We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of our employees, conducting training programs, and getting the accreditation, certificates, licenses, and credentials we need to serve you. ADDITIONAL USES AND DISCLOSURES In addition to using and disclosing your medical information for treatment, payment, and healthcare operations, we may use and disclose medical information for the following purposes Notification: Medical information to notify or help notify a family member, your personal representative, or other person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share the information, or give you the opportunity to refuse permission. In the case of an emergency, and if you are not able to give or refuse permission, we will share only medical information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, or medical information for you. Fundraising: If we undertake any fundraising activities, we may contact you. In any fundraising materials, we will provide you a description of how you may choose not to receive future fundraising communications. Research in Limited Circumstances: We may share medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information. You will be given the choice to participate in such research or to decline, without affecting your treatment here at New Heart. Funeral Director, Coroner, or Medical Examiner: To help them carry out their duties, we may share the medical information of a person who is deceased with a coroner, medical examiner, funeral director, or an organ procurement organization. Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim, or missing person. We may share the medical information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances. Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury, or disability, including abuse or neglect. We may also disclose your medical information to persons subject to the jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacement, to track products, or to conduct activities required by the Food and Drug Administration. We may also, when law authorizes us to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition. Domestic Violence: We may disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of domestic violence or other crime. We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health and safety of others. We may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody. 2

3 Danger, Abuse, or Neglect to/of Self or Others: In the event that we become aware of imminent danger to you or another person (i.e., if you or someone involved in your care discloses information to us of this nature), we are obligated to share this information with the appropriate authorities. We would share this information only in cases where our staff has reason to believe that the safety of you or someone involved in your care is in jeopardy (as in cases of suicidality or threats to self or others). Workers Compensation: We may disclose medical information when authorized and necessary to comply with laws relating to workers compensation or other similar programs. Health Oversight Activities: We may disclose medical information to an agency providing health oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities. Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies. You have a right to: YOUR INDIVIDUAL RIGHTS 1. Look at or request photocopies of your medical information. You may request that we provide copies in a format other than photocopies. We will provide the information in the format that you request unless it is not practical for us to do so. You must make your request in writing or in person at our front office. 2. Receive a list of all the times we or our business associates shared medical information for purposes other than treatment, payment or healthcare operations, and other specified exceptions. 3. Request that we place additional restrictions on our use or disclosure of your medical information. We will abide by our agreement (except in the case of an emergency). 4. Request that we change your medical information. We may deny your request if we did not create the information that you want changed or for certain other reasons. If we deny your request, we will provide you with a written explanation. You may respond with a statement of disagreement that will be added to the information that you want changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people that you name, of the change and to include the changes in any future sharing of that information. QUESTIONS AND COMPLAINTS If you have any questions about this notice, or if you think that we may have violated your privacy rights, please contact us by calling our office at (505) or sending a written complaint to our office, Attention: Office Manager. We will not retaliate in any way if you choose to file a complaint. 3

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5 NOTICE OF PRIVACY POLICY THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. By law, we are required to provide you with our Privacy Policy. This Policy describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information. As a patient, you have the following rights: 1. The right to inspect and copy your information. 2. The right to request corrections to your information. 3. The right to request that your information be restricted. 4. The right to request confidential communications. 5. The right to a report of disclosures of your information. 6. The right to a paper copy of this form. We want to assure you that your medical/protected health information is secure with us. This Policy contains information about how we will insure that your information remains private. If you have any questions or concerns about this Policy, please ask our staff. Acknowledgement of Privacy Policy I hereby acknowledge that I have received a copy of this practice s Privacy Policy. I understand that if I have any questions or complaints regarding my privacy rights that I may contact the office. I understand that the practice will offer me updates to this Privacy Policy should it be amended, or change in any way. I authorize New Heart staff to contact me by the designated means noted below: Home phone Home answering machine/voice mail Office/Work place phone/voice mail Cell phone/voice mail I also authorize New Heart staff to communicate information regarding appointments, medical results and billing issues to: Myself only or we may also speak to: Spouse (spouse s name) Other (name and relationship) Print name Signature Date 5

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