Spine Surgery, PSC is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information (your medical information).

This Notice describes how we may use or disclose your "protected health information" for various purposes. It also describes your rights to accedss and control of your protected health information. "Protected health information" is information about you that may identify you and relates to your past, present or future physical or mental health or condition and related health services.

Spine Surgery, PSC is required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that we maintain. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office (502) 585-2300 and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1. Uses and Disclosures of Protected Health Information For Treatment, Payment and Health Care Operations

Uses and Disclosures of Protected Health Information Based Upon Your Written Consent

Upon arrival at our office, you will be asked to complete and sign our consent form in order to treat you, and bill for our services, You must complete and sign this Consent Form before you will be seen by our doctors. The Consent Form gives us permission to provide treatment to you, send your medical information to any other doctors you may be referred to and bill for our services. You are specifically giving us permission to send any of your protected health information which may contain information if you have any chemical dependency, substance abuse, drugs, alcohol, sexually transmitted diseases or mental health problems. We will not be able to send your medical information if we do not have this permission from you. you will also be asked to list anyone who has your permission to access your medical information. Only people you list on your Consent Form will be allowed access to your protected health information. It will be your responsibility to notify us of any changes to your Consent Form.

Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of this practice.

Following are examples of the types of uses and disclosures of your protected health care information that the practice is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your heath care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you when we have the necessary permission from you to disclose your protected health information. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. Finally, we may use and disclose protected health information for the treatment activities of another health care entity or provider.

If you call our office requesting information regarding billing, treatment, etc. you will be asked to give us the last four digits of your social security number for identification purposes. If you are unable to provide this security information to us, we will not be able to provide you with any of your protected health information.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. We may also use and disclose protected health information for the payment activities of another health care entity or provider.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of this practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of spine fellows, licensing, and conducting or arranging for other business activities.

For example, we may disclose your protected health information to spine fellows that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information to another entity in order for that entity to conduct specific health care operations, which include quality assessment activities and reviewing the competence of health care professionals.

We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involved the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.

Uses and Disclosures That May Be Made With Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke such an authorization, at any time, in writing, except to the extent that your physician or the practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Uses and Disclosures That May Be Made Unless You Object

We may use and disclose your protected health information in the following instances. In these instances, you have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Others Involved in Your Healthcare:

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 is in your best interest based on our professional judgment. We may use or disclose protected health information 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.

If you request that another individual (who is listed on your Consent Form as having your permission for access to your patient information) pick up a copy of your medical record, a written prescription, x-rays, etc. it will be accommodated. The individual who picks up your patient information will be required to produce a picture ID and complete a "Patient Information Pick-Up Form" before your protected health information will be released. If you request an individual who is not listed on your Consent Form as having your permission to your protected health information pick up your patient information, your request will be denied.

If you are accompanied to the office by a caretaker, we will require the caretaker to sign a Confidentiality Statement. This statement will say that the caretaker will keep your protected health information confidential.

Disaster Relief: We may use or disclose your protected health information 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.

Disclosures That May Be Made Without Your Authorization or Opportunity to Object

We may use or disclose your protected health information in the following situations without your authorization. These situations include:

Required By Law: We may use or disclose your protected health information 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.

Public Health: We may disclose your protected health information 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 protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. We may also disclose protected health information if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose your protected health information, as 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 protected health information 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 or Neglect: We may disclose your protected health information to public officials who are authorized by law to receive reports of abuse, neglect or domestic violence.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration 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 protected health information in the course of any judicial or administrative proceedings, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) requests for limited information for identification and location purposes, (3) requests pertaining to victims of a crime, and (4) alerting law enforcement officials when (a) there is suspicion that death has occurred as a result of criminal conduct, (b) in the event that a crime occurs on the Practice's premises, or (c) a medical emergency exists (not on the Practice's premises) and it is likely that a crime has occurred.

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

Research: We may disclose your protected health information to researchers 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 protected health information.

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

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits; or (3) to foreign military authority if you are a member of that foreign military services. 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 protected health information may be disclosed by us as authorized to comply with workers' compensation laws and other similar legally-established programs. You may be asked to sign an additional authorization forms in order for us to disclose your protected health information to case workers, adjustors, insurance companies, etc.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. The Corrections Officer accompanying you on your office visit will be asked to sign a Confidentiality Statement requiring them to keep your protected health information confidential.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the privacy standards applicable to your protected health information.

2. Your Rights Regarding Your Protected Health Information

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 the 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 a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records and any other records that your physician and the practice use for making decisions about you. In order for you to obtain or inspect a copy of your protected health information you will have to make the request in writing by completing the "Request for Access of Medical Information" form and allow us a minimum of two business days to obtain your records. Kentucky law requires us to provide you with one free copy of your patient information. Any additional copies you request will be made for you at a cost of 50 cents per page.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be renewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer, if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information: This means you may ask us not to use or disclose any part of your protected health information for the purposes 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 of for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. You will have to fill out a "Request to Restrict Protected Health Information" form in order to request a restriction. This restriction will remain in effect until you inform us that you no longer want it to remain in effect.

Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.

We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing by completing the "Request for Confidential Communication" form. This request will remain in effect until you tell us in writing to change your confidential communication.

You may have the right to have your physician amend your protected health information.

This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. You will have to complete the "Request to Amend Patient Information" form to request any changes to your patient information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal. Please contact our Privacy Officer to determine if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices as well as disclosures made in accordance with your authorization. It also excludes disclosures we may have made to you, to family member or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter time frame. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notification from us, upon request, even if you have agreed to accept this notice electronically.

3. Complaints

You may complain to us or to the Secretary of Health and Human Services (www.hhs.gov/ocr/hipaa), Office for Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth Street SW, Atlanta, GA 30303-8909, if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.

You may contact our Privacy Officer at (502) 585-2300 for further information about the complaint process.

This notice was published and becomes effective on April 14, 2003 at this address: Spine Surgery, PSC, 210 East Gray Street, Suite 601, Louisville, Kentucky 40202.

3/20/2003