Welcome to Clarian Arnett Health

Arnett Surgery Center, LLC
Notice Of Privacy Practices

Effective Date: 5/1/06

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.

If you have any questions about this Notice, please contact Arnett’s Privacy Officer at (800) 899-8448, or (765) 448-8000 for further information.

Our Commitment To You
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights to access and control your protected health information, as well as certain obligations we have regarding the use and disclosure of your protected health information. “Protected health information” ("PHI") is medical information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to your PHI. We are also required to abide by the terms of this Notice as currently in effect. Other providers outside of Arnett Surgery Center, LLC may have different policies or notices regarding their use and disclosures of your medical information created in their office.

This Notice describes how Arnett Surgery Center, LLC health care practitioners, departments, and units that provide health care, as well as our employees and staff will use and disclose your PHI. Arnett Surgery Center, LLC personnel follow the terms of this Notice. This Notice also covers our third party "business associates" who perform various activities for us to provide you treatment or to administer our business. Before we disclose any of your PHI to one of our business associates, we will enter into a written contract with them that contains terms to protect the privacy of your PHI.

Uses And Disclosures Of Your Protected Health Information:
The following categories describe different ways that we use and disclose your protected health information ("PHI"). For each category we will explain what we mean and try to give some common examples. The Notice does not list every possible use and disclosure, however, it lists all of the general categories how we are permitted to use and disclose your PHI.

For Treatment.

We may use your PHI to provide you with medical treatment or services. We will use or disclose your PHI to provide, coordinate and manage your health care, including consulting with, and referring you to, other health care providers.
We may disclose your PHI to physicians, nurses, technicians, medical students, or other personnel who are involved in taking care of you.

For Payment.

We may use and disclose your PHI so that the treatment and services you receive at Arnett Surgery Center, LLC may be billed to, and payment may be collected from, you, an insurance company, or a third party.
For example, we may need to get a prior approval from your health plan to determine if the plan covers the treatment you are seeking. We may also need to disclose PHI to your health plan in order to get paid for services we have provided to you.

For Health Care Operations.

We may use and disclose your PHI for purposes of health care operations. These uses and disclosures are necessary to manage Arnett Surgery Center, LLC and to make sure that all of the patients receive quality health care.

For example, we may use medical information to review our treatment and services and to evaluate our performance.
We may combine medical information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective.
We may disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes.
We may combine the medical information we have with medical information from other providers to compare how we are doing and see where we can make improvements in the care and services we offer.
We may remove information that identifies you from your health information so others may use it to study health care and health care delivery without learning about whom the information relates.

Appointment Reminders. We may use and disclose your PHI in order to contact you and remind you of an upcoming appointment for treatment or health care services.

Treatment Alternatives. We may use and disclose your PHI to inform you of or recommend possible treatment alternatives that may be available to you.

Health-Related Benefits and Services. We may use and disclose your PHI to inform you of health-related benefits or services that may be available to you. For example, this may include a new procedure or piece of equipment that we offer.

Emergencies. We may use or disclose some or all of your PHI in an emergency treatment situation. As soon as practicable, you will be given the opportunity to object. The PHI will be disclosed only if it is thought to be in your best interest.

Individuals Involved in Your Health Care or Payment for Your Health Care. We may disclose your PHI to a family member or friend who is involved in your medical treatment or care such as a family member or friend accompanying you prior to, and after, your surgical procedure.

We may also disclose this information to a person who is involved in the financing of your health care. Arnett Surgery Center, LLC has “family billing;” that is, all family members are under one account and one bill is sent to the guarantor of that account. If you wish to have a separate account set up for any reason, please let us know.

We may inform your family or friends as to your condition, location, or death. If you are present, you will be given the opportunity to object to all of these disclosures. However, if you are not present, only a disclosure that is in your best interest and directly relevant to the inquiring person's involvement in your health care will be made. In addition, we may disclose PHI to a public or private entity assisting in a disaster relief effort so that your family can be notified as to your condition, location, or death, or so that care or rescue efforts can be coordinated.

As Required By Law.

We will use and disclose your PHI when required to do so by federal, state, or local law, to the extent that such use and disclosure is limited to the relevant requirements of such law.

Public Health Activities. We may disclose your PHI for purposes of public health activities. These activities generally include the following:

to prevent or control disease, injury, or disability;
to report births and deaths;
to report the conduct of public health surveillance, investigations, and interventions;
to report child abuse or neglect;
to report adverse events relating to product defects, problems, or biological deviations;
to track FDA‑regulated products;
to notify people and enable product recalls, repairs, replacement, or lookback;
to conduct post marketing surveillance;
to notify a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition;
to conduct an evaluation relating to the medical surveillance of the workplace; and
to evaluate whether an individual has a work-related illness or injury.

Abuse, Neglect, or Domestic Violence. We may notify the appropriate government authority if we reasonably believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities authorized by law. These oversight activities include, by way of example, audits; civil, administrative or criminal investigations and proceedings; inspections; and licensure and disciplinary actions. These activities are necessary for the government to monitor the health care system, government benefit programs, compliance with program standards, and compliance with civil rights laws.

Judicial and Administrative Proceedings. We may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by another person involved in the dispute, but only if we believe that the party seeking the PHI has made reasonable efforts to tell you about the request or to obtain an order protecting the information requested.

Limited Data Sets. We may use or disclose certain parts of your medical information, called a limited data set, for purposes of research, public health reasons or for health care operations. These data sets do not contain information that can directly identify you. We may disclose a limited data set to third parties that have provided us with satisfactory assurances that they will use or disclose your medical information only for limited purposes.

Law Enforcement. We may disclose your PHI, within limitations, if asked to do so by a law enforcement official for a law enforcement purpose, if it is:

in response to a court order, subpoena, warrant, summons or similar process, or required by law;
to identify or locate a suspect, fugitive, material witness, or missing person;
about the victim of a crime if the individual agrees to the disclosure, or due to incapacity or emergency, we are unable to obtain the individual's agreement;
about a death we suspect may have resulted from criminal conduct;
about criminal conduct we believe in good faith to have occurred on our premises; and
in an emergency situation, in order to report the commission and nature of a crime; the location of the crime or its victims; or the identity, description or location of the individual who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may disclose your PHI to a coroner or medical examiner. This disclosure may be necessary in order to identify a deceased person or determine the cause of death. We may also disclose your PHI, as necessary, in order for the funeral directors to carry out their duties.

Organ, Eye and Tissue Donation. If you are an organ donor, we may disclose your PHI to an organ procurement organization or other entity involved in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of facilitating the donation and transplantation process.

Research. We may use and disclose your PHI for certain limited research purposes. For some research projects, we may seek your authorization to use or disclose your PHI. Under other circumstances, we may use or disclose your PHI for research purposes without your authorization if we receive special approval from an Institutional Review Board ("IRB"). This IRB reviews the research proposal and ensures that the PHI we want to use or release is necessary for research purposes. We may also use your PHI to determine whether you might be an appropriate subject for a research study and to discuss participation in the study with you. However, we will not use your PHI for the research study, or release it to anyone else for research, without your authorization or without permission from an IRB.

To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI when we believe in good faith, it is necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public. Any disclosure, however, would only be to a person able to help prevent the threat.

Military and Veterans. We may disclose the PHI of individuals who are members of the Armed Forces, as required by appropriate military command authorities. PHI may be disclosed for purposes of determining an individual's eligibility for or entitlement to benefits under appropriate military laws. We may also disclose the PHI of foreign military personnel to the appropriate foreign military authority.

National Security and Intelligence Activities. We may disclose your PHI to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities as authorized by law.

Protective Services for the President and Others. We may disclose your PHI to authorized federal officials, so they may adequately provide protection to the President, other authorized persons, or foreign heads of state. PHI may also be disclosed to conduct special investigations.

Inmates. We may disclose your PHI, as long as you are an inmate of a correctional institution or under the custody of a law enforcement official, to the correctional institution or law enforcement official. The disclosure must be necessary: (1) for the institution or law enforcement official to provide you with health care; (2) to protect your health and safety or the health and safety of others in and employed by or in connection with the correctional institution; and (3) for the safety and security of the correctional institution.

Workers' Compensation. We may disclose your PHI for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Other Uses and Disclosures Of Your Protected Health Information. Other uses and disclosures of your protected health information not covered by this Notice or the laws that apply to us, will be made only with your written authorization. If you have given us your authorization, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose the PHI for the reasons covered by your written authorization, except to the extent that we have taken action in reliance on your authorization. Please note that we are unable to withdraw any disclosures we have already made with your written authorization, and that we are required by law to maintain our records as to the health care that we have provided to you.

Your Rights Regarding Your Protected Health Information
You have the following rights regarding your protected health information ("PHI") which we maintain, as required by law:

Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for purposes of treatment, payment, or health care operations. You also have the right to request that we restrict the disclosure of your PHI from those involved in your health care or the payment for your health care, such as a family member or friend. For example, you may request that we not use or disclose your PHI relating to a procedure you may have had.

We are not required to agree with your request for restrictions. However, if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

To request restrictions, you must make your request in writing by filling out the appropriate form provided by Arnett Surgery Center, LLC and submitting it to Privacy Officer, P.O. Box 5545, Lafayette, IN 47903-5545. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse or children.

Right to Request Confidential Communications. You have the right to request that we communicate with you about your personal health matters in a particular way or at a particular location. For example, you can request that we only contact you at work or at a friend's house.

To request confidential communications, you must make your request in writing by filling out the appropriate form provided by Arnett Surgery Center, LLC and submitting it to Privacy Officer, P.O. Box 5545, Lafayette, IN 47903-5545. We will not ask you the reason for your request. We will accommodate all reasonable requests. However, we may condition granting your request on receiving appropriate information regarding how you will handle payment, as well as, how or where you would like us to contact you.

Right to Inspect and Copy. You have the right to inspect and copy your PHI that is kept in a designated record set. This may include medical and billing records, but does not include: (1) psychotherapy notes; (2) information compiled in anticipation of or for use in legal actions or proceedings; or (3) protected health information that is maintained by Arnett Surgery Center, LLC to which access is prohibited by law.

To inspect and copy your PHI, you must make your request in writing by filling out the appropriate form provided by Arnett Surgery Center, LLC and submitting it to Arnett Surgery Center, LLC, P.O. Box 5545, Lafayette, IN 47903-5545. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or preparing the requested documents.

We may deny your request to inspect and copy in certain very limited circumstances:

the PHI you are requesting to inspect is specifically prohibited by law;
you are an inmate and providing you with a copy of your PHI could be dangerous to your health, safety, security, custody, or rehabilitation, or that of others;
the PHI you are requesting may have been created or obtained by a covered health care provider in the course of research in which you agreed to limit your access;
denial in accordance with the federal Privacy Act; or
the information you are requesting was confidentially obtained from a source other than a health care provider and if you were granted access you could find out the identity of the source.

If you are denied access to your PHI, for reasons other than those listed above, you may request that the denial be reviewed. A licensed health care professional chosen by Arnett Surgery Center, LLC will review your request, as well as the basis for the denial. The person conducting the review will not be the person who denied your request the first time. The outcome of the review will be the final decision.

Right to Amend. You have the right to request that we amend your PHI if it is incorrect or incomplete. You have the right to request an amendment for as long as the information is kept by or for Arnett Surgery Center, LLC within a designated record set.

To request an amendment, you must make your request in writing by filling out the appropriate form provided by Arnett Surgery Center, LLC and submitting it to Privacy Officer, P.O. Box 5545, Lafayette, IN 47903-5545. You must provide a reason to support your request for an amendment.

We may deny your request for an amendment if the request does not include a reason to support the request for an amendment. Furthermore, we may deny your request for an amendment if you request that we amend PHI that:

was not created by us, unless the person or covered entity that created the PHI is no longer available to make the amendment;
is not part of the health information kept by or for Arnett Surgery Center, LLC within the designated record set which includes:
- health information created and/or maintained by Arnett Surgery Center, LLC;
- paper records stored in the medical record folder maintained by Arnett Surgery Center, LLC;
- copies of records from other health care providers for access only;
- financial records, paper and automated;
- working dictation tapes;
- photographs of patients; and
- x-ray film.
is not part of the information that you would be permitted to inspect and copy by law; or
is accurate and complete.

If your request to amend is denied, you may seek further review. The review process will be described in the letter we send to you denying your request.

Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures made by Arnett Surgery Center, LLC. This is a list of the disclosures we have made of your PHI.

To request an accounting of disclosures, you must make your request in writing by filling out the appropriate form provided by Arnett Surgery Center, LLC and submitting it to Arnett Surgery Center, LLC, P.O. Box 5545, Lafayette, IN 47903-5545. Your request must state a time period which may not be longer than six years, but which may be shorter, and may not include dates before May 1, 2006 (the date Arnett Surgery Center, LLC came into existence). The first accounting you request within a 12-month period will be free. For additional accountings, we may charge you for the costs of providing the accounting. We will notify you of the costs involved and give you an opportunity to withdraw or modify your request before any costs have been incurred.

You have a right to receive an accounting of disclosures made by Arnett Surgery Center, LLC within the past six years from the date of your request, except for disclosures that have been made:

to carry out treatment, payment or health care operations;
to you;
incident to a use or disclosure permitted or required by law;
pursuant to an authorization;
to those involved in your care or for notification purposes;
for national security or intelligence purposes;
to correctional institutions or law enforcement of officials;
as part of a limited data set; and
prior to May 1, 2006 (the date Arnett Surgery Center, LLC came into existence).

Right to a Paper Copy of this Notice. You have the right to receive a paper copy of this Notice. You may request that we give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to receive a paper copy.

You may obtain a copy of this Notice at our website, www.arnett.com.

In the alternative, to obtain a paper copy of this Notice, please contact our Patient Referral Nurses at (765) 448-8000 or (800) 899-8448.

Changes To This Notice:
We reserve the right to change the terms of this Notice. We reserve the right to make the new Notice provisions effective for all protected health information we currently maintain, as well as any information we receive in the future. We will post a copy of the current Notice in all clinic locations. Please note, on the first page, in the top right-hand corner of the Notice, you will find the effective date. A Notice with a more recent date supercedes a Notice with an older date.

Complaints:
If you believe your privacy rights have been violated, you may file a complaint with Arnett Surgery Center, LLC or with the Secretary of the Department of Health and Human Services. You will not be retaliated against or penalized for filing the complaint. To file a complaint with Arnett Surgery Center, LLC, contact Privacy Officer, P.O. Box 5545, Lafayette, IN 47903-5545. All complaints must be submitted in writing.