NORTHWEST RADIOLOGY NETWORK 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 IT CAREFULLY.

If you have any questions about this notice, please contact the Northwest Radiology Network (NWR) Executive Director/Privacy Officer:

317-328-5050 or 1-800-400-XRAY (9729)

5901 Technology Center Drive

Indianapolis, Indiana 46278

1. WHO WILL FOLLOW THIS NOTICE
   This notice describes the information privacy practices followed by NWR physicians, technologists, imaging center staff, billing personnel and other office staff.
2. YOUR HEALTH INFORMATION
   This notice applies to the information and records we have about your health and the health care services you receive at an NWR office. NWR is required by law to notify you of our privacy practices. This document will tell you about the ways in which we may use and disclose protected health information (PHI) about you and describes your rights and our obligations, regarding the use and disclosure of that information; it is the complete Notice and available upon a patient’s request. A Patient Privacy Summary and Acknowledgement will be obtained from all patients or his or her representative, effective April 14, 2003.
3. YOUR CONSENT TO USE AND DISCLOSE HEALTH INFORMATION
   We must have your Consent to use and disclose health information for the following purposes:3a) For Treatment – NWR may use health information about you to provide you with medical services. We may disclose health information about you to doctors, nurses, technologists, office staff or other personnel, who are involved in taking care of you and your health. For example, a pre-existing condition may affect the results of your exam or could complicate your treatment. The radiologist may use your medical history to decide what treatment or test is best for you. The radiologist may also tell another medical provider about your condition, to help determine the most appropriate care for you. Different personnel in our office may share information about you and disclose information to people who do not work in an office in order to coordinate your care, such as calling to obtain previous medical records or ordering additional radiological studies. Other health care providers may be part of your medical care, outside this office, and may require information that we have about you.3b) For Payment – NWR may use and disclose health information about you so that the services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a service you received at our facility, so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a service you are going to receive to obtain prior approval, or to determine whether your plan will cover the exam.3c) For Health Care Operations – NWR may use and disclose health information about you in order to manage our offices and make sure that you and our other patients receive quality care. For example, we may use your health information to evaluate the performance of our staff, in caring for you. We may also use health information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient or whether certain exams are effective.Other examples of health care operations include instances such as, contacting you as a reminder that you have an appointment for an exam at an NWR office. We could tell you about or recommend possible treatment options or alternatives that may be of interest to you. In addition, NWR may tell you about health-related products or services that may be of interest to you.Please notify NWR in writing if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services. If you advise us in writing at the address listed at the top of this Notice that you do not wish to receive such communications, we will not use your information for these purposes. You may use the Request for Restriction on Uses and Disclosures of PHI form to notify NWR of your wishes.You may revoke your Consent to use and disclose your personal health information at any time, by giving us written notice. Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures, which occurred before that time, nor will it prevent NWR from collecting payment for services rendered prior to the revocation.If you do revoke your Consent, we will not be permitted to use or disclose information for purposes of future treatment, payment or health care operations, and we may, therefore, choose to discontinue providing you with health care services.
4. SPECIAL SITUATIONS COVERED UNDER YOUR CONSENT
   NWR may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:To Avert a Serious Threat to Health or Safety – NWR may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.Required By Law – NWR will disclose health information about you when required to do so by federal, state or local law.Organ and Tissue Donation – If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary, to facilitate such donation and transplantation.Military, Veterans, National Security and Intelligence – If you are, or were, a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.Workers’ Compensation – NWR may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.Public Health Risks – NWR may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.Health Oversight Activities – NWR may disclose health information, to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the healthcare system, government programs, and compliance with civil rights laws.Lawsuits and Disputes – If you are involved in a lawsuit or a dispute, NWR may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.Law Enforcement – NWR may release health information, if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.Coroners, Medical Examiners and Funeral Directors – NWR may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.Information Not Personally Identifiable – NWR may use or disclose health information about you in a way that does not personally identify you or reveal who you are.Family and Friends – NWR may disclose health information to your family or friends, if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room, during treatment or while treatment is discussed.Not Able to Give Consent In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), NWR may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. For example, if an emergent situation arises during your appointment, we may inform the person who accompanied you of your medical status and provide updates on your progress and prognosis. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, x-rays or radiological reports.
5. DISCLOSURES OF HEALTH INFORMATION REQUIRING SEPARATE AUTHORIZATION
   NWR will not use or disclose your health information for any purposes other than those identified in the previous sections, without your specific, written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. For example, we may use and disclose health information about you for research projects. We will ask you for your permission, if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the office.If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you, for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made, with your permission.
6. YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
   You have the following rights regarding health information NWR maintains about you:6a) Right to Inspect and Copy You have the right to inspect and copy your health information, such as medical and billing records. You must complete a Request to Inspect PHI form in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy, in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If required by law, we will select a licensed healthcare professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.6b) Right to Amend If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment, as long as the medical information is kept by NWR.To request an amendment, complete and submit a Medical Record Amendment/Correction Form to the address on this Notice, to the attention of the Privacy Officer. NWR may deny your request for an amendment, if it is not in writing or does not include a reason to support the request. In addition, we may deny your request, if you ask us to amend information, that:We did not create, unless the person or entity that created the information is no longer available to make the amendment.
   Is not part of the health information that NWR keeps on file.
   You would not be permitted to inspect and copy.
   Is accurate and complete6c) Right to an Accounting of Disclosures You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you, for purposes other than treatment, payment and healthcare operations, and would have required a signed Authorization. To obtain this list, you must submit your request in writing to the address on this Notice and to the attention of the Privacy Officer. It must state a time period, which may not be longer than six years and may not include dates before April 1, 2003. We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time, before any costs are incurred.6d) Right to Request Restrictions You have the right to request a restriction or limitation on the health information NWR uses or discloses about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. We are Not Required to Agree to Your Request If we agree, we will comply with your request, unless the information is needed to provide you emergency treatment. To request restrictions, you may complete and submit the Request for Restriction on Uses and Disclosures of PHI form at the address listed in the Notice.6e) Right to Request Confidential Communications You have the right to request that NWR communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.To request confidential communications, you may complete and submit the Request for Restriction on Uses and Disclosures of PHI form to the Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.6f) Right to a Paper Copy of This Notice You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. It is available in any NWR outpatient imaging center, the NWR business office or you may request a copy by mail.
7. CHANGES TO THIS NOTICE
   NWR reserves the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. A Summary of the current notice will be available in each of our imaging centers and the complete Notice is always available by request. You are entitled to a copy of the notice currently in effect.
8. COMPLAINTS
   If you believe your privacy rights have been violated, you may file a complaint with our office or with the Office of Civil Rights of the Department of Health and Human Services at www.hhs.gov/ocr/hipaa. A Complaint form is available for you to file with our office, to the attention of the Privacy Officer at the address listed at the top of this Notice. You will not be penalized for filing a complaint.