Privacy Notice

of the ways we are permitted to use and disclose information will fall within one of the categories. Information may be disclosed in writing, orally, by facsimile, or electronically.

Ø For Treatment. We will use and disclose your health information to provide, coordinate, or manage your health care and any related services. We may disclose your information to doctors, nurses, technicians, medical students and other personnel who are involved in your care. This includes the coordination or management of your health care with a third party for treatment purposes. For example, we may disclose your health information to a pharmacy to fill a prescription or to a laboratory to order a blood test. We may also disclose your health information to physicians who may be treating you or consulting with respect to your care. In some cases, we may also disclose your health information to an outside treatment provider for purposes of the treatment activities of the other provider.

Ø For Payment. We may use and disclose health information about you so that we can bill and collect payment for the treatment and services you receive. For example, we may provide health information to your insurance company relating to treatment you received so that they will pay us or reimburse you. We may also tell your insurance company about a treatment you are going to receive to obtain prior approval or to determine whether your insurance company will cover the treatment.

Ø For Health Care Operations. We may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to members of our medical staff, risk or quality improvement personnel, and others to:

• evaluate the performance of our staff;

• assess quality of care;

• learn how to improve our facilities and services; or

• determine how to continually improve the quality and effectiveness of the medical care we provide.

Ø Appointment Reminders. We may use and disclose health information about you to contact you as a reminder that you have an appointment for treatment or medical care.

Ø Treatment Alternatives. We may use and disclose health information about you to tell you about (or recommend) possible treatment options or alternatives that may be of interest to you.

Ø Health Related Benefits and Services. We may use and disclose health information about you to inform you about health related benefits or services that may be of interest to you.

Ø Fundraising Activities. We may use health information about you to contact you for fundraising purposes. If you do not want us to contact you for fundraising efforts, you must so notify our Privacy Officer in writing at 702 Barnhill Drive, Rm. 4270, Indianapolis, Indiana 46202.

Ø Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may release health information about you to a member of your family, a relative, a close friend or any other person you identify who is involved in your medical care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. Finally, we may use or disclose your 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 directly involved in your medical care.

Ø Business Associates. We may contract with certain business associates to perform operational tasks on our behalf. An example of a business associate would be a third party that we contract with to provide billing and collection services on our behalf. In connection with the services to be provided by a business associate, we may disclose health information about you to the business associate so that such business associate is able to perform the tasks that we have contracted with them to provide. However, we require that each of our business associates appropriately protects and safeguards any health information received from us.

Ø Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example:

· We may release information about you to researchers preparing to conduct a research project who need to know how many patients have a specific health problem.

· We may also use and disclose health information about you for research purposes if the research has been subjected to a careful review process conducted by a specially selected and trained committee and received this committee's approval. This process evaluates a proposed research project and its use of health information, and balances the potential benefit of the research against individual patients' need for privacy of their health information.

· A research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. In that situation, you would not be identified or contacted, but your health information may be used but kept confidential.

· In other studies, if a doctor caring for you believes you may be interested in, or benefit from, a research study, your doctor and the committee will approve someone to contact you to see if you are interested in the study. At that time, you would be contacted with more information and you would have the right to authorize continued contact or refuse further contact.

Ø As Required By Law. We will disclose health information about you when required to do so by applicable law.

Ø To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Ø Organ and Tissue Donation. If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Ø Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Ø Workers' Compensation. We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work related injuries or illness.

Ø Public Health Risks. We may disclose health information about you for certain public health activities. These activities may include the following:

· to prevent or control disease, injury or disability;

· to report births and deaths;

· to report actual or suspected child abuse or neglect;

· to report reactions to medications or problems with products;

· to notify people of recalls of products they may be using;

· to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or

· to notify the appropriate government authority if we 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.

Ø Health Oversight Activities. We may disclose health information about you to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Ø Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Ø Law Enforcement. We may release health information if asked to do so by a law enforcement official:

· in response to a court order, subpoena, warrant, summons or similar process;

· to identify or locate a suspect, fugitive, material witness, or missing person;

· about the victim of a crime, under certain limited circumstances, if we are unable to obtain the person's agreement;

· about a death we believe may be the result of criminal conduct;

· about criminal conduct at our practice; or

· in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Ø Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Ø National Security and Intelligence Activities. We may release health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Ø Protective Services for the President and Others. We may disclose health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

OTHER DISCLOSURES AND USES OF HEALTH INFORMATION

Other uses and disclosures of your health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information, you may revoke that permission, at any time, by providing us written notice of such revocation. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provide to you.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights regarding health information we maintain about you:

Ø Right to Inspect and Copy. You have the right to access, inspect and/or obtain a copy of your health information. Usually, this includes medical and billing records, but does not include psychotherapy notes.

A request to access, inspect and/or obtain a copy of your health information must be submitted in writing to Records Release, University Pediatric Associates, P.O. Box 1026, Indianapolis, Indiana 46206-1026. If you request a copy of information, we may charge a fee that will not exceed (i) in the case of x-rays, our actual cost in providing a copy of the x-rays, (ii) in the case of other medical records, a retrieval fee of $15 and a copying fee of $.25 per page (which copying fee shall not apply to the first ten (10) pages copied), and (iii) actual postage costs, as applicable.

We may deny your request to access, inspect and/or copy your health information in certain very limited circumstances. If we deny your request, you may request that the denial be reviewed. Another licensed medical care professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Ø Right to Amend. If you feel that health information we maintain 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 maintained by or for us.

A request to amend your health information must be submitted in writing to Records Release, University Pediatric Associates, P.O. Box 1026 Indianapolis, Indiana 46206-1026. You must include in your written request the reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

· was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

· is not part of the health information kept by or for us;

· is not part of the information which you would be permitted to inspect and copy pursuant to the privacy rule; or

· is accurate and complete.

Ø Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures made by us of your health information outside of treatment, payment, and operational purposes (and without an authorization) during the six (6) year period immediately prior to such request (excluding any time period prior to April 14, 2003).

A request for an accounting of disclosure must be submitted in writing to our Privacy and Security Officer, 702 Barnhill Drive, Rm. 4270, Indianapolis, Indiana 46202. The first accounting of disclosures you receive from us in a twelve (12) month period will be free. For additional accountings you request from us within the same twelve (12) month period, we may charge you for the costs of providing the accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Ø Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health 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 a surgery you had. However, 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, or a use or disclosure is otherwise required by applicable law.

To request restrictions, you must make your request in writing to our Privacy and Security Officer, 702 Barnhill Drive, Rm. 4270, Indianapolis, Indiana 46202. In your request, you must tell us (i) what information you want to limit; (ii) whether you want to limit our use, disclosure or both; and (iii) to whom you want the limits to apply.

Ø 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.

To request confidential communications, you must make your request in writing to our Privacy and Security Officer, 702 Barnhill Drive, Rm. 4270, Indianapolis, Indiana 46202. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Ø Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to 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 a paper copy of this Notice. You may obtain a paper copy of this Notice at our offices/facilities from any member of our staff.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice, and to make the revised or changed Notice effective for health 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 at our offices/facilities. In addition, each time before your receive treatment or medical care services from us, we will offer you a copy of the current Notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the United States Department of Health and Human Services. A complaint filed with our practice must be in writing and directed to the attention of our Privacy and Security Officer at 702 Barnhill Drive, Rm. 4270, Indianapolis, Indiana 46202. All complaints must be submitted in writing.

You will not be penalized or retaliated against for filing a complaint with either us or the Secretary of the United States Department of Health and Human Services.

CONTACT PERSON

The contact person for all issues regarding patient privacy and your rights under the federal privacy standards is our Privacy and Security Officer. Information regarding matters covered by this Notice of Privacy Practices can be requested by contacting our Privacy and Security Officer at (317) 278-7985, or 702 Barnhill Drive, Rm. 4270, Indianapolis, Indiana 46202

EFFECTIVE DATE

This Notice is effective April 14, 2003.

By signing this document, I hereby acknowledge that I have received a copy of the Notice of Privacy Practices of University Pediatric Associates, Inc. and Riley Children's Specialists.