LINDSAY HOUSE* PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

*Lindsay House Surgery Center, LLC and Vito C. Quatela, MD, PLLC are separate legal entities under common ownership and control. For purposes of this Privacy Notice, the two entities will be referred to independently and collectively as the "Lindsay House."

Lindsay House includes the physicians and other providers who work in Lindsay House. Some of those providers are not employees of Lindsay House. However, for purposes of compliance with the HIPAA Privacy Rules, Lindsay House is deemed to be an Organized Health Care Arrangement, which means: that it operates as an integrated unit; that all providers will share protected health information in order to carry out treatment (including coverage for each other), payment for treatment and health care operations; that this Notice is provided as a joint notice made by each of them; and, that each of them will abide by the terms of this Notice.

POLICY STATEMENT

Lindsay House is committed to maintaining the privacy of your protected health information ("PHI"), which includes information about your medical condition and the care and treatment you receive from Lindsay House and other health care providers. This Notice details how your PHI may be used and disclosed to third parties for purposes of your care, payment for your care, health care operations of Lindsay House, and for other purposes permitted or required by law. This Notice also details your rights regarding your PHI.

USE OR DISCLOSURE OF PHI

Lindsay House may use and/or disclose your PHI for purposes related to your care, payment for your care, and health care operations. The following are examples of the types of uses and/or disclosures of your PHI that may occur.

Care - In order to provide, coordinate and manage your care, Lindsay House will provide your PHI to those health care professionals, whether a Lindsay House staff person or not, directly involved in your care so that they may understand your medical condition and needs and provide advice or treatment (e.g., a specialist or laboratory).

Payment - In order to get paid for some or all of the health care provided by Lindsay House, Lindsay House may provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements. For example, Lindsay House may need to provide your health insurance carrier or, if you are over 65, the Medicare program with information about health care services that you received from Lindsay House so that Lindsay House can be properly reimbursed. Lindsay House may also need to tell your insurance plan about the need to hospitalize you so that the insurance plan can determine whether or not it will pay for the expense.

Health Care Operations - In order for Lindsay House to operate in accordance with applicable law and insurance requirements and to provide quality and efficient care, it may be necessary for Lindsay House to compile, use and/or disclose your PHI. For example, Lindsay House may use your PHI in order to evaluate the performance of personnel providing care to you.

AUTHORIZATION NOT REQUIRED

Lindsay House may use and/or disclose your PHI, without a written Authorization from you, in the following instances:

De-identified Information - Your PHI is altered so that it does not identify you and, even without your name, cannot be used to identify you.

Business Associate - To a business associate, which is someone who Lindsay House contracts with to provide a service necessary for your treatment, payment for your treatment, and health care operations (billing service). Lindsay House will obtain satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI.

Personal Representative - To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.

Public Health Activities - Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease, injury or disability. This includes reports of child abuse or neglect.

Food and Drug Administration - If required by the Food and Drug Administration to report adverse events, product defects or problems or biological product deviations, or to track products, or to enable product recalls, repairs or replacements, or to conduct post marketing surveillance.

Abuse, Neglect or Domestic Violence - To a government authority if Lindsay House is required by law to make such disclosure. If Lindsay House is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm or if Lindsay House believes that you have been the victim of abuse, neglect or domestic violence. Any such disclosure will be made in accordance with the requirements of law, which may also involve notice to you of the disclosure.

Health Oversight Activities - Such activities, which must be required by law, involve government agencies involved in oversight activities that relate to the health care system, government benefit programs, government regulatory programs and civil rights law. Those activities include, for example, criminal investigations, audits, disciplinary actions, or general oversight activities relating to the community's health care system.

Judicial and Administrative Proceeding - For example, Lindsay House may be required to disclose your PHI in response to a court order or a lawfully issued subpoena.

Law Enforcement Purposes - In certain instances, your PHI may have to be disclosed to a law enforcement official for law enforcement purposes. Law enforcement purposes include: (1) complying with a legal process (i.e., subpoena) or as required by law; (2) information for identification and location purposes (e.g. suspect or missing person); (3) information regarding a person who is or is suspected to be a crime victim; (4) in situations where the death of an individual may have resulted from criminal conduct; (5) in the event of a crime occurring on the premises of Lindsay House; and (6) a medical emergency (not on Lindsay House premises) has occurred, and it appears that a crime has occurred.

Coroner or Medical Examiner - Lindsay House may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death, or to a funeral director as permitted by law and as necessary to carry out its duties.

Organ, Eye or Tissue Donation - If you are an organ donor, Lindsay House may disclose your PHI to the entity to whom you have agreed to donate your organs.

Research - If Lindsay House is involved in research activities, your PHI may be used, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI such as approval of the research by an institutional review board and the requirement that protocols must be followed.

Avert a Threat to Health or Safety - Lindsay House may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the threat.

Specialized Government Functions - When the appropriate conditions apply, Lindsay House may use 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 Veteran Affairs of eligibility for benefits; or (3) to a foreign military authority if you are a member of that foreign military service. Lindsay House may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities including the provision of protective services to the President or others legally authorized.

Inmates - Lindsay House may disclose your PHI to a correctional institution or a law enforcement official if you are an inmate of that correctional facility and your PHI is necessary to provide care and treatment to you or is necessary for the health and safety of other individuals or inmates.

Workers' Compensation - If you are involved in a Workers' Compensation claim, Lindsay House may be required to disclose your PHI to an individual or entity that is part of the Workers' Compensation system.

Disaster Relief Efforts - Lindsay House may use or disclose your PHI to a public or private entity authorized to assist in disaster relief efforts.

Required by Law - If otherwise required by law, but such use or disclosure will be made in compliance with the law and limited to the requirements of the law.

AUTHORIZATION

Use and/or disclosure of your psychotherapy notes (if applicable) that do not fall within certain limited exceptions, use of your PHI for marketing purposes, disclosures resulting from the sale of your PHI, and any other use and or disclosure not described above will not be made without your written Authorization, which you may revoke at any time.

SIGN-IN SHEET

Lindsay House may use a sign-in sheet at the registration desk. Lindsay House may also call your name in the waiting room when your physician is ready to see you.

APPOINTMENT REMINDER

Lindsay House may, from time to time, contact you to provide appointment reminders. The reminder may be in the form of a letter or postcard. Lindsay House will try to minimize the amount of information contained in the reminder. Lindsay House may also contact you by phone and, if you are not available, a message will be left for you.

TREATMENT ALTERNATIVE/BENEFITS

Lindsay House may, from time to time, contact you about treatment alternatives, or other health benefits or services that may be of interest to you.

FUNDRAISING

Lindsay House_may use and/or disclose some of your PHI in order to contact you for fundraising activities supportive of Lindsay House. Any fundraising materials sent to you will describe how you may opt out of receiving any further communications.

FAMILY/FRIENDS

The Practice may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person's involvement with your care or the payment for your care. The Practice may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply:

  1. The Practice may use or disclose your PHI if you agree, or if the Practice provides you with opportunity to object and you do not object, or if the Practice can reasonably infer from the circumstances, based on the exercise of its judgment, that you do not object to the use or disclosure.
  2. If you are not present, the Practice will, in the exercise of its judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person's involvement with your care.

YOUR RIGHTS

You have the right to:

  1. Revoke any Authorization, in writing, at any time. To request a revocation, you must submit a written request to Lindsay House's Privacy Officer.
  2. Request restrictions on certain use and/or disclosure of your PHI as provided by law, but Lindsay House is not obligated to agree to any requested restrictions. However, Lindsay House must agree to a request to restrict disclosure of your PHI to a health plan if: the disclosure is for the purpose of carrying out payment or health care operations and is not required by law, and the PHI pertains solely to a health care item or service for which you or someone else has paid Lindsay House in full. To request restrictions, you must submit a written request to Lindsay House's Privacy Officer. In your written request, you must inform Lindsay House of what information you want to limit, whether you want to limit Lindsay House's use or disclosure, or both, and to whom you want the limits to apply. If Lindsay House agrees to your request, Lindsay House will comply with your request unless the information is needed in order to provide you with emergency treatment.
  3. Receive confidential communications of PHI by alternative means or at alternative locations. You must make your request in writing to Lindsay House's Privacy Officer. Lindsay House will accommodate all reasonable requests.
  4. Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written request to Lindsay House's Privacy Officer. In certain situations that are defined by law, Lindsay House may deny your request, but you will have the right to have the denial reviewed. Lindsay House can charge you a fee for the cost of copying, mailing or other supplies associated with your request.
  5. Amend your PHI as provided by law. To request an amendment, you must submit a written request to Lindsay House's Privacy Officer. You must provide a reason that supports your request. Lindsay House may deny your request if it is not in writing, if you do not provide a reason and support of your request, if the information to be amended was not created by Lindsay House (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by Lindsay House, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with Lindsay House's denial, you have the right to submit a written statement of disagreement.
  6. Receive an accountin of disclostires of your PHI as provided by law. To request an accounting, you must submit a written request to Lindsay House's Privacy Officer. The request must state a time period which may not be longer than six years. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a 12 month period will be free, but Lindsay House may charge you for the cost of providing additional lists in that same 12 month period. Lindsay House will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.
  7. Receive a paper copy of this Privacy Notice from Lindsay House upon request to Lindsay House's Privacy Officer.
  8. Be notified following a breach of your unsecured PHI if so required by law.
  9. Complain to Lindsay House, or to the Secretary of Health and Human Services, Office of Civil Rights if you feel we have violated your rights. You may contact a regional office of the Office of Civil Rights, which can be found at www.hhs.gov/ocr/office/about/rgn-hqaddresses.html. To file a complaint with Lindsay House, you must contact Lindsay House's Privacy Officer. All complaints must be in writing.
  10. To obtain more information on, or have your questions about your rights answered, you may contact Lindsay House's Privacy Officer, John Goehle, at 973 East Avenue, Rochester, New York 14607 or by phone at 585-594-1167 or via email at jgoehle@ah-strategies.com

LINDSAY HOUSE REQUIREMENTS

Lindsay House:

  1. Is required by law to maintain the privacy of your PHI, and to provide you with this Privacy Notice of Lindsay House's legal duties and privacy practices with respect to your PHI.
  2. Is required to abide by the terms of this Privacy Notice.
  3. Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.
  4. Will not retaliate against you for making a complaint.
  5. Must make a good faith effort to obtain from you an acknowledgement of receipt of this Privacy Notice.
  6. Will post this Privacy Notice on Lindsay House's web site, if Lindsay House maintains a web site.
  7. Will provide this Privacy Notice to you by e-mail if you so request. However, you also have the right to obtain a paper copy of this Privacy Notice.

EFFECTIVE DATE: This Notice is in effect as of October 25, 2013.

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The Lindsay House

973 East Avenue
Rochester, NY 14607
Phone: (585) 244-1000

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