Wabash Valley Urological Associates, Inc.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

Notice of Privacy Practices

Effective Date of this Notice: April 14, 2003

WHAT IS HIPAA?

Congress enacted the Health Insurance Portability and Accountability Act of 1996 (HIPAA) due to continued growth in the number of health care providers, increases in insurance claims, aggressive marketing of health care services and products and the growing concern of the public regarding today's advantages in technology and how their health information is stored, shared, and used. This Notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

If you have any questions about this notice you may call the office at 812.232.9596 and talk to any office staff member or if they can not answer your questions you may contact the Office Manager.

OUR PLEDGE REGARDING MEDICAL INFORMATION:

We understand that medical information about you and your health is personal and we are committed to protecting your privacy. We create a record of the care and services you receive at this facility. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all records of your care generated by this facility whether in paper or electronic form.

Law requires us to:

Give you this Notice of our legal duties and privacy practices.

Follow the terms of the Notice that is currently in effect.

THE RIGHTS LISTED IN THIS NOTICE WILL NOT APPLY TO INMATES OF CORRECTIONAL INSTITUTIONS.

We will collect only the personal information that is necessary to conduct our business. This means just what is necessary to provide quality healthcare and accurately bill you or your insurance carrier.

WHO HAS ACCESS TO YOUR INFORMATION?

We restrict access to your personal information to only those persons with a need to know. We maintain physical, electronic and procedural safeguards that meet state and federal regulations to guard your personal medical information. We will not use or disclose your medical information without your authorization, except as otherwise described in this Notice.

HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION.

The following categories describe different ways that we use and disclose medical information. Information may be disclosed in writing, orally or electronically. Not every use or disclosure in each category will be listed, however, all the ways we are permitted to use and disclose information will f Il within one these categories.

FOR TREATMENT:
We will use your medical information to provide you with quality treatment or services. Various people who are involved in your care may access your information (example: doctors, nurses, technicians, students, clerks, laboratory personnel, etc). Different departments may share medical information with another physician if you are referred for specialized care. We may also share your medical information with a family member or friend who will assist with your care outside the facility.
FOR PAYMENT:
We will use and disclose your medical information so that we can bill for the services you received and collect payment. For example: we may share information with your insurance company to obtain prior approval for treatment when applicable, or to bill and receive reimbursement for treatment you received. We may also share your information with other affiliated or contracted entities that performed service for you during your visit to our facility. (Example: allied physicians or technicians).
FOR OPERATIONS:
We may use and disclose your medical information as necessary to run our facility and provide our patients with quality care. Examples of uses and disclosures include, but are not limited to the following:
To send you appointment reminders.
To inform you about or recommend possible treatment options or alternatives that may be of interest to you.
For research purposes under certain circumstances.
To outside organizations called our Business Associates who perform a task on our behalf, such as an outside billing agency or transcription service.
To doctors, nurses, students and other personnel for review and learning purposes.
AS REQUIRED BY LAW:
We may use and disclose your medical information as required in the following situations:
To prevent a serious threat to your health and safety or the health and safety of another person or the public;
To report public health activities or risks, such as infectious diseases or abuse cases;
To report births or deaths;
For health oversight activities, which could include audits, investigations, inspections and licenser;
To a court or in response to an administrative order, subpoena, discovery request or other process if you are involved in a lawsuit or dispute;
To law enforcement officials in response to a criminal investigation, warrant, etc.
To federal officials for intelligence and other national security activities authorized by law;
To coroners, medical examiners or funeral directors;
To workers compensation programs when applicable;
To organ donation or procurement programs when applicable;
To military command authorities, as applicable, if you are a member of the Armed Forces.
OTHER USES OF MEDICAL INFORMATION:
Other uses and disclosures of medical information not covered by the Notice or law will be made only with your WRITTEN permission. If you provide us permission to use or disclose your medical information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures we may have already made while we had your permission and that we are required by law to retain our records of care we provided to you.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:

RIGHT TO INSPECT AND COPY
As a patient of ours, you have the opportunity to review your information or receive copies of your records. This includes medical and billing records, but does not include psychotherapy notes. If you request a copy of the records, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. .To see or obtain copies of your medical records AND to request amendments to them a request must be in writing; we have 60 days to act upon the request. We are NOT MANDATED to make the change requested, but we must fairly evaluate each request. All decisions, whether approved or denied, must be returned in writing to the patient and must become a permanent part of the medical record. This will be sent to the patient by certified mail and return signature required.

When you request to review your medical records we will make you an appointment to do so and it will be when we do not have appointments scheduled while a doctor is here. An employee must be with you at all times while you are reviewing your chart in a private area. If you want a copy of your chart we will charge $3.00 for the first 10 pages and 25 cents each page thereafter. Attorney and Insurance Company fees are different.

If you have questions about the chart you will be given an appointment to talk to the doctor and we have 30 days in which to give you an appointment.

RIGHT TO AMEND:
If you feel the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept. To request an amendment, contact the Office Manager at (812) 232-9596. We will give you the appropriate form to complete, which must include the reason for your request. We will deny your request for an amendment if it is not in writing or does not include a reason for the request. In addition, we may deny your request if it is deemed that our information is accurate and complete.

RIGHT TO ACCOUNTING OF DISCLOSURES:
You have the right to request an accounting of disclosures, that is a list of the persons to whom we sent some or all of your medical information. This accounting can begin no earlier than our HIPAA privacy Standards compliance effective date of April 14, 2003, and can include a maximum six year period. Contact the Office Manager at 812.232.9596 to begin this process. We will charge you for the cost of providing more than one accounting during a 12-month period. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any charges are incurred.

RIGHT TO REQUEST RESTRICTIONS:
You have the right to request a restriction or limitation of the medical information we use or disclose about you for treatment, payment or other health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about this visit. WE ARE NOT REQUIRED TO AGREE TO YOUR REQUEST. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, contact the Office Manager at 812.232.9596. You will be given the appropriate form to complete your request, which must include:

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS:
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. You may request confidential communication during your registration process. Any request made after you have been registered should be made to the Billing Department at 812.232.9596.

FOR MORE INFORMATION OR TO REPORT A PROBLEM:
If you have any questions or would like additional information about our privacy practices or the Notice, you may contact any of the office employees during normal business hours. Monday -Friday 9:00 a.m. through 5:00 p.m. at 812.232.9596.

If you believe your privacy rights have been violated, you can file a complaint with the Office Manager at

Or with:

OUR WEBSITE:
www.urologychannel.com/wabash

CHANGES TO THIS NOTICE:
We reserve the right to change our practices and this Notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. We will post a copy of the current Notice in the facility.

Wabash Valley Urological Associates, Inc.
1235 Ohio Street
Terre Haute, Indiana 47807
Tel: 812.232.9596
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