Notice of Privacy Practices

Tri Rivers Surgical Associates is required by law to maintain the privacy of your medical information. We are also required to provide you with notice of our legal duties and privacy practices with respect to this information.

Any information about your health, your health care or payment for that care is considered confidential and protected by Tri Rivers. Generally, your protected health information is any information that:

• Relates to your past, present or future physical or mental health or condition.
• Relates to the provision of health care to you.
• Relates to payment for health care provided to you.
• Individually identifies you or reasonably can be used to identify you.

We are required to abide by the terms of the notice in effect at the time your protected medical information is used or disclosed.

We reserve the right to change the terms of this notice and to make provisions of the revised notice effective for all medical information we maintain.

We will have a copy of the current notice posted in our office at all times. You may request a copy of the current notice each time you come to the practice for treatment or other health-care services.

Section A

The following provides descriptions and examples of the ways in which we may use and disclose your medical information:

1. For treatment
We may provide medical information about you to health-care providers, other personnel in our practice or third parties involved in the provision, management or coordination of your care.

The following provides a description and examples of the ways in which we may use and disclose your medical information:

• Delivering your care. Your medical information will be shared among physicians, nurses and other allied health-care providers who are involved in your care. For example, during an office visit, our physicians and other staff may review your medical record, as well as share and discuss your medical information with each other.
  
  
• Coordinating your care. We may share and discuss your medical information with entities such as:
  • A non-Tri Rivers physician with whom we are consulting regarding your care, as well as another health-care provider who seeks information for purposes of treating you.
  • An outside laboratory, radiology center or other health-care facility where we have referred you for testing, as well as a hospital or another health-care facility where we are admitting you or treating you.
  • A home health agency, a durable medical equipment agency or another health-care agency to whom we have referred you for health-care services or products.
  
  
• Appointment reminders and other scheduling matters. We may use and disclose medical information to provide appointment reminders, alert you to other scheduling issues or share information with you about treatment alternatives or other health-related benefits.

In addition, we may use a patient sign-in sheet in our waiting areas that is accessible to other patients. We also may page you in the waiting room when it is time for you to go to an examination room.

2. For payment
We may use or disclose your medical information so that we can collect or make payment for the health-care services you receive or are going to receive.

For example, if you participate in a health insurance plan, we will disclose necessary information to that plan to obtain preauthorization, if required, or payment for your care.

We may also disclose your medical information to another health-care provider, a health plan or a health-care clearinghouse for the payment activities of that entity.

3. For health-care operations
We may use or disclose your medical information for our activities and operations. These uses and disclosures are necessary to run our practice and to make sure that all of our patients receive quality care. Specific examples of this include:

• Quality improvement. We may use or disclose your medical information to review quality of care or the competence of health-care providers.
• Sale of the practice. We may need to disclose your medical information if we ever sell or transfer our practice.
• For quality-related or fraud-and-abuse activities If you have or had a relationship with another health-care provider, a health plan or a health-care clearinghouse, we may also disclose your medical information to that entity for purposes of carrying out those types of health-care operations.

Section B

• As required by law. We may use or disclose your medical information to the extent required by law, provided that the use or disclosure complies with and is limited to the relevant requirements of such law.
  
  
• To carry out public health activities. To the extent authorized or required by law, we may disclose your medical information:
  • To a public health authority to report a birth, death, disease or injury.
  • As part of a public health investigation.
  • To report child or adult abuse, or domestic violence.
  
  To the extent authorized or required by the Food and Drug Administration (FDA), we may disclose your medical information to a person or organization authorized to report adverse events, track products, enable product recalls, repairs, or replacement, and/or conduct post-marketing surveillance. This means we may disclose to non-governmental persons information about the quality, safety and effectiveness of FDA- regulated products and activities.
  
  
• When we suspect abuse, neglect or domestic violence. If we believe you have been a victim of abuse, neglect or domestic violence, we may disclose your medical information to a government authority. We will make this disclosure if it is necessary to prevent serious harm to you or other potential victims, you are unable to agree due to your incapacity, you agree to the disclosure, or when required by law.
  
  
• To carry out health oversight activities. We may disclose medical information to a health oversight agency for activities authorized by law. These activities include audits, investigations, inspections and licensure. These activities are necessary for appropriate oversight of the health-care system and government benefit and regulatory programs, as well as for compliance with civil rights laws.
  
  
• In the event of judicial and administrative proceedings. We may disclose medical information about you as required by a court or administrative order. We may also disclose protected medical information under certain circumstances in response to a subpoena, discovery request or other legal process.
  
  
• Law enforcement. We may release medical information to law enforcement officials as required by the law. Under limited circumstances, we may release your medical information to report a crime or in response to a court order, grand jury subpoena, warrant or administrative request.
  
  
• Decedents. Consistent with applicable law, we may release medical information to a coroner, medical examiner or funeral director.
  
  
• Organ, eye and tissue donation. For purposes of facilitating organ, eye or tissue donation and transplantation, we may use or disclose medical information to entities engaged in procurement, banking or transplantation of cadaveric organs, eyes or tissue.
  
  
• Research. We may use and disclose protected medical information about you if a researcher: (1) has obtained the required waiver from the appropriate Institutional Review Board or Privacy Board; and (2) has demonstrated that the information is both necessary to the research and carries a minimal risk of inappropriate use or disclosure.
  
  If a researcher has not obtained the required waiver, we will not disclose your medical information without your written authorization, other than in a limited data set (described below).
  
  
• Limited data set. For purposes of research, public health or health-care operations, it may be necessary to use or disclose some of your medical information for certain activities and/or to persons we are not otherwise authorized to give your information to.
  
  In this situation, we may use your medical information to create a limited data set, in which certain required direct identifiers (such as your name) have been removed. We will disclose the information in the limited data set for these purposes only if we have obtained satisfactory assurances from the recipient that the recipient will only use or disclose the information for limited purposes.
  
  
• To avert a serious threat to health or safety. We may use and disclose protected medical information when we believe a good-faith disclosure is necessary to prevent a serious threat to your health and safety or to the health and safety of others.
  
  
• Specialized government functions. Medical information may be disclosed for military and veterans affairs, for national security and intelligence activities, or for correctional activities.
  
  
• Workers' compensation: We may release medical information relating to injuries associated with workers' compensation or similar programs that provide benefits for work-related injuries or illnesses.
  
  
• Business associates: We may disclose your information to a person or organization that performs a function or activity on behalf of Tri Rivers Surgical involving the use or disclosure of protected health information, such as a billing services company. The business associate must agree in writing to protect the confidentiality of the information.
  
  
• Personal representative. We may disclose your information to a person who has authority under the law to act on your behalf in making decisions related to health care.
  
  

Section C

• Individuals involved in your care or the payment for your care. We may release relevant medical information about you to a friend or family member who is involved in your medical care. We may also notify these individuals of your location, general condition or death.
  
  
• Disaster relief. We may disclose medical information about you to an entity assisting in a disaster relief effort, so that your family can be notified about your condition, status and whereabouts.
  
  

Section D

Section E

1. The right to request restrictions
You have the right to request a restriction or limitation on the medical information we disclose about you for treatment, payment or health-care operations.

You also have the right to request a limit on the medical information we disclose about you for notification purposes or to someone who is involved in your care or the payment for your care, such as a family member or friend.

We are not required to agree to your request.

If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

To request a restriction, you must make your request in writing to our privacy officer. (See page 7 for contact information.) The requested restriction will not be effective unless and until it has been reviewed and approved by the privacy officer. For purposes of ensuring proper documentation, we may require that you make your request using a form that we give you.

We may terminate an agreed-upon restriction without your consent. In that instance, the restriction will only apply to protected health information created or received before you were informed of the termination of the restriction.

2. The right to receive confidential communication.
You have the right to request that we 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 must make your request in writing to our privacy officer. (See page 7 for contact information.) Your request may specify how or where you wish to be contacted.

We will not ask you the reason for your request, and we will accommodate all reasonable requests.

In making your request, we may ask you to:

• Provide information as to how payment will be handled and
• Specify an alternative method of contact

For purposes of ensuring proper documentation, we may require that you make your request using a form we give you.

3. The right to inspect and copy.
You have the right to inspect and obtain a copy of most of your medical information maintained at the practice. You must submit your request in writing to our privacy officer.

For purposes of ensuring proper documentation, we may require that you make your request using a form that we give you. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and obtain a copy in certain limited circumstances. If you are denied access, you may have the right to ask that the denial be reviewed. Another licensed health-care professional chosen by Tri Rivers will review your request and the denial. The professional conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

4. The right to amend
If you believe that medical 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 for as long as the information is kept by the practice.

To request an amendment, your request must be made in writing and submitted to our privacy officer. In addition, you must provide a reason that supports your request. For purposes of ensuring proper documentation, we may require that you make your request using a designated form.

We 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:

• Was not created by us
• Is not part of the medical information kept by or for the practice
• Is not part of the information you would be permitted to inspect and copy, or
• Is accurate and complete

5. The right to an accounting of disclosures
You have the right to request an accounting of certain disclosures. This means that you can ask for a list of the disclosures we have made of your protected medical information.

You have the right to request an accounting of certain disclosures by the covered entity that were made after April 14, 2003, and for a period of time less than six years from the date of your request.

To request an accounting you must submit a written request to our privacy officer. Your request should indicate the form in which you would like to receive the list - for example, on paper or electronically.

We will comply with your request within 60 days, or we will provide you with an explanation for the delay. The first list you request within a 12-month period will be free.

For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved. You may choose to withdraw or modify your request at that time before any costs are incurred.

The right to an accounting does not apply to all disclosures. For example, you do not have a right to an accounting of disclosures pursuant to an authorization; disclosures to carry out treatment, payment or health-care operations; or disclosures of a limited data set.

6. Right to a paper copy of this "Notice of Privacy Practices"
You have the right to receive a paper copy of this notice upon request. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy.

There are three ways in which you can obtain paper copies of this notice:

• You may view and print this notice from our web site, www.tririversortho.com, where you will find this notice under the "Notice of Privacy Practices" link.
• You may ask for a copy at registration when you visit Tri Rivers Surgical for services.
• You may contact our privacy officer and request a paper copy.

Section F

To file a complaint with the practice, you must submit the complaint in writing to our privacy officer at the following address:

Privacy Officer
Tri Rivers Surgical Associates
9104 Babcock Blvd, Suite 2120
Pittsburgh, PA 15237

You will not be retaliated against for filing a complaint.

If you have questions:
For more information about the matters covered by this notice, you may contact our privacy officer at the above address.

You may also contact the privacy officer by telephone at (412) 367-0600.