HAND & PLASTIC SURGERY CENTRE, P.L.C. 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 our practice’s privacy official at (616) 459-4131 or via regular mail at 245 Cherry St. SE, Grand Rapids, MI 49503.

WHO WILL FOLLOW THIS NOTICE.

This notice describes the medical information practices of our physician practice and that of any health care professional or other employee within our practice who is authorized to enter information into your chart.

All of these persons and entities will follow the terms of this notice. In addition, these persons and entities may share medical information with each other for treatment, payment or healthcare operations purposes described in this notice.

PRIVACY OF MEDICAL INFORMATION:

Medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive from our practice. We need this record to provide you with quality care and to comply with certain legal requirements.

This notice applies to all of the records of your care generated by our practice, whether made by your doctor or any other employee of our practice. However, other medical professionals not associated with us may have different policies or notices regarding their use and disclosure of your Protected Health Information. You should consult their Notice of Privacy Practices for information about how they may use and disclose your records.

This notice tells you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:
• make sure that medical information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose medical information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other persons who are involved in taking care of you. We also may disclose medical information about you to people outside our practice who may be involved in your medical care. For example, if we refer you to another physician for treatment, we may supply that physician with medical information about you.

• For Payment. We may use and disclose medical information about you so that the treatment and services you receive from our practice may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may disclose details about your treatment to your health plan, or to a billing or collection agency. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

• For Health Care Operations. We may use and disclose medical information about you for our practice’s operations. For example, we may review information in your records as part of a general effort to improve our efficiency and quality of care. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. We may also disclose information to doctors, nurses, technicians, medical students, and hospitals for review and learning purposes. We may also combine the medical information we have with medical information from other practices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who specific patients are.

• Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at our office.

• Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

• Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to one or more friends or family members who are involved in your medical care.

• Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. We may also disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave our offices. We will ask for your advance specific permission if a researcher will have access to your name, address or other information that reveals who you are.

• As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.

• To Avert a Serious Threat to Health or Safety. 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 or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

• 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.

• Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:

• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child 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 if you agree or when required or authorized by law.

• Health Oversight Activities. We may disclose your medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with laws.

• 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, but only after efforts have been made to inform you of the request or to obtain an order protecting the requested information.

• 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 in our practice office or facility; 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.

• Funeral Directors, Coroners and Medical Examiners. We may release medical information to a funeral director, coroner, or medical examiner to permit them to carry out their duties. For instance, it may be necessary to establish a cause of death or to identify a deceased individual.

• National Security and Intelligence. We may release your medical information to certain federal authorities, as authorized by law, for intelligence, counterintelligence, and national security purposes.

• Veterans And The Military. If you are in the armed services, we may release your medical information as required by military command authorities.

• Organ Donation and Research. If you are an organ donor, we may release your health information to facilitate organ donation and transplantation. We may also release health information, in very limited circumstances, for certain research purposes.

Uses and disclosures that do not fall within the categories listed above will be made only if you provide a written authorization.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to our privacy official, via fax at (616) 459-4131 or via regular mail at 245 Cherry St. SE, Grand Rapids, MI 49503. 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 copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another person affiliated with our practice 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.

Right to Amend. If you feel 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 or for our practice.

To request an amendment, your request must be made in writing and submitted to our privacy official, via fax at (616) 459-4131 or via regular mail at 245 Cherry St. SE, Grand Rapids, MI 49503. In addition, you must provide a reason that supports your request.

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, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by us;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of certain disclosures we made of medical information about you.

To request this list or accounting of disclosures, you must submit your request in writing to our privacy official, via fax at (616) 459-4131 or via regular mail at 245 Cherry St. SE, Grand Rapids, MI 49503. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or by e-mail or on a disk). 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 and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or 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 to someone who is involved in your care or the payment for your care, like 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 treatment in an emergency.

To request restrictions, you must make your request in writing to our privacy official, via fax at (616) 459-4131 or via regular mail at 245 Cherry St. SE, Grand Rapids, MI 49503. In your request, you must tell us (1) 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, such as disclosures to your children or your spouse.

Right to Request Confidential Communications. 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 official, via fax at (616) 459-4131 or via regular mail at 245 Cherry St. SE, Grand Rapids, MI 49503. Your request must specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.

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

You may obtain a copy of this notice at our website, www.handandplasticsurgery.com.

To obtain a paper copy of this notice you may make your request in writing to our privacy official, via fax at (616) 459-4131 or via regular mail at 245 Cherry St. SE, Grand Rapids, MI 49503.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right 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. We will post a copy of the current notice in our office waiting area. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register for treatment at our front desk, you may obtain a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our privacy official, via fax at (616) 459-4131 or via regular mail at 245 Cherry St. SE, Grand Rapids, MI 49503, or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. Please remember that we are unable to take back any disclosures we have already made with your permission.