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NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY LOUISVILLE ORTHOPAEDIC CLINIC AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE READ IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. Individually identifiable health information includes: patient name, social security number, date of birth, guarantor name, etc….This Act gives you, the patient, parent of a minor child, or legal guardian, significant rights to understand and control how your health information is used. Any misuse of personal health information is subject to penalties provided by HIPAA.

As outlined by HIPAA, we may use and disclose your medical records only for each of the following purposes:

Treatment- providing, coordinating or managing health care and related services by one or more health care providers. For example, we would use this information to treat you in the office, call in a prescription to your pharmacy, or refer you to another facility or physician.

Payment- obtaining reimbursement for services, confirming coverage, billing or collection activities, and chart audits for appropriate billing/reimbursement. For example, we would use this information to send a bill for your visit to your insurance company for payment.

Health care business operations- including customer service and all aspects of running a business. For example, we may use this information to schedule, remind, or verify your appointment.

Studies and Reports- we may create and distribute de-identified health information by removing all references to individually identifiable information. For example conducting blind studies and publishing the result.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request:

Restrictions- you have the right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. If we do not agree to a restriction, a reason for disagreement will be documented.

Location- you have the right to make a reasonable request to receive confidential communications of protected health information from us by alternative means or at alternative locations (phone, mail, fax, at hospital etc…).

Inspect/Copy- you have the right to inspect and have an employee of Louisville Orthopaedic Clinic copy your protected health information. Applicable copying fees may apply.

Amend- you have the right to amend, in writing, your protected health information. We are, however allowed to disagree with your amendment in writing.

Accountability- you have the right to receive an accounting of disclosures of protected health information.

Privacy Notice- you have the right to obtain a paper copy of this notice from us upon request.

Louisville Orthopaedic Clinic is required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective April 14, 2003. We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we have previously created and currently maintain. We will post in our office and on our web site (louisvilleorthopedic.com) the current/revised copy of the Notice of Privacy Practices of this office or you may request a paper copy.

If you feel that your privacy protections have been violated, you have recourse. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information or to file a complaint:

Administrator

Louisville Orthopaedic Clinic

4130 Dutchmans Lane, Ste 300

Louisville, KY 40207

(502)897-1794

For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services

Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

(202)619-0257