Privacy Practices

Effective Date – April 14, 2003

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 and maintain it with your important health papers.

The terms of this Notice of Privacy Practices apply to the physician office practice of Midwestern Cardiac Surgery and / or Midwestern Pulmonary Associates. The members of these offices will share personal health information of our patients as necessary to carry out treatment, payment and health care operations as permitted by law.

We are required by law to maintain the privacy of our patients’ personal health information and to provide patients with notice of our legal duties and privacy practices with respect to their personal health information. We are required to abide by the terms of this notice so long as it remains in effect. We reserve the right to change the terms of this notice as necessary and to make the new notice effective for all personal health information maintained by us.

Except as outlined below, we will not use or disclose your personal health information for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization at any time. You must revoke authorization in writing. Revoking authorization does not apply to information used or disclosed prior to our receipt of your written notice revoking authorization.

Uses and Disclosures for Treatment
With your signed consent for treatment, we will use and disclose your personal health information as necessary for your treatment. Doctors and other health care professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan your treatment, including procedures, medications, tests and other services. Since your personal health information is vital to providing quality care, without your permission to use your information in this way, we may elect to not provide treatment to you, except in an emergency situation.

Uses and Disclosures for Payment
With your signed consent for payment, we will use and disclose your personal health information as necessary for payment purposes. For instance, we may forward information regarding your medical treatment to your insurance company to obtain approval and arrange payment for the services provided to you. We may use your information to prepare a bill to send to you or to the person responsible for payment for services you received. We may disclose your information to others who have provided care to you for their billing purposes as well. Should you not sign this consent, you will personally be financially responsible for all services you receive.

Uses and Disclosures for HealthCare Operations
We will use and disclose your personal health information as necessary and as permitted by laws for our health care operations, which include clinical improvement, professional peer review, business management, accreditation, licensing and other matters. For instance, we may use and disclose your personal health information for purposes of improving the clinical treatment and care of our patients.

Family and Friends Involved in Your Care
We may from time to time disclose your personal health information to designated family, friends and others who are involved in your care or in payment for your care. This is to help that person in caring for you or in arranging payment for your care. If you are unavailable, incapacitated or facing an emergency medical situation, we may determine that a limited disclosure is in your best interest. In this case, we may share limited personal health information with such individuals without your approval or consent. We may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons who may be involved in some aspect of caring for you.

Business Associates
Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, legal services, and other services. At times it may be necessary for us to provide certain parts of your personal health information to one or more of these outside persons or organizations to assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.

Appointments and Services
We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. You have the right to request that we communicate with you by an alternate method or alternate location. We will try to accommodate such requests if it is within our capability to do so. For example, you may wish appointment reminders and other messages to not be left on voicemail / message machines, to be called to an alternate phone number or sent to an alternate address. You must request such confidential communication in writing, by sending notice to the Office Administrator – 770 Balgreen Dr. Suite 107, Mansfield, OH 44906

In limited circumstance, we may use and disclose your personal health information for research purposes. For example, a researcher may wish to compare outcomes of all patients that received a particular drug and will need to review a series of medical records. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements.

Other Uses and Disclosures
We are permitted or required by law to make certain other uses and disclosures of your personal health information without your authorization. We may release your personal health information:
· For public health activities, such as required reporting of disease, injury, birth, death or any other required public health investigation
· As required by law if we suspect any abuse or neglect of a child or elder of if we believe you are a victim of abuse, neglect or domestic violence.
· To the U.S. Food and Drug Administration if necessary to report adverse events, product defects or to participate in product recalls.
· To your employer when we have provided health care to you at the request of your employer. In most cases, you will be requested to authorize information to be disclosed to your employer.
· If required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings.
· To worker’s compensation agencies if necessary for your worker’s compensation benefit determination.
· If required to do so by a court or administrative order.
· To law enforcement officials as required by law to report wounds and injuries and as related to certain crimes.
· To coroners and / or funeral directors consistent with law.
· If necessary to arrange an authorized organ or tissue donation from you or a transplant to you.
· In limited portions for certain research purposes, when such research is approved by an institutional review board with established rules to ensure privacy, including clinical registries and databases.
· If you are a member of the military as required by armed forces services. We may also release your personal health information if necessary for national security or intelligence activities.
· For any purpose required by law, such as reporting of criminal activities, warning of a threat, etc.
· We may release your personal health information, billing information, contact information and demographic information to others who have provided care for you.

Rights That You Have
Access to your Personal Health Information: You have the right to review and / or obtain a copy of much of the personal health information that we retain on your behalf. We may charge you a specified amount per page if you request a copy of the information. We may also charge for postage if you request a mailed copy and may charge for preparing a summary of the requested information if you request such a summary.

Amendments to your Personal Health Information : You have the right to request in writing that personal health information we maintain about you be amended or corrected. We are not obligated to make all requested amendments, but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative and must state the reason(s) for the amendment/correction request. If we make the requested changes, we may also notify others who work with us and who have copies of the uncorrected record if we believe such notification is necessary. We may contact the provider who provided the information being amended to determine whether they wish to respond to your request.

Accounting for Disclosure of Personal Health Information: You have the right to receive an accounting of certain disclosures made by us of your personal health information after April 14, 2003. Requests must be made in writing and signed by you or your representative. The first accounting in any 12-month period is free. You may be charged a fee for each subsequent accounting you request within the same 12-month period.

Restrictions on Use and Disclosure of your Personal Health Information: You have the right to request restrictions on certain of our uses and disclosures of your personal health information for treatment, payment or health care operation. This request must be made in writing. We are not required to agree to your restriction request, but will attempt to accommodate reasonable requests. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing any agreed-to restriction.

Complaints: If you believe your privacy rights have been violated, you can file a complaint with us. You may also file a complaint with governmental authorities in writing within 180 days of the violation of your rights. There will be no retaliation in response to filing of a complaint.
Regional Office for Civil Rights – U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240, Chicago, IL 60601

Acknowledgement of Receipt of Notice
You will be asked to sign an acknowledgement form that you received this Notice of Practice Practices. As a patient you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested a copy by e-mail or other electronic means.

For Further Information
If you have questions or need further assistance regarding this notice, you may contact us at Midwestern Cardiac Surgery and / or Midwestern Pulmonary Associates, 770 Balgreen Dr. Suite 107, Mansfield, OH 44906.