Our Privacy Commitment

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.

Our Policy on Medical Record Privacy
This Notice describes the way The South Bend Clinic and it’s practices will treat medical records and other health information that we have regarding your medical care. We are required to keep records for each of our patients in order to keep a record of your care, including your diagnosis, treatment, services you receive, and other information. We are required by law to protect your personal medical record by keeping it private and following certain rules that dictate whether and when we can use or disclose your information.

This Notice informs you of the ways we may use and disclose your health information. It also notifies you of your rights and our obligations in our use and disclosure of your health information.

The law requires us to keep your health information private. We are also required to give you this Notice. You have the right to request additional copies of this Notice at any time by contacting the Privacy Officer identified below.

We reserve the right to change this Notice. We reserve the right to apply those changes to health information we currently have, as well as information we may receive in the future. If we change this Notice, you may request a new copy of the Notice at any time by contacting the Privacy Officer identified below. We will also keep a current copy of the Notice on display in our office. We are required to follow the terms of the Notice that is currently in effect.

Our definition of The South Bend Clinic
The South Bend Clinic is a Partnership of 60+ physicians currently operating from eight (8) locations. Current practices within the South Bend Clinic include: Granger Family Medicine, South Bend Clinic at Granger, Michiana Pediatrics, South Bend Internal Medicine, Family Care Associates, Skyway Primary Care, Ironwood Medical Group and The South Bend Clinic and SurgiCenter. All these entities and locations may share medical information with each other for treatment, payment or operations as described below.

Those also covered by this Notice
This notice also covers services provided to you at the South Bend Clinic through two independent providers, Diagnostic Imaging Physicians, P.D. and PRA Medical, Inc. and their designates for coverage within the South Bend Clinic. These providers act on the request of the South Bend Clinic to provide interpretation of Radiological Procedures as well as implementation of anesthesia as may be necessary through the Ambulatory Surgery Center. These providers will adhere to the terms as stated within the Notice. These providers will share PHI as needed to carry out treatment, payment, and operations related to their arrangement with the South Bend Clinic.

How we may Use and Disclose Your Health Information
We may use and disclose your health information for a number of purposes in connection with your medical care and in running our practice. The following lists a number of typical uses and disclosures within our practice, with explanations to help you understand your rights. You will not be asked to separately authorize us to do these things.

Treatment.
We may use your health information to provide you with medical treatment. For example, we may use your health information to diagnose your illness or injury, provide you with services, or refer you to another physician. We may disclose your health information to doctors, nurses, technicians, medical students, or other personnel who are involved in your care. We may also disclose your health information to people outside of our medical practice that may be involved in your medical care, such as family members, or others.

Payment.
We may use and disclose your health information to your health plan, insurance company, HMO, or other third party in order to bill and collect for services provided to you. For example, we may give your health plan information regarding your diagnosis and treatment in order to be paid for your office visits, procedures, x-rays, or laboratory work. We may also provide information to determine whether your health plan pays for the medical care you need, and whether we need to get authorization from the health plan before treating you.

Health Care Operations.
We may use and disclose your health information in the process of running our medical practice and ambulatory surgery center. For example, we may use or disclose your information if we conduct quality assessment and improvement activities to ensure that our patients receive top quality medical care. We may also use or disclose your information in training and evaluation of our physicians and other staff, or as part of a medical review, audit, or legal activities.

Appointment Reminders and Follow-up.
We may use and disclose your health information to contact you as a reminder that you have an appointment with a department within the Clinic or to notify you that results of a procedure have been received and that we’d like to speak with you.

Treatment Alternatives.
We may use and disclose your health information to tell you about or recommend treatment alternatives or health-related benefits and services that may be of interest to you.

Fundraising.
We may use and disclose your health information to contact you to raise funds on behalf of our medical practices or on behalf of a charitable foundation that is related to us.

Individuals Involved in Your Care or Payment for Your Care.
We may disclose your health information to a family member or friend who is involved in your medical care, or who helps pay for your care. We may also tell your family or friends about your condition, for example, if you are admitted to the hospital. In addition, we may disclose your health information in the event of a disaster relief effort, so that your family can be notified about your condition, status and location.

Required By Law.
We will disclose your health information when required to do so by federal, state or local law.

Public Health Risks.
We may disclose your health information for public health activities, such as reporting disease, injury or disability; births and deaths; child abuse or neglect; defects, recalls, or problems with drugs, medical devices, or other products; to prevent or control disease, injury or disability; exposure to or risk for diseases or conditions. We may also notify authorities if we believe you have been the victim of abuse, neglect or domestic violence, if we are required or permitted by law to do so, or if you agree to the notification.

Health Oversight Activities.
We may disclose health information to a health oversight agency authorized by law for audits, investigations, inspections, and licensure. Health oversight agencies generally oversee the health care system, government health programs (such as Medicare and Medicaid), and the enforcement of civil rights laws.

Judicial and Administrative Proceedings.
We may disclose your health information in response to a court order or administrative order. We may also disclose your health information to respond to a subpoena, discovery request, or other request that is not issued by a judge or administrator, but only if efforts have been made to inform you of the request or to get a protective order for the information.

Law Enforcement.
We may release health information if asked to do so by a law enforcement official under the following circumstances:

• If you have incurred certain injuries or wounds that are legally required to be reported;
• In response to a court order, subpoena, warrant, summons, investigative demand, or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if under certain limited circumstances;
• About a suspicious death that we believe may be the result of criminal conduct;
• About criminal conduct on our premises; and
• In emergency circumstances to report a crime, its location, or information about the person who may have committed the crime.

Coroners, Medical Examiners, and Funeral Directors.
We may disclose your health information to a coroner or medical examiner. This may be necessary, for example, to identify or determine the cause of death of a deceased person, or as otherwise required by law. We may also disclose health information to funeral directors as necessary to carry out their duties.

Organ and Tissue Donation.
We may use or disclose your health information to organizations that handle organ procurement to facilitate organ or tissue donation and transplantation.

To Avert a Serious Threat to Health or Safety.
We may use and disclose your health information when necessary to prevent or lessen a serious threat to the health and safety of you, the public, or another person. Any disclosure would be made to law enforcement or someone else who can help prevent or lessen the threat.

Research.
We may use and disclose your health information for medical research if an Institutional Review Board or similar body approves the use and disclosure without your authorization, or if the use and disclosure is solely for purposes preparatory to research, such as preparing a research protocol, or if the use and disclosure is solely for research on individuals who are deceased.

Specialized Government Functions.
We may use or disclose your health information for military command authorities, upon your separation or discharge from military service, to authorized officials. We may also disclose your health information to the appropriate government officials when it is necessary to conduct intelligence or other national security activities authorized by federal law. In addition, we may release your health information if it relates to protection of the President of the United States or foreign heads of state. Finally, we may disclose certain information related to members of the armed services and foreign military services to the appropriate personnel.

Inmates.
If you are an inmate of a correctional facility or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official in order to provide you with medical services, protect you or others, or to ensure the safety of the correctional facility.

Workers' Compensation.
We may disclose your health information in relation to workers' compensation or similar program established by law that provides benefits for work-related illness or injuries.

We may also disclose your health information to your employer if the health care services we provide to you are at the request of your employer in order to carry out work-place medical surveillance, but only if we notify you first. Your Rights Regarding Your Health Information Your Right to Restrict our Activities.

You have the right to request that we restrict the use or disclosure of your health information for treatment, payment, or healthcare operations (as described above). You may also restrict us from disclosing your health information to family members or friends. For example, you may request that we limit what information we provide to your family members regarding medication you may be taking. Please remember any request applies to all departments and providers within the South Bend Clinic.

We are not required to agree to your request. If we agree to your restrictions or limitations, we will comply with your wishes unless the information is needed to provide emergency treatment to you. To request restrictions or limitations, you must make a written request to your physician’s office. In your written request, you must tell us (1) what information you want to limit; (2) whether you want to limit use of the information and/or disclosure of the information; and (3) to whom the limitations or restrictions will apply (for example, disclosures to your spouse).

Your Right to Request Confidential Communications.
You have the right to tell us how you would like us to communicate with you. For example, you may ask that we call you at a certain phone number, or you may tell us whether we may leave a message for you.

To request confidential communications, you must make your request in writing to your physician’s office. Your request must specify how or where you wish to be contacted. We will follow all reasonable requests for confidential communications.

Your Right to Inspect and Copy.
You have the right to inspect and receive a copy of your health information, including most of your medical and billing records. You do not have the right to review any psychotherapy notes, information created for use in legal actions, or other information covered by certain laws.

If you would like to inspect and/or receive a copy of your health information, you must submit your request in writing to your physician’s office or the Medical Records Department. If you request a copy of the information, we may charge you a reasonable fee for copying, postage, or other expenses related to your request.

We may deny your request to inspect and/or receive a copy of your health information. If we do, you may request that the denial be reviewed. We will choose a licensed health care professional to 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.

Your Right to Amend.
If you feel that your health information is incorrect or incomplete, you may ask us to amend your records. To request an amendment, you must submit a written request to your physician’s office. Your request must state the reason you believe an amendment is necessary.

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: (a) we did not create the information (unless the entity that created the information is no longer available); (b)the information is not in our possession or control; (c) you would not be permitted to inspect or copy the information; or (d) the information is accurate and complete.

Your Right to an Accounting of Disclosures.
You have the right to request an "accounting of disclosures." This is a list of certain disclosures of your health information that we have made outside of treatment, payment, and operations and other discloses covered within this Notice. To request this list of disclosures, you must submit a written request to your physician’s office or the Medical Records Department. Your request must state a time period for which the accounting is requested. The time period may not be longer than six years and may not include dates before April 14, 2003. You will receive one list per year without charge. We may charge you for the costs of providing additional lists within one year after your first request. We will notify you of the cost involved and you may choose to withdraw or modify your request if you do not wish to pay the cost.

Your Right to Receive a Paper Copy of this Notice.
If you downloaded this from our website or received this electronically, you have the right to request a paper copy of this notice by making a request to your physician’s office or to the Privacy Officer identified below.

Changes to this notice
We reserve the right to change this notice, and to apply the revisions or changes notice to health information we already have about you, in addition to information we create or receive in the future.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer identified below. You may also file a complaint with the United States Secretary of the Department of Health and Human Services. To file a complaint with The South Bend Clinic, you may contact the Privacy Officer at the phone number or address listed below to file a written complaint. We will not retaliate against you in any way if you file a complaint.

Other Uses of Your Health Information
This notice only describes the ways we may use and disclose your health information without obtaining further permission from you. There may be other reasons we may request to use or disclose your health information. If we need to do so, we are required to get your written authorization. If you grant us this further authorization, you may revoke it at any time by giving us written notice that you no longer authorize us to use or disclose your health information for those purposes. Other uses and disclosures of 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 your health information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your health information 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 provided to you.

The regulations require that we obtain your signature acknowledging receipt of this Notice. We will ask you to acknowledge in writing that this statement was received.

Effective: February 26, 2003