NOTICE OF PRIVACY POLICY


This Notice of Privacy Policy describes how we may use and disclose your protected health information to carry out treatment, initiate payment, or conduct health care operations and for other purposes that are permitted or required by law. Dubuque Orthopaedic Surgeons reserves the right to access and control your protected health information. “Protected health information” is 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.

OUR PRIVACY PRINCIPLES

? We do not sell client information
? We do not provide client information to persons or organizations outside of Dubuque Orthopaedic Surgeons, P.C. who are doing business on our behalf, for their own marketing purposes.
? We contractually require any person or organization providing products or services to clients on our behalf to protect the confidentiality of the Dubuque Orthopaedic Surgeons, P.C. client information.

INFORMATION WE MAY COLLECT

We collect and use information we believe is necessary to administer our business, to advise you about our services and to provide you with client service. We may collect and maintain several types of client information needed for these purposes, such as those below.


Types of information we may collect and how we gather it:

? From you, (on registration forms, through telephone or in-person interviews) information such as your address, birth date, social security number, employer and telephone number.
? From your transactions with us such as your payment history, health insurance card, insurance claim documents.
? From non-Dubuque Orthopaedic Surgeons entities such as your personal physician or their representative who is requesting our services.

HOW WE USE INFORMATION ABOUT YOU

The following categories describe ways that we use and disclose medical information. Examples of each category are included. Not every use or disclosure in each category is listed; however, all the ways we are permitted to use and disclose information falls into one of these categories:

? For Treatment: We may use medical information about you to provide, coordinate, or manage your medical treatment or services. We may disclose medical information about you to other physicians or health care providers who are or will be involved in taking care of you. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. Another example is that 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.

? For Payment: We may use and disclose medical information about you so that the treatment and services you receive at our practice may be billed to and payment may be collected from you, an insurance company, or a third party. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, to determine whether your plan will cover the treatment, and for 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.

? For Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of our practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. We may 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, as necessary, to contact you to remind you of your appointment.

We may share your protected health information with third party “business associates” that perform various activities (e.g. billing, transcription service) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected, 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. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. You may contact our Privacy Officer to request that these materials not be sent to you.

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USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

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 are entitled to revoke your authorization of disclosure at any time, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. This request must be made in writing to Dubuque Orthopaedic Surgeons, P.C. and will be kept as a part of your protected health information.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITH YOUR CONSENT OR OPPORTUNITY TO OBJECT

We may use and disclose your protected health information in the following 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 physician may, using professional judgment, determine whether the 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 it 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. Finally, 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.

Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your acknowledgement of receipt of the Notice of Privacy Practices as soon as reasonably practicable after the delivery of treatment.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT

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

Required by Law: We may use or disclose your protected health information to the extent that law requires the use or disclosure. 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 uses or disclosures.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is required 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.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk for 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 a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental agency or entity authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of the applicable federal and state laws.

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 proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (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 the 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 disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaver organ, eye or tissue donation purposes.

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally established programs.

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.

Sale or Closure of the Practice: In the event that Dubuque Orthopaedic Surgeons, P.C. is sold or acquired by another facility or physician group, your protected health information will be disclosed to that group or entity.

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 requirements of Section 164.500 et.seq.


YOUR RIGHTS AS A PATIENT

You have the following rights as a patient of Dubuque Orthopaedic Surgeons P.C.:

? To request restrictions on certain uses and disclosures (including a statement saying Dubuque Orthopaedic Surgeons, P.C. is not required to agree to a requested restriction).
? To receive confidential communications of your protected health information.
? To inspect and copy your protected health information.
? To amend your protected health information.
? To obtain an accounting of disclosures of your protected health information.


OUR DUTY AS YOUR PHYSICIAN

Dubuque Orthopaedic Surgeons, P.C. is legally obligated to maintain the privacy of your protected health information, to provide this notice of privacy practices and to abide by the terms of this notice. Dubuque Orthopaedic Surgeons, P.C. reserves the right to change its privacy practices and apply revised privacy practices to your protected health information without additional notification to you.

COMPLAINTS REGARDING VIOLATION OF PRIVACY RIGHTS

To register a complaint regarding violation of privacy rights, contact the office manager at Dubuque Orthopaedic Surgeons, P.C., 1500 Delhi St. Suite 4200, Dubuque, IA 52001 in writing with your complaint. You must also file a complaint with the Secretary of the Department of Health and Human Services. We will not retaliate against you for filing a complaint.

You may obtain additional information about any of the matters identified in this notice by contacting the office manager at Dubuque Orthopaedic Surgeons P.C.

Privacy procedures at Dubuque Orthopaedic Surgeons P.C. are effective April 14, 2003.


I acknowledge that I have been given a copy of the Notice of Privacy Practices of Dubuque Orthopaedic Surgeons, P.C.


Signed: _________________________________________________________

Date: ____________________________________