Health Notice of Privacy Practices

Effective date: November 18, 2016
Date Amended: None
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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.

WHO WILL FOLLOW THIS NOTICE

Braden Clinic is a single Affiliated Covered Entity (ACE) for the purposes of the
HIPAA Privacy Rule. This notice describes the health information practices. All entities,
sites and locations will follow the terms of this notice.

We value the privacy of your medical information as an important part of our
“patient first” pledge. We view the protection of patient privacy as an essential component
of our vision to be the Trusted Leader in Caring for People and Advancing Health and our
mission to serve our patients. We strive to use only the minimum amount of your health
information necessary for the purposes described in this Notice of Privacy Practice
(“Notice”).

We collect information from you and use it to provide you with quality care, and to
comply with certain legal requirements. We are required by law to maintain the privacy
of your health information, and to give you this Notice of our legal duties, our privacy
practices, and your rights. We are required to follow the terms of our most current Notice.

When we disclose information to other persons and companies to perform services for us,
we will require them to protect your privacy. There are other laws we will follow that
may provide additional protections, such as laws related to mental health, alcohol and
other substance abuse, and communicable disease or other health conditions.

This Notice covers the following sites and people: all health care professionals
authorized to enter information into your chart, all volunteers authorized to help you
while you are here, all of our associates and on- site contractors, all departments and units
within the hospital, all health care students, all health care delivery facilities and
providers within the Braden Clinic, and your personal doctor and others while they are
providing care.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION

Treatment: We may use and disclose your health information to provide treatment
or services, to coordinate or manage your health care, or for medical consultations or
referrals. We may use and disclose your health information among doctors, nurses,
technicians, medical students and other personnel who are involved in taking care of you
at our facilities or with such persons outside our facilities. We may use or share
information about you to coordinate the different services you need, such as
prescriptions, lab work and x-rays. We may disclose information about you to people
outside our facility who may be involved in your care after you leave, such as family
members, home health agencies, therapists, nursing homes, clergy, and others. We may
give information to your health plan or another provider to arrange a referral or
consultation.

Payment: We may use and disclose your health information so that we can receive
payment for the treatment and services that were provided. We may share this
information with your insurance company or a third party used to process billing
information. (As described below, if you pay for your health care in full and out-of-pocket,
you may request that we not share your information with your insurance company.) We
may contact your insurance company to verify what benefits you are eligible for, to
obtain prior authorization, and to tell them about your treatment to make sure that they
will pay for your care. We may disclose information to third parties who may be
responsible for payment, such as family members, or to bill you. We may disclose
information to third parties that help us process payments, such as billing companies,
claims processing companies, and collection companies.

Healthcare Operations: We may use and disclose your health information as
necessary to operate our facility and make sure that all of our patients receive quality
care. We may use health information to evaluate the quality of services that you received,
or the performance of our staff in caring for you. We may use health information to
improve our performance or to find better ways to provide care. We may use health
information to grant medical staff privileges or to evaluate the competence of our health
care professionals. We may use your health information to decide what additional
services we should offer and whether new treatments are effective. We may disclose
information to students and professionals for review and learning purposes. We may
combine our health information with information from other health care facilities to
compare how we are doing and see where we can make improvements. We may use
health information for business planning, or disclose it to attorneys, accountants,
consultants and others in order to make sure we are complying with the law. We may
remove health information that identifies you so that others may use the de-identified
information to study health care and health care delivery without learning who you are.
If operating as a health plan, we will not use or disclose genetic information for
underwriting purposes (this does not apply to long term care plans) .

Business Associates: There are some services provided in the Braden Clinic through
contracts with business associates. Examples included a copy service we use when
making copies of your health record, consultants, accountants, lawyers, medical
transcriptionist and third party billing companies. When these services are contracted, we
may disclose your health information to our business associate so that they can perform
the job we’ve asked them to do. To protect your health information, however, we require
the business associate to appropriately safeguard your information.

Certain Marketing Activities: We may use your medical information to forward
promotional gifts of nominal value, to communicate with you about products, services
and educational programs offered by the Braden Clinic, to communicate with you about
case management and care coordination and to communicate with you about treatment
alternatives. We do not sell your health information to any third party for their
marketing activities unless you sign an authorization allowing us to do this.

Health Information Exchanges: We may participate in health information
exchanges to facilitate the secure exchange of your electronic health information
between and among several health care providers or other health care entities for your
treatment, payment, or other health care operations purposes. This means we may share
information we obtain or create about you with outside entities (such as hospitals, doctors
offices, pharmacies, or insurance companies) or we may receive information they create
or obtain about you (such as medication history, medical history, or insurance
information) so each of us can provide better treatment and coordination of your health
care services.

Appointment Reminders and Service Information: We may use or disclose your
health information to contact you to provide appointment reminders, or to let you know
about treatment alternatives or other health related services or benefits that may be of
interest to you.

Individuals Involved In Your Care or Payment for Your Care: We may give your
health information to people involved in your care, such as family members or friends,
unless you ask us not to. We may give your information to someone who helps pay for
your care. We may share your information with other health care professionals,
government representatives, or disaster-relief organizations, such as the Red Cross, in
emergency or disaster-relief situations so they can contact your family or friends or
coordinate disaster-relief efforts

Individuals Involved In Your Care: We may give your health information to people
involved in your care, such as family members or friends, unless you ask us not to. We
may give your information to someone who helps pay for your care. We may share your
information with other health care professionals, government representatives, or
disaster-relief organizations, such as the Red Cross, in emergency or disaster-relief
situations so they can contact your family or friends or coordinate disaster-relief efforts.

Patient Directories: We may keep your name, location, and your general condition
in a directory to give to anyone who asks for you by name. We may give this information
and your religious affiliation to clergy, even if they do not know your name. You may ask
us to keep your information out of the directory. Even if you ask us to keep your
information out of the directory, we may share your information for disaster-relief
efforts or in declared emergency situations.

Fundraising Activities: We depend extensively on philanthropy to support our
health care missions. We may use your name and other limited information to contact
you, including the dates of your care, the name of your treating physician so that we may
provide you with an opportunity to make a donation to our programs. If we do contact
you for fundraising or philanthropy purposes, you will be told how you may ask us not to
contact you in the future.

Research: We may use or disclose your health information for research that has
been approved by one of our official research review boards, which has evaluated the
research proposal and established standards to protect the privacy of your health
information. We may use or disclose your health information to a researcher preparing to
conduct a research project.

Organ and Tissue Donation: We may use or disclose your health information in
connection with organ donations, eye or tissue transplants or organ donation banks, as
necessary to facilitate these activities.

Public Health Activities: We may disclose your health information to public health
or legal authorities whose official activities include preventing or controlling disease,
injury, or disability. For example, we must report certain information about births, deaths,
and various diseases to government agencies. We may disclose health information to
coroners, medical examiners, and funeral directors as allowed by the law to carry out
their duties. We may use or disclose health information to report reactions to
medications, problems with products, or to notify people of recalls of products they may
be using. We may use or disclose health information to notify a person who may have
been exposed to a disease or may be at risk for contracting or spreading a disease.

Serious Threat to Health and Safety: We may use or disclose your health
information when necessary to prevent a serious threat to your health and safety, or the
health and safety of the public or another person. We will only disclose health
information to someone reasonably able to help prevent or lessen the threat, such as law
enforcement or government officials.

Required by Law, Legal Proceedings, Health Oversight Activities, and Law

Enforcement: We will disclose your health information when we are required to do
so by federal, state and other law. For example, we may be required to report victims of
abuse, neglect or domestic violence, as well as patients with gunshot and other wounds.
We will disclose your health information when ordered in a legal or administrative
proceeding, such as a subpoena, discovery request, warrant, summons, or other lawful
process. We may disclose health information to a law enforcement official to identify or
locate suspects, fugitives, witnesses, victims of crime, or missing persons. We may disclose
health information to a law enforcement official about a death we believe may be the
result of criminal conduct, or about criminal conduct that may have occurred at our
facility. We may disclose health information to a health oversight agency for activities
authorized by law, such as audits, investigations, inspections and licensure.

Specialized Government Functions: If you are in the military or a veteran, we will
disclose your health information as required by command authorities. We may disclose
health information to authorized federal officials for national security purposes, such as
protecting the President of the United States or the conduct of authorized intelligence
operations. We may disclose health information to make medical suitability
determinations for Foreign Service.

Correctional Facilities: If you are an inmate of a correctional institution or under
the custody of a law enforcement official, we may release your health information to the
correctional institution or law enforcement official. We may release your health
information for your health and safety, for the health and safety of others, or for the
safety and security of the correctional institution.

Workers Compensation: We may disclose your health information as required by
applicable workers compensation and similar laws.

Health Plan: When the Braden Clinic operates as a health plan, we will not use or
disclose your genetic information for underwriting purposes.

Your Written Authorization: Other uses and disclosures of your health
information not covered by this Notice, or the laws that govern us, will be made only with
your written authorization. These include the sale of your health information, use of your
health information for marketing purposes, and certain disclosures of psychotherapy
notes. You may revoke your authorization in writing at any time, and we will discontinue
future uses and disclosures of your health information for the reasons covered by your
authorization. We are unable to take back any disclosures that were already made with
your authorization, and we are required to retain the records of the care that we provided
to you.

YOUR PRIVACY RIGHTS REGARDING YOUR HEALTH INFORMATION

Right to Obtain a Copy of This Notice of Privacy Practices

A copy of our current Notice will be available upon request. To request a copy of our
current Notice of Privacy Practices, please call 1-239-867-4395.

Right to See and Copy Your Health Record

You have the right to look at and receive a copy of your health record or your
billing record. To do so, please contact the facility where you received treatment, or the
Privacy Office listed below. You may be required to make your request in writing. You
may request an electronic copy of this information, and we will provide access in the
electronic form and format requested if it is readily reproducible in the requested format.
If not, we will discuss the issue with you and provide a copy in a readable electronic form
and format upon which we mutually agree, depending on the information and our
capabilities at the time of the request. You may also request that we send your health
information directly to a person you designate if your written request is signed, in writing
and clearly identifies both the person designated and an address to send the requested
information.

If you would like a copy of your health record, a fee may be charged for the cost of
copying or mailing your record (and the electronic media if the request is to provide the
information on portable electronic media), as permitted by law.
We will provide a copy of your health record usually within 30 days. In certain situations,
we may deny your request. If we do, we will tell you, in writing, our reasons for the denial
and explain your right to have the denial reviewed.

Right to Update Your Health Record

If you believe that a piece of important information is missing from your health
record, you have the right to request that we add an amendment to your record. Your
request must be in writing, and it must contain the reason for your request. To submit
your request, please contact the facility where you received treatment, or the Privacy
Office listed below. We will make every effort to fulfill your request usually within 60
days. We may deny your request to amend your record if the information being amended
was not created by us, if we believe that the information is already accurate and complete,
or if the information is not contained in records that you would be permitted by law to see
and copy. If we deny your request, you will be notified in writing usually within 60 days.
Even if we accept your amendment, we will not delete any information already in your
records.

Right to Get a List of the Disclosures We Have Made

You have the right to request a list of the disclosures that we have made of your
health information. This list is not required to include disclosures made for treatment,
payment, and health care operations, and certain other disclosure exceptions. Your
request must be in writing and indicate in what form you want the list (for example, on
paper, electronically). To request a list of disclosures, please contact the facility where you
received treatment, or the Privacy Office listed below. The first list you request in a 12-
month period is free. For additional lists, we may charge a fee, as permitted by law.

Right to Request a Restriction on Certain Uses or Disclosures

You have a right to request a restriction on how we use and disclose your medical
information for treatment, payment and health care operations, and to certain family
members or friends identified by you who are involved in your care or the payment of
your care. We are not required to agree to your request, and will notify you if we are
unable to agree. Your request must be in writing and it must (1) describe what information
you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to
whom you want the limits to apply. In some instances, you may choose to pay for a
healthcare item or service out of pocket rather than submit a claim to your insurance
company. You may request that we not submit your medical information to a health plan
or your insurance company, if you, or someone on your behalf, pays for the treatment or
service out-of pocket in full. To request this restriction, you must make your request in
writing prior to the treatment or service. In your request you must tell us (1) what
information you want to restrict and (2) and to what health plan the restriction applies.

Right to Breach Notification

You have the right under HIPAA, or as required by law, to be notified if there is a
breach of your unsecured medical information. If requested, this notification may be
provided to you electronically.

Right to Choose a Representative

You have the right to choose someone to act on your behalf. If you have given
someone medical power of attorney or if someone is your legal guardian, that person can
exercise your rights and make choices about your health information. We will make
efforts to verify the person you designate has this authority and can act for you before we
take any action.

Right to Choose How You Receive Your Health Information

You have the right to request that we communicate with you in a certain way,
such as by mail or fax, or at a certain location, such as a home address or post office box.
We will try to honor your request if we reasonably can. Your request must be in writing,
and it must specify how or where you wish to be contacted. To submit a request, please
contact the facility where you received treatment, or the Privacy Office listed below.

CONTACT PERSON

If you believe your privacy rights have been violated, you may call or file a complaint in
writing with the Braden Clinic Privacy Office or the Department of Health and Human
Services (please reference the contact information below). We will take no retaliatory
action against you if you file a complaint about our privacy practices.

Kasia Pakaluk, Privacy Officer
Braden Clinic
5050 Ave Maria Blvd.
Ave Maria, FL 34142
info@bradenclinic.com

U.S. Department of Health and Human Services Office for Civil Rights
200 Independence Avenue, S.W., Washington, D.C. 20201,
1-877-696-6775 (toll free)
www.hhs.gov/ocr/privacy/hipaa/complaints/

If you have questions about this Notice, or would like to exercise your Privacy Rights,
please contact the facility where you received treatment, or the Braden Clinic Privacy
Office.

CHANGES TO THIS NOTICE OF PRIVACY PRACTICES

We reserve the right to change this Notice. We reserve the right to make the
revised Notice effective for medical information we already have about you as well as any
information we receive in the future. We will post a copy of the current Notice in each
Braden Clinic facility and on our website. In addition, each time you register, or have
healthcare services as an inpatient or outpatient, we will offer you a copy of our current
Notice in effect.

Rev. 11-2016
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