BLUESTONE HEALTH ASSOCIATION INC.

Bluestone Health Center : Prudich Medical Center

Clinic Privacy Notice

BLUESTONE HEALTH ASSOCIATION, INC.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

Bluestone Health Association, Inc. is committed to providing quality health care while protecting the privacy of your health information. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) and your rights to access and control your information. "Protected health information" is health information that identifies you, such as information concerning your past, present or future physical or mental conditions, care you have received or payments made for such care. We also are required to provide you with this notice of our legal duties, our privacy practices and your rights concerning your PHI. We are required to follow the terms of the notice of privacy practices we have in effect at the time. As noted above this notice is affective for health care services provided on and after April 14, 2003 until we revise or replace it.

We reserve the right to revise or amend our Notice of Privacy Practices at any time. Any revision or amendment to our Notice will be effective for all PHI that our organization has created or maintained in the past, and for any PHI that we may create or maintain in the future. Our organization will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT OUR PRIVACY OFFICER AT (304) 431-5499.

WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) FOR TREATMENT. PAYMENT AND OUR OPERATIONS AND AS OTHERWISE PERMITTED IN THE FOLLOWING WAYS

Treatment: We may use PHI to treat you. For example, we may ask you to have laboratory tests and we may use the results to help us reach a diagnosis. Our medical staff may use or disclose PHI in order to treat you or to refer you to other health care providers to assist in your care.

Payment: We may use and disclose PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits and we may provide your insurer with details regarding your treatment to determine if your insurer will pay for your treatment.

Healthcare Operations: We may use or disclose PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, we may use PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our organization.

Other Permitted Uses: We may use or disclose PHI to remind you of appointments or to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. Unless your make an alternative request, we may send postcards to your home or le aye messages on your answering machine or with whomever answers your phone to remind you of appointments, to ask you to contact us concerning your care or to seek or coordinate your participation in programs we offer, such as disease management programs. We may also send you newsletters concerning treatment or care alternatives, benefits, services and containing general health care information. We may share your protected health information with third party "business associates" that perform various activities for us; however, we will require protection of PHI in our written agreements with our business associates. We may also use and disclose PHI for certain of our fund raising activities as permitted by applicable regulations. If you do not want to receive these materials, please contact our Privacy Officer and provide a written request to be removed from our distribution list for these materials.

We may also use or disclose PHI in accordance with federal and state law in the following situations that do not require your authorization for an opportunity for you to object:

Required By Law: We may use or disclose your PHI as required by law, such as when required by the Secretary of the Department of Health and Human Services to determine our compliance with privacy laws and regulation.

Public Health: We may disclose PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. We may also use or disclose PHI for the purpose of controlling disease, injury or disability or to prevent the spread of communicable diseases. West Virginia law requires reporting of: child or vulnerable adult abuse; weapon or burn-related injuries; communicable diseases; cancer; lead poisoning; and duty to warn of imminent harm. Our disclosure of PHI will be limited to the relevant requirements of the law.

Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Such oversight agencies 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 suspected abuse, neglect or domestic violence consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose PHI as required by the Food and Drug Administration to report adverse events, product defects or problems.

Legal Proceedings: If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or administrative order. We may also disclose PHI in response to a subpoena, discovery request, or other lawful process, but only if the party making the request has made efforts to notify you about the request or to obtain a protective order.

Law Enforcement: We may also disclose PHI for certain law enforcement purposes. These include (1) to respond to a court order or as otherwise required by law; (2) limited information requests for identification and location purposes; (3) pertaining to suspects, fugitives, material witnesses, crime victims, or missing persons; (4) suspicion that death has occurred as a result of criminal conduct, (5) concerning a crime on our premises; and (6) to report a crime in emergency circumstances.

Coroners, Funeral Directors: and Organ Donation: We may disclose PHI to a coroner or medical examiner for identification purposes for determining cause of death or for other duties authorized by law. We may also disclose PHI to funeral directors to carry out their duties. PHI may be used and disclosed for organ, eye or tissue donation purposes.

Research: We may disclose PHI to researchers when their research has been approved by an institutional Review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. We may disclose PH) to prevent or lessen a serious and imminent threat to the health or safety of the public or another person.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities.

Workers' Compensation: We may disclose PHI to comply with West Virginia Workers' Compensation laws.

Inmates: We may use or disclose PHI concerning inmates of a correctional facility that we created or received in the course of providing care to such inmates.;

USES AND DISCLOSURES OF PHI THAT MAY BE MADE UNLESS YOU OBJECT

We may use and disclose your PHI in the following instances unless you object. If you are not present or able to agree or object to the use or disclosure of the PHI, then we may, using our professional judgement, determine whether the disclosure is in your best interest, in this case, only PHI that is relevant to your health care' will be disclosed. Unless you object, we may disclose PHI: .- to a member of your family, a relative, a close friend or any other person that you involve in your health care, but only to the extent that the PHI directly relates to that person's involvement in your health care; - to notify a family member or other person responsible for your care of your location, general condition or death; or .- to entities (such as the American Red Cross) to assist in disaster relief efforts.

USES AND DISCLOSURES OF PHI BASED UPON YOUR WRITTEN AUTHORIZATION

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke such authorization at any time, in writing, except to the extent that our organization has taken any action in reliance on the use or disclosure indicated in the authorization.

MORE STRINGENT REQUIREMENTS UNDER WEST VIRGINIA LAW

You should note that the foregoing summary of permitted uses and disclosures of PHI is based upon federal requirements are to be followed unless West Virginia law offers PHI greater protection. In certain situations, West Virginia has adopted stronger protections for PHI than the federal provisions. Since we are providing your health care in West Virginia, these laws will apply, even though you may be a citizen of another state. In West Virginia, mental health information obtained in the course of our care for is considered to be confidential and may not be disclosed without patient authorization, by qualified court order or where necessary to protect someone from clear and substantial danger of imminent harm, For this purpose, mental health information includes the (fact someone is our patient or has received treatment; Information related to diagnosis or treatment and PHI concerning physical, mental or emotional condition and advice, instructions or prescriptions related to such care, treatment or diagnosis. Also under West Virginia law, we may not release or disclose PHI of a minor receiving treatment or services for birth control, prenatal pare, drug rehabilitation or venereal disease without the minor's Prior written consent (even to parents or guardians). Under West Virginia law, the identity of a person who has received an HIV-related test and the results of such test may not be disclosed Without the person's consent. However, disclosure is permitted to certain parties, such as to the victim of a sexual assault or to health care workers involved in the treatment of the person. Recipients of such information under on of these exceptions are prohibited from re-disclosing the PHI. We also cannot disclose to third parties PHI concerning substance abuse treatment without patient authorization.

THE FOLLOWING IS A STATEMENT OF YOUR RIGHTS REGARDING YOUR PHI AND HOW YOU MAY EXERCISE THESE RIGHTS:

You have the right to Inspect and copy your protected health Information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records that we use for making health care or business operation decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to such information or was obtained from someone other than a health care provider upon a condition of confidentially. You may request an appointment to inspect and copy your PHI by completing an Access Request form and submitting it to our Privacy Officer. If your request is granted, we will schedule a mutually convenient time for such action. We are required to respond to your request to inspect and copy your records within 30 days of receipt of your request if the requested information is maintained on-site (60 days if off-site), unless we extend this response time by up to an additional 30 days, with written notice to you of the reasons for the delay and the date by which we will complete our action on your request. We may deny your request to inspect and copy your records in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. One of our medical staff will 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. Please note that all original health records created by us in the course of your care remain our property. We are required to take reasonable measures to safeguard these records and to prevent unauthorized additions, deletions, or changes in these documents. Accordingly, while you have a general right to inspect and copy your medical records under federal and state law, we must control the conditions and circumstances under which any inspection and copying occurs. No patient or authorized representative will be permitted unsupervised access to any medical record and no medical records may leave our control for inspection and copying purposes. We may charge you a fee for the cost of copying, mailing or searching these records in accordance with applicable laws, except where prohibited by such governing laws and regulations. If you request, we may prepare a summary of your PHI (a fee will be charged). You may request information concerning our fees from our Privacy Officer.

You have the right to request a restriction of your protected health Information. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations or to family members or friends who may be involved in your care. Your request must state the specific restriction requested. We are not required to agree to a restriction that you may request. If our health care providers believe it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If our health care providers do agree to the requested restrictions, we may not use or disclose your PHI as restricted unless it is needed to provide emergency treatment or in the event the restriction is terminated. You may request a restriction by completing a Request for Restriction of PHI form and submitting it to our Privacy Officer. Copies of these forms may be obtained from our Privacy Officer.

You may request to receive communications from us by alternative means: For example, you may ask that we only contact you at home, not at work. We will accommodate requests. We may condition this accommodation by asking you for information as to how payment will be handled. We will not request a reason for your request. Please make this request to our Privacy Officer by completing an Alternative Contact Request Form that is available from our Privacy Officer.

You have the right to request amendment of your PHI. This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. To request an amendment, your request must be on forms available from our Privacy Officer (Request for Amendment/Correction of PHI). You must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support your request. In addition, we may deny your request if you ask us to amend information that:

- Was not created by us, unless the person or entity that created the information is no longer available to make the amendments;

- Is not part of the designated record set kept by us;

-Is not part of the information which you would be permitted to inspect and copy; or 

-Is accurate and complete

If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement. We will provide you with a copy of any such rebuttal. Your statement of disagreement may not exceed 250 words. If you submit a statement of disagreement or clearly indicate in writing that you want your request for amendment to be made part of your medical record, we will attach it to your records and include in whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

You have the right to receive an accounting of certain disclosures of your PHI. This right applies to disclosures for purposes other than treatment, payment or health care operations or as otherwise permitted by law. It also excludes disclosures we may have made to you or to others pursuant to your authorization or to family members or friends involved in your care. You may request an accounting of these disclosures for up to six years prior to the data on which your accounting is requested or a shorter time frame; however, we are not required to include any disclosures prior to April 14, 2003. The right to receive this information is subject to certain other exceptions, restriction and limitations. The first accounting of disclosures you request within a 12-month period is free of charge, but our organization may charge you for additional requests, and you may withdraw your request before you incur any costs.

You have the right to obtain a paper copy of the notice from us. Upon request, even if you have agreed to accept this notice electronically. You may contact our Privacy Officer for a paper copy.

Complaints: You may complain to us or to the Secretary or Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. You may contact our Privacy Officer at (304) 431-5499 for further information about the complaint process.

Bluestone Health Association has Mal-Practice coverage under Federal Tort Claim Act (FTCA) through Federal Government.