Effective Date: 01/01/2013

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.

Our Pledge to You.
We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care that we maintain, whether created by facility staff or your personal doctor. We are required by law to:

  • maintain the privacy of your medical information.
  • give you this notice of our legal duties and privacy notices with respect to medical information about you.
  • follow the terms of the notice that is currently in effect.

How We May Use and Disclose Medical Information About You
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” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

It is not the intent of the law or our policies to impede patient care. We may use and disclose your protected health information in any circumstance that we determine to be urgent or emergent in nature. For example, we may notify you at the contact numbers provided by you. We may leave a message with pertinent information..

Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice.

Following are examples of the types of uses and disclosures of your protected health care information that the physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

For Treatment
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.

  1. This includes the coordination or management of your health care with a third party.
    For example: We would disclose your protected health information, as necessary, to a home health agency that provides care to you.
  2. We will also disclose protected 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 to ensure that the physician has the necessary information to diagnose or treat you.
  3. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g. specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnoses or treatment to your physician.

For Payment
Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may require of us before it approves or pays for the health care services we recommend for you such as;

  • Making a determination of eligibility or coverage for insurance benefits
  • Reviewing services provided to you for medical necessity
  • Undertaking utilization review activities, such as obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

In addition, we may release your medical information to other providers entities covered by privacy laws for the payment activities of that other organization.

For Health Care Operations
We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging other business activities. For example, we may disclose your protected health information to medical school students that 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 your 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 will 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 communicate to you via newsletters, mail outs or other means regarding scheduled appointments, test results, preparation for tests, treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives our facility is participating in.

We may disclose your medical information to other entities covered by privacy laws for the operations of the other entity, if the entity already has a relationship with you and the operations pertain to activities such as quality assurance, training or fraud and abuse detection.

Patient Status Inquiries
Unless you object, we will use and disclose the location at which you are receiving care and your condition (in general terms). All of this information will be disclosed to people that ask for you by name.

Others Involved in Your Healthcare
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 or payment for your care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or to other individuals involved in your health care.

Incidental Uses and Disclosures
We may occasionally inadvertently use or disclose your medical information when such use or disclosure is incident to another use or disclosure that is permitted or required by law. For example, while we have safeguards in place to protect against others overhearing our conversations that take place between doctors, nurses or other personnel, there may be times that such conversations are in fact overheard. Please be assured, however, that we have appropriate safeguards in place to avoid such situations, and others, as much as possible.

Disclosures to You
Upon a request by you, we may use or disclose your medical information in accordance with your request.

Limited Data Sets
We may use or disclose certain parts of your medical information, called a "limited data set," for purposes of research, public health reasons or for our health care operations. We would disclose a limited data set only to third parties that have provided us with satisfactory assurances that they will use or disclose your medical information only for limited purposes.

Disclosures to the Secretary of Health and Human Services
We might be required by law to disclose your medical information to the Secretary of the Department of Health and Human Services, or his/her designee, in the case of a compliance review to determine whether we are complying with privacy laws.

De-Identified Information
We may use your medical information, or disclose it to a third party whom we have hired, to create information that does not identify you in any way. Once we have de-identified your information, it can be used or disclosed in any way according to law.

Disclosures by Members of Our Workforce
Members of our workforce, including employees, volunteers, trainees or independent contractors, may disclose your medical information to a health oversight agency, public health authority, health care accreditation organization or attorney hired by the workforce member, to report the workforce member's belief that we have engaged in unlawful conduct or that our care or services could endanger a patient, workers or the public. In addition, if a workforce member is a crime victim, the member may disclose your medical information to a law enforcement official.

Disclosures of Medical Information of Minors
Under Indiana law, we cannot disclose the medical information of minors to non-custodial parents if a court order or decree is in place that prohibits the non-custodial parent from receiving such information. However, we must have documentation of the court order prior to denying the non-custodial parent such access.

Disclosures of Records Containing Drug or Alcohol Abuse Information
Because of federal law, we will not release your medical information if it contains information about drug or alcohol abuse without your written permission except in very limited situations.

Disclosures of Mental Health
Records If your records contain information regarding your mental health, we are restricted in the ways that we can use and disclose them. We can disclose such records without written permission only in the following situations:

  • If the disclosure is made to you (unless it is determined by a physician that the release would be detrimental to your health);
  • Disclosures to our employees in certain circumstances;
  • For payment purposes;
  • For data collection, research, and monitoring managed care providers if the disclosure is made to the division of mental health;
  • For law enforcement purposes or to avert a serious threat to the health and safety of you or others;
  • To a coroner or medical examiner;
  • To satisfy reporting requirements;
  • To satisfy release of information requirements that are required by law;
  • To another provider in an emergency;
  • For legitimate business purposes;
  • Under a court order;
  • To the Secret Service if necessary to protect a person under Secret Service protection; and
  • To the Statewide waiver ombudsman.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:

Public Health Purposes
We may disclose your protected health information for public health activities. These generally include the following:

  • to prevent or control disease, injury or disability;
  • to report births or deaths;
  • to report abuse or neglect;
  • to report reactions to medications or problems with products;
  • to notify people of recalls of products they may be using;
  • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure when required or authorized by law.

Health Oversight Activities
We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

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 established protocols to ensure the privacy of your protected health information.

Coroners, Funeral Directors, and Organ Donation
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to a funeral director, as necessary and authorized by law, in order to permit the funeral director to carry out their duties. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Workers’ Compensation
We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Custodial Situations
If you are an inmate in a correctional institution and if the correctional institution or law enforcement authority makes certain representations to us, we may disclose your health information to a correctional institution or law enforcement official. Except for disclosures to another provider for your treatment, the information disclosed will be limited to your contact information or physical characteristics.

To Avert a Serious Threat to Health or Safety or In Disaster Situations
We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public, another person or in the event of a disaster. Any disclosure, however, would only be to someone able to help prevent the threat or to assist in the disaster relief efforts.

Military Activity and National Security
When the appropriate conditions apply, we may use or disclose protected health information 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 Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also 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.

Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

Law Enforcement
We may release medical information if asked to do so by a law enforcement official:

  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct on our premises; and
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

In these cases, information that is disclosed will be limited to demographic information or information regarding physical characteristic.

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 above. 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.

Your Rights Regarding Medical Information About You
You may request, in writing, that we restrict our use or disclosure of your medical information for treatment, payment or healthcare operations, to persons involved in your care, in an emergency or when specifically authorized by you. We will consider your request but we are not legally required to accept it. We will inform you of our decision regarding your request.

You have the right to request that medical information about you be communicated to you via alternative means, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use to communicate with you. We will not request an explanation from you as to the basis of this request. We will comply with any request that we can reasonably accommodate. We will inform you of our decision regarding your request.

In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care, when you submit a written request. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records initiated or created by us used for making decisions about you. If you request copies, we may charge a fee for the cost of copying, mailing or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision. Another health care professional will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the records, by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend a record if the information was not created by us; if it is not part of the medical information maintained by us; or if we determine that the record is accurate. You may appeal, in writing, a decision by us not to amend a record.

You have the right to a list of those instances where we have disclosed medical information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003. You may receive the list in paper or electronic form. The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before you incur any costs.

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. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

Changes to this notice
We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the changes occur. Before we make a significant change in our policies, we will change our notice and post the new notice in waiting areas, exam rooms, and on our Web site ( A current copy of the notice may be obtained at any time upon request. The effective date is listed just below the title of this notice. You will also be asked to acknowledge in writing your receipt of this notice.

If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to or amendments to your records, you may contact our Privacy Officer Leisa Heinzman at (317) 814-4117. You may also send a written complaint to U.S. Department of Health and Human Services Office of Civil Rights. Under no circumstances will you be penalized or retaliated against for filing a complaint.