This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully. This Notice applies to all of the records of your care compiled by our Practice, whether made by our Practice or an Associated facility.

This Notice of Privacy Practices describes how Indiana Neuroscience Associates may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Your protected health information is information about you, which may identify you and relates to your past, present or future physical or mental health and related health care services.

As a Practice, Indiana Neuroscience Associates respects the confidentiality of all medical records. Indiana Neuroscience Associates is required to abide by the terms of our Notice of Privacy Practices. We may revise the terms of our notice at any time. The revised notice will be effective for all your protected health information that we maintain at the time. Upon your request, Indiana Neuroscience Associates will provide you with a revised Notice of Privacy Practices by calling our office and requesting a copy be sent to you in the mail or by asking for one at the time of your next appointment.

Indiana Neuroscience Associates provides this notice to comply with the Privacy Regulations issued by the Department of Health and Human Resources in accordance with the Health Insurance Portability and the Accountability Act of 1996 (HIPAA).

This Notice describes our Practice's policies concerning privacy, which extend to:

• Any health care professional authorized to enter information into your chart including physicians, PAs, RNs, etc.
• All departments of the Practice including front desk, administration, billing and collection, etc.
• All staff and other personnel that work for or with our Practice
• Our business associates including billing services, facilities to which we refer our patients, on-call doctors, etc.

Uses and Disclosures of Protected Health Information WITH Written Consent

You will be asked by Indiana Neuroscience Associates to sign a consent form. Once you have consented to the use and disclosure of your protected health information for treatment, payment and health care operations by signing the consent form, our Practice will use or disclose the information as described in the section below.

Treatment: Indiana Neuroscience Associates will use and disclose your protected health information to provide, coordinate and manage your health care and any related services. Therefore, we may, and most likely will, disclose medical information about you to doctors, nurses, technicians and/or other health care personnel who are involved in your care. For example, 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 diagnosis and treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for services and procedures so that they may be billed and collected from you, your insurance company and/or any third party. Insurance companies often request patients' health information to make a determination of eligibility or coverage for insurance benefits or to review services provided for medical necessity.

Health Care Operations: We may use or disclose your protected health information in order to support the business activities of our Practice.

First, Indiana Neuroscience Associates may use and disclose your health information in order to run our practice more efficiently and to ensure all patients receive quality care. This may include reviewing our treatment and services to evaluate staff performance, reviewing particular services to determine their necessity and/or effectiveness.

Secondly, Indiana Neuroscience Associates may use protected health information in order to run day-to-day operations more efficiently. For example, we may use a sign-in sheet at the registration desk asking for your name and physician, we may call you by name in the waiting room and use demographic information to call and remind you of your appointments.

In addition, Indiana Neuroscience Associates may share your protected health information with third party "business associates" that perform various activities (billing, transcription services, etc.) for the Practice.

Other Permitted and Required Uses and Disclosures That May Be Made WITH Your Consent, Authorization or Opportunity to Object

Indiana Neuroscience Associates 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 your health information then your physician may, using professional judgment, determine whether the disclosure is in your best interest. Only the protected information relevant to your health care will be disclosed. Unless you object, we may disclose your protected health information to a member of your family, relative or any other person you identify that is directly involved in your care.

Emergencies: Indiana Neuroscience Associates may use or disclose you protected health information in an emergency treatment situation. If this happens, your physician will try to obtain your consent as soon as reasonably possible after the treatment.

Communication Barriers: Indiana Neuroscience Associates may use or disclose your protected health information if our physicians attempt to obtain consent but are unable to do so because of substantial communications barriers and your physician determines, using professional judgment, that you intend to consent under the circumstances.

Workers' Compensation: Indiana Neuroscience Associates may use or disclose your protected health information, so that, benefits may be provided for your work-related injury or illness.

Other Permitted and/or Required Uses and Disclosures That May Be Made WITHOUT Your Consent, Authorization or Opportunity to Object

Health Oversight: Indiana Neuroscience Associates may disclose protected health information to local, state or federal agencies involved in overseeing health care operations. Oversight activities required by law often include: audits, investigations, inspections and licensures.

Inmates: Indiana Neuroscience Associates may disclose your protected health information if you are an inmate of a correctional facility and your physician created or received information in the course of providing care to you.

Law Enforcement: Indiana Neuroscience Associates may also disclose protected health information for law enforcement purposes. Law enforcement purposes may include: legal processes, limited information requests for identification and location purposes and injuries and/or deaths related to criminal conduct.

Legal Proceedings: Indiana Neuroscience Associates may disclose protected health information in the course of any judicial or administrative proceedings in the response to a court order, subpoena or other lawful processes.

Military Activity/National Security: Indiana Neuroscience Associates, when appropriate situations apply, may use or disclose protected health information of individuals who are armed forces personnel. For example, for activities deemed necessary by commanding officers and/or for determination of eligibility of benefits by the Department of Veterans Affairs. Indiana Neuroscience Associates may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities.

Public Health: Indiana Neuroscience Associates may disclose your protected health information to a public health authority that is permitted by law or public policy to collect and receive the information. These circumstances generally include:

• To prevent or control disease, injury or disability;
• To report births or deaths;
• To report child abuse or neglect;
• To report reactions to, problems w/ or recalls of medications;
• To notify a person who may have been exposed to or at risk for contracting or spreading a disease
• To notify a government agency of abuse, neglect or domestic violence.

This section describes your rights and the obligations of Indiana Neuroscience Associates regarding the use and disclosure of your protected health information.

1. The Right to Inspect and Copy

   You have the right to inspect and copy your own medical record (protected health information) that may be used to make decisions about your care. This information includes your own medical and billing records. To inspect and/or copy your medical record, you must submit your request in writing to medical records. If you request a copy you will be charged a fee to cover the cost of supplying your records.

   Under federal law, you may not inspect or copy the following records; psychotherapy notes, information compiled for use in a civil, criminal or administrative proceeding. In addition, a physician, in their professional judgment, may decline to release information that could pose a danger to the patient.

2. The Right to Amend.

   You have the right to request an amendment to your medical record, if you feel it is incorrect or incomplete. To request an amendment, you must submit it in writing with your intended amendment, a reason for the amendment, signature, date and notarization.

   Your physician may deny your request for an amendment if: you do not have a reason to support it, Indiana Neuroscience Associates professionals did not create the information or the information in your amendment is inaccurate.

3. The Right to Request Restrictions.

   You have the right to request a restriction or limitation on the protected health information Indiana Neuroscience Associates uses or discloses about your treatment, payment or health care operations. In addition, you have the right to limit the information we disclose to someone involved in your care (family, friend, etc.). Any restrictions must be made in writing with the information to be limited, whether you want to limit use, disclosure or both and to whom you want the limits to apply.

4. The Right to Request Confidential Communications.

   You have the right to request that Indiana Neuroscience Associates communicate with you about medical information by a certain means or at certain locations. For example, you may ask we only contact you at home, or at work, or by mail or that we do not leave voice-mails. Please submit all requests in writing with specifics of how to contact you.

5. The Right to an Account of Disclosures.

   You have the right to request a list of the disclosures Indiana Neuroscience Associates made concerning your protected health information. Your request must be submitted in writing, with a period of no longer than six years and not before the date of the implementation of the HIPAA Privacy Regulations. We will notify you of the cost involved depending on the extensiveness of the request.

6. Complaints

   If you believe your privacy rights have been violated, you may file a complaint with Indiana Neuroscience Associates or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer (Castleton Office), who will direct you on how to go about filing an official complaint. All complaints must be submitted in writing, and all complaints shall be investigated, without repercussions to you.

Our concern for your privacy

As our patient, we create paper and electronic medical records about your health, our care for you and the services and/or items we provide to you as our patient. We need this record to provide for you care and to comply with certain legal requirements. We understand that your medical information is personal to you, and we are committed to protecting this information about you. In addition, in all cases Indiana Neuroscience Associates will work to use and disclose only the minimium amount of information necessary to accomplish the intended purpose ("minimum necessary guideline").