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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.

A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your protected health information (PHI). In conducting
our business, we will create records regarding you and the treatment and services we provide to you. We are
required by law (the Health Insurance Portability and Accountability Act of 1996 or HIPAA) to maintain the
confidentiality of health information that identifies you. We also are required by law to provide you with this notice of
our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state
law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:

How we may use and disclose your PHI

Your privacy rights concerning your PHI

Our obligation concerning the use and disclosure of your PHI
The terms of this notice apply to all records containing your PHI that are created or retained by our
practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or
amendment to this notice will be effective for all of your records that our practice has created or
maintained in the past, and for any of your records that we may create or maintain in the future. Our
practice will post a copy of our current Notice in our offices in a visible location at all times, and you
may request a copy of our most current Notice at any time.

B. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Privacy Officer 813 West 2nd Street Bloomington, IN 47403 Phone: (812) 330-0303

C. Uses and Disclosures of Health Information
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 health care
providers who are involved in taking care of you now or in the future.
We may also use health information about you to call you or send you a letter to remind you about an appointment,
to follow up with diagnostic tests results, or to provide you with information about other treatment and care that
could benefit your health.
For payment:We may use and disclose medical information about you so that the treatment and services you
receive at the hospital may be billed and payment may be collected from you, an insurance company or a third
party.
For healthcare operations: Our practice may use and disclose your PHI to operate our business. As examples of
the ways in which we may use and disclose your information for our operations, our practice may use your PHI to
evaluate the quality of care you received from us, or to conduct cost-management and business planning activities
for our practice. Every effort will be made to insure anonymity.

D. Other Disclosures
Business Associates: We will share your PHI with third party associates that perform various activities for the
clinic. Whenever any arrangement between our clinic and a business associate involves the use of disclosure of your
PHI, we will have a written contract that contains terms that will protect the privacy of your PHI.
Communication with others involved with your care: Our health professionals may, in the event you are
incapacitated or in an emergency circumstance, using their judgment, disclose to a family member, or other relative,
close personal friend or any other person you identify, health information directly relevant to that person?s
involvement in your care or payment related to your care.
Research: Under certain circumstances, we may use and disclose health information about you from your medical
record for research purposes. All research projects, however, are subject to a special approval process designed to
protect the privacy of your health information.
Required by law: We may use 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 disclosures.
Public Health Risks:Our practice may disclose your PHI to public health authorities that are authorized by law to
collect information for the purpose of:
Maintaining vital records, such as births and deaths
Reporting child abuse or neglect
Preventing or controlling disease, injury or disability
Notifying a person regarding potential exposure to a communicable disease
Notifying a person regarding a potential risk for spreading or contracting a disease or condition
Reporting reactions to drugs or problems with products or devices
Notifying individuals if a product or device they may be using has been recalled or withdrawn, needs repairs or
replacement

Notifying appropriate government agency (ies) and authority (ies) regarding the potential abuse or neglect of
an adult patient (including domestic violence); however, we will only disclose this information if the patient
agrees or we are require or authorized by law to disclose this information
Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical
surveillance

Health Oversight Activities: Our practice may disclose your PHI to a health oversight agency for activities
authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure
and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the
government to monitor government programs, compliance with civil rights laws and the health care system in
general.

Legal Proceedings: We may disclose your PHI in the course of any judicial or administrative proceeding, in
response to an order of a court or administrative tribunal, in certain conditions in response to a subpoena, discovery
request or other lawful purpose.

Law Enforcement: We may release PHI if asked to do so by a law enforcement official:

Regarding a crime victim in certain situations, if we are unable to obtain the person?s agreement.

Concerning a death we believe has resulted from criminal conduct

Regarding criminal conduct at our offices
In response to a warrant, summons, court order, subpoena or similar legal process

To identify/locate a suspect, material witness, fugitive or missing person.
In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identify
or location of the perpetrator)

Deceased Patients: Our practice may release PHI to a medical examiner or coroner to identify a deceased
individual or to identify the cause of death. If necessary, we also may release information in order for funeral
directors to perform their jobs.
Organ and Tissue Donation: Our practice may release your PHI to organizations that handle organ, eye or tissue
procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation
and transplantation if you are an organ donor.

Research: Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We
will obtain your written authorization to use your PHI for research purposes except when: (a) our use or disclosure
was approved by an Institutional Review Board or a Privacy Board; (b) we obtain the written agreement of a
researcher that (i) the information being sought is necessary for the research study; (ii) the use or disclosure of your
PHI is being used only for the research and (iii) the researcher will not remove any of your PHI from our practice; or
(c) the PHI sought by the researcher only relates to decedents and the researcher agrees in writing that the use or
disclosure is necessary for the research and, if we request it, to provide us with proof of death prior to access to the
PHI of the decedents.

Serious Threats to Health or Safety: Our practice may use and disclose your PHI when necessary to reduce or
prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under
these circumstances, we will only make disclosures to a person or organization able to help prevent or lessen the
threat.

Military: Our practice may disclose your PHI if you are a member of the U.S. Armed Forces, a veteran, or a member
of foreign military forces for activities deemed necessary by appropriate military commend authorities, including the
Department of Veteran?s Affairs for the purpose of your eligibility for or entitlement to certain benefits provided by
law.

National Security: Our practice may disclose your PHI to federal officials for intelligence and national security
activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other
officials or foreign heads of state, or to conduct investigations.

Inmates: Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an
inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for
the institution to provide health care services to you (b) for the health, safety and security of the institution, and its
officers and employees and/or (c) to protect your health and safety or the health and safety of other individuals.

Workers Compensation: Our practice may release your PHI for workers? compensation and similar programs to
the extent necessary to comply with applicable laws.

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
requirement of Section 164.500 et. seq.

We will not use information in your records for marketing purposes.
Other uses and disclosures from your medical record will be made only with your written authorization or approval.

E. YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding the PHI that we maintain about you:

1. Confidential Communications. You have the right to request that our practice communicate with you about
your health and related issues in a particular manner or at a certain location. For instance, you may ask that we
contact you at home, rather than work. In order to request a type of confidential communication, please use the
contact information below to make an appointment to complete the form. Our practice will accommodate reasonable
requests. You do not need to give a reason for your request.

2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for
treatment, payment or health care operations. Additionally you have the right to request that we restrict our
disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family
members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our
agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat
you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing
using the contact information below. Your request must describe in a clear and concise fashion:

(a) the information you wish restricted;
(b) whether you are requesting to limit our practice?s use, disclosure or both; and
(c) to whom you want the limits to apply.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make
decisions about you, including patient medical records and billing records. However, you may not obtain
psychotherapy notes or information compiled in reasonable anticipation of a civil, criminal or administrative action or
proceeding. You must submit your request in writing using the contact information below in order to inspect and/or
obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies
associated with your request. Our practice may deny your request to inspect and/or copy in certain limited
circumstances; however, you may request a review of our denial. Another licensed health care professional chosen
by us will conduct reviews.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and
you may request an amendment for as long as the information is kept by our practice. To request an amendment,
your request and reason for the request must be made in writing using the contact information below. You must
provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to
submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask
us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the
practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) was not created by our
practice, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an ?accounting of disclosures?. An ?
accounting of disclosures? is a list of certain non-routine disclosures our practice has made of your PHI for nontreatment
or operations purposes. Use of your PHI as part of the routine patient care in our practice is not required
to be documented. For example, the doctor sharing information with the nurse; or the billing department using your
information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your
request in writing using the contact information below. All requests for an ?accounting of disclosures? must state a
time period, which may not be longer than six (6) years from the date the ?accounting of disclosures? is requested
and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of
charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify
you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy
practices. You may ask us to give you a copy of this notice at any time by contacting us utilizing the contact
information below.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with
our practice or with the Secretary of the Department of Health and Human Services. You will not be retaliated
against for filing a complaint. To file a complaint with our practice, use the contact information below.

8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written
authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any
authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing.
After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the
authorization. Please note: We are required to retain records of your care.

Contact Information:
Privacy Officer
813 West 2nd Street Bloomington, IN 47403
Phone: (812) 330-0303 Fax: (812) 330-0404