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.

If you feel your privacy has been violated by anyone on our staff please contact our practice manager Holly Cross, at 937.439.3600

This notice of Privacy Practices describes how we 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. Protected health information means health information, including demographic information, collected from us and created or received by my physician, another health care provider, health plan, my employer, or a health care clearinghouse. This projected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information my identify me.

We are required to abide by the terms of the Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we may obtain at that time. Upon your request, we will provide you with any revised notice of privacy practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1. Uses and Disclosures of Protected Health Information Based Upon your Written consent.

You will be asked by your physician 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, your physician will use or disclose protected health information for the following purposes.

Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred.

Payment. Your protected health information will be used to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for your health care services, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

For example, obtaining approval for an office procedure or a hospital stay may require that your protected health information be disclosed to the health plan to obtain approval for the procedure or hospital admission.

Health Care Operations. We may use or disclose your protected health information in order to support the business activities of the practice. These activities include, but are not limited to, the day-to-day running of the practice, quality assessments, employee reviews, training of medical students, licensing, marketing, and fundraising, and conducting or arranging for other business activities.

For example, we may disclose your protected health information to medical school students who see patients at our office. In addition, we may use a sign in sheet at the registration desk where you will be asked to sign you name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may contact you to remind you of your appointment.

We may share your protected health information with third party "business associates" that perform various activities (e.g. billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information to provide you with information about the treatment, alternatives or other health related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products and services that we believe may be beneficial to you. You may contact our privacy officer to request that these materials not be sent to you.

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our privacy officer and request that these materials not be sent to you.

2. Uses and Disclosures of Protected Health Information 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 as described below. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

3. Other Permitted and Required Uses and Disclosures that may be made with your Consent, Authorization, or Opportunity to Object.

We 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 the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.  In this case, only the protected health information that is relevant to your health care will be disclosed.

4. Other Permitted and Required Uses and Disclosures that may be made without your Consent, Authorization, or Opportunity to Object.

We may use or disclose protected health information in these following situations without our consent or authorization. These situations include:

Required by Law: We may use and disclose your protected health information it the use or disclosure is required by law. The use or disclosure will be made in compliance with the law.

Public Health: We may disclose your protected health information to the public health authorities for purposes related to controlling disease, injury, or disability. This includes:

  . Communicable Disease: We may disclose your protected health information to a

     person who may have been exposed to a communicable disease or may otherwise be

     at risk of contracting or spreading the disease or condition.

  . Tumor Board: We may disclose your protected health information to a monthly

      review board consisting of physicians and other medical staff to analyze patient

      information and test results regarding potential malignancies to help establish a

      recommended plan of patient care.

  .  Health Oversight: We may disclose your protected health information for activities

      such as audits, investigations, and inspections by government oversight agencies.

  .  Abuse or Neglect: We may disclose your protected health information to report

      abuse or neglect. In addition, we may disclose your protected health information if

      we believe that you have been a victim of abuse, neglect, or domestic violence.

Food and Drug Administration: We may disclose your protected health information to report adverse events and product defects or problems, to enable product recalls; or to make repairs or replacements.

Legal Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding.

Law Enforcement: We may disclose protected health information to a law enforcement official for purposes such as legal proceedings, request for identification and location of a suspect, fugitive, material witness, or missing person; pertaining to victims of crime; suspicion that death has occurred as a result of criminal conduct; that a crime has occurred on the premises of the practice; and medical emergency (not on the practice's premises) and it is likely that a crime has occurred.

Coroners and Funeral Directors: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform their duties. We may also disclose protected health information to a funeral director, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death.

Organ Donation: We may disclose protected health information to organizations involved in organ and tissue donation and transplant.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and establish protocols to ensure the privacy of your protected health information.

Criminal Activity: We may disclose protected health information, it we believe that the use of disclosure is necessary to prevent or lessen a serious and eminent threat to the health or safety of a person or the public.

Military Activity and National Security: We may use or disclose your protected health information to individuals who are armed forces personnel for activities deemed necessary by appropriate military command authorities, or for the purpose of a determination by the Department of Veteran's Affairs of your eligibility for benefits. We may disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Worker's Compensation: Your protected health information may be disclosed by us as authorized to comply with Worker's Compensation laws and other similar legally established programs.

Correctional Facilities: We may disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing you care.

5. Others Involved in your Health Care.

Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person's involvement in your health care.  We may disclose protected health information to notify or assist in notifying a family member, personal protected health information to an authorized public or private entity to assist in disaster relief efforts.

Emergencies. We may use or disclose your protected health information in an emergency situation. If this happens, your physician shall try to obtain your consent as soon as possible after the emergency.

Communication Barriers. We may use or disclose your protected health information it your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to communication barriers and the physician determines that you intend to consent to use or disclose under the circumstances.

6. Office Communications/Reminders.

Telephone: We will call you regarding appointments, test, and/or billing matters at the telephone number you have provided to us which may include your work telephone number. We will leave a message on your answering machine/voice mail or with a family member who answers the phone.

Mail. We will mail you appointment reminder cards, statements, and other office related communications.

7. Your Health Information 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 for as long as we maintain the protected health information. We will provide this information as expediently as possible. Time not to exceed 30 days.

Under federal law, there may be instances where you may not inspect or copy your protected health information. Depending on the circumstances, a decision to deny access may be reviewed. Please contact our privacy contact person if you have any questions about access to your protected health information.

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 protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If your physician believes 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 your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restrictions you wish to request with your physician.

You have the Right to Request to Receive Confidential Communications from us by Alternative means or at an Alternative Location: We will accommodate reasonable requests. Please make this request in writing to our privacy contact person.

You may have the right to have your physician amend your protected health information: This means you may request to have your protected health information changed for as long as we maintain this information. In certain cases, we may deny your request to have your protected health information changed. If we deny your request for a change, you have the right to disagree with us. Please contact our privacy contact person if you have questions about making changes to your protected health information and how you can disagree with our decision.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in the Notice of Privacy Practices. It excludes disclosures we may have made to you, family members, or friends involved in your care or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions, and limitations.

You have the right to obtain a paper copy of this notice from us: If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our privacy contact person.

8. Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy right have been violated by us. You may file a complaint with us by notifying our privacy contact person of your complaint. We will not retaliate against you for filing a complaint.

You may contact our privacy contact person, Melody Hart at (937) 439-3600 for further information about the complaint process.

9. Change of Ownership

In the event the Pulmonary Medicine Of Dayton, Inc. is sold or merged with another organization, your protected health information/medical record will become the property of the new owner.

Patient Access to the Medical Record Policy

Effective date April 14, 2003

Patients have the right to inspect and receive copies of their medical records. This practice may charge for the copying of the record, as well as supplies, labor, and postage, and the patient should be notified of this cost in advance. The patient should agree to this financial responsibility in writing, in advance. (See form)

This practice has the right to deny a patient's request and copy their medical records. This denial must be in writing and explain why the request has been denied.

There are several circumstances when the denial may not be appealed (Unreviewable Denial):

  . Physocotherapy notes.

  . Information compiled in reasonable anticipation of or for use in a civil, criminal, or

    administrative action proceeding.

  . Protected health information (PHI) maintained by a practice subject of Clinical

    Laboratory Improvements Amendments (CLIA) (to the extent access to an individual

    Would be prohibited by law).

  . Correctional facility can deny part or total access.

  . In research situations.

  . If the information was obtained from someone other than the health care provider and

     if access would compromise an individual providing information under a promise of

     confidentiality.

 The patient can appeal the denial and has the right to request review by another licensed health professional designated by the practice and who was not a part of the original decision to deny access (reviewable denial).

   . If a licensed health care professional determines that, the requested access    

     would endanger the life or physical safety of the individual or another person.

  . If the record makes reference to another person and the licensed health professional

     believes the access could cause substantial harm to that person.

  . Request has been made by patient's personal representative and the licensed

     professional believes it could cause harm to that individual or another person.

Patient should make this request on the attached form, which is then submitted to the privacy officer for action.

Minimum Necessary Disclosure Policy

Effective date of policy: April 14, 2003

When protected health information (PHI) is released from this office, reasonable efforts will be made to assure that only minimum amount of information needed to satisfy the request will be released. Professional judgment will determine the amount of information to be released. The minimum necessary standard is not intended to impede the provision of quality health care.

Disclosures of PHI between providers for treatment purposes are explicitly exempt from this standard.

Privacy Complaint Policy

Effective date of policy: April 14, 2003

Patients have the right to file a formal complaint if they feel we have not adequately protected their privacy. This complaint must be submitted in writing to the privacy officer or may be submitted directly to the U.S. Department of Health Services Secretary. The complaint must be submitted within 180 days of the event of concern.

The privacy officer is responsible for the investigation and resolution of the complaint.

The practice must maintain a record of the complaints and the resolution, if applicable, for six (6) years.

Medical Record Amendment Policy

Effective date of policy: April 14, 2003

Any patient may request that his/her medical record be changed, or amended. This request must be in writing and must include the reason for the desired change, amendment, or correction.

This practice may accept or deny this request and will inform in writing of the decision within sixty (60) days. One 30-day extension is permitted if the patient is notified of the reason for the delay.  If the request is denied, the practice must give a reason for denying the request.

Requests will be retained for six (6) years and must be included in future releases of the patient's protected health information (PHI). If the amendment has been denied, this denial letter must also be included in future PHI disclosures.

Requests for amendment of medical records should be submitted to the privacy officer for action.