NOTICE OF PRIVACY PRACTICES

Effective: April 14, 2003

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.

Physician Anesthesia Service, P.C. uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of Physician Anesthesia Service, P.C.

How Physician Anesthesia Service, P.C. May Use or Disclose Your Health Information

For Treatment. Physician Anesthesia Service, P.C. may use your health information to provide you with medical treatment or services. For example, health care providers, such as physicians, anesthetists, nurses, or other persons providing health services to you, will record information in your record that is related to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions taken by them in the course of your treatment and note how your respond to the actions.

For Payment. Physician Anesthesia Service, P.C. may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, we may send a bill to you or a third-party payor, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment.

For Health Care Operations. Physician Anesthesia Service, P.C. may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to members of our staff and others to:

• Evaluate the performance of our staff;

• Assess the quality of care and outcomes in your case and similar cases;

• Learn how to improve our services; or,

• Determine how to continually improve the quality and effectiveness of the health care we provide.

Appointments and Patient Recall Reminders. Physician Anesthesia Service, P.C. may use your information to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. We may contact you by telephone, in writing, email, or otherwise and may involve leaving a message which could potentially be picked up by others.

Others Involved in Your Care. We may disclose information about you to others who may be involved in your medical care. Unless you clearly instruct us to the contrary, we may disclose information to a friend or family member who is involved in your medical care.

Required By Law. Physician Anesthesia Service, P.C. may use and disclose information about you as required by law. For example, Physician Anesthesia Service, P.C. may disclose information for the following purposes:

For judicial and administrative proceedings pursuant to legal authority;

To report information related to victims of abuse, neglect or domestic violence; and,

To assist law enforcement officials in their law enforcement duties.

Written Authorization. Other uses or disclosures not covered by this Notice or the applicable laws may be made with your specific written permission. You may revoke your written permission at any time and we will immediately cease such uses or disclosures. You understand that we cannot take back any disclosures already made prior to your revocation.

Public Health. Physician Anesthesia Service, P.C. may use and disclose your health information for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.

Decedents. Physician Anesthesia Service, P.C. may use and disclose your health information to funeral directors, medical examiners, or coroners to enable them to carry out their lawful duties.

Organ/Tissue Donation. If you are an organ donor, Physician Anesthesia Service, P.C. may use and disclose your health information for cadaveric organ, eye or tissue donation purposes.

Research. Physician Anesthesia Service, P.C. may use and disclose your information for research purposes when the research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Health and Safety. Physician Anesthesia Service, P.C. may use and disclose your health information to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

Government Functions. Physician Anesthesia Service, P.C. may use and disclose your information for specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your information.

Workers Compensation. Your health information may be used and disclosed to comply with laws and regulations related to Workers Compensation.

Inmates. If you are an inmate or under custody of a law enforcement official, we may release information about you to the correctional institution or law enforcement official: (1) for the institution to provide you with healthcare; (2) to protect your health and safety or that of others; or, (3) for the safety and security of the correctional institution.

Your Health Information Rights

You have the right to:

• Request a restriction on certain uses and disclosures of your information; however, Physician Anesthesia Service, P.C. is not required to agree to a requested restriction;

• Obtain a paper copy of the Notice of Privacy Practices upon request;

• Inspect and obtain a copy of your health record as permitted by law;

• Request an amendment of your health record;

• Request communications of your health information by alternative means or at alternative locations; and,

• Receive an accounting of disclosures made of your health information.

Contact the Privacy Official for more information on how to exercise your rights.

Obligations of Physician Anesthesia Service, P.C.

Physician Anesthesia Service, P.C. is required to:

• Maintain the privacy of protected health information;

• Provide you with this notice of its legal duties and privacy practices with respect to your health information;

• Abide by the terms of this notice;

• Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;

• Accommodate reasonable request you may make to communicate health information by alternative means or at alternative locations; and

• Obtain your written authorization to use of disclose your health information for reasons other than those listed above and/or permitted by law.

Complaints

You may complain to Physician Anesthesia Service, P.C. and to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint. To file a complaint with Physician Anesthesia Service, P.C., contact our Privacy Official. All complaints must be in writing.

Changes to this Notice

We reserve the right to change this Notice at any time and to make the revised Notice effective for health information we already have about you. We will post a copy of the current Notice in the admissions department, pre-operative testing area and our office. You may request a copy of this Notice at any time.

Contact Information

If you have any questions or complaints, please contact:

Ms. Karen Leisman

1200 East Michigan Ave

Suite 370

Lansing, MI 48912

517-484-4451

The undersigned acknowledges receipt of the Notice of Privacy Practices of Physician Anesthesia Service, P.C. on the dated noted below.

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Signature of Patient or Legal Representative

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Printed Name

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Date