COORDINATED HEALTH SYSTEMS
(including CHS Professional Practice, P.C.
and CHS Ambulatory Surgery Lehigh Valley L.P.)

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 Privacy Contact at
610-927-2939

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.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website at www.chs4health.com, calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
We may use or disclose your protected health information as described in this Section. Your protected health information may be used and disclosed by your health care providers at this entity, 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 by us to obtain payment for the health care services furnished to you and to facilitate the operation of this health care entity.

The following are examples of the types of uses and disclosures of your protected health care information that this entity is permitted to make. These examples are not exhaustive, nor are they intended to be exhaustive.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained or will be obtaining (based upon our reasonable belief) your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to a hospital or home health agency or another health care provider that is providing or will be providing care to you in conjunction with care that we are providing or have requested; so they have the necessary information to diagnose or treat you.

Payment: We will use and disclose your protected health information, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake 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, and undertaking utilization review activities. For example, 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. We may also disclose patient information to another provider involved in your care for the other provider's payment activities.
Healthcare Operations: We may use or disclose your protected health information, as-needed, to facilitate the operation of this health care entity. These activities include, but are not limited to: quality assessment activities; accreditation, licensing or certification of our health care providers or the practice or related entities; credentialing of our health care providers with different health care insurers and hospitals; securing liability insurance and obtaining its benefits; evaluating and defending allegations of liability; employee review activities; training of medical students; marketing and fundraising activities; and conducting or arranging for other business activities. In certain circumstances, we may also disclose patient information to another provider or health plan for their health care operations.

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 health care provider. We may also call you by name in the waiting room when your health care provider 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 demand the protection of the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you and/or to remind you of appointments. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you.

We may use or disclose your demographic information and the dates that you received treatment from your health care provider, as necessary, in order to contact you for fundraising activities supported by us or related entities. If you do not want to receive these materials, please contact our Privacy Contact and request that these fundraising materials not be sent to you.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Generally, other uses and disclosures of your protected health information will be made only with your written authorization; however, we may use or disclose your protected health information without your written authorization to the extent permitted or required by law. You may revoke a written authorization at any time, so long as it is provided in writing to the Privacy Contact; however, please note that we are permitted to rely and take action on the authorization until we have the reasonable opportunity to process your revocation of the authorization.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object

We may use and disclose your protected health information in the following instances, to which you have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or not able to agree or object to the use or disclosure of the protected health information, then your health care provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Members of the clergy will be told your religious affiliation.

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; and 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. You should notify your health care provider or the Privacy Contact in writing of any objections to such disclosures. 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 other individuals involved in your health care.

Emergencies: We may use or disclose your protected health information, as needed, in an emergency treatment situation. If this happens, your health care provider shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your health care provider or another health care provider affiliated with the practice is required by law to treat you and the health care provider has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.

Communication Barriers: We may use and disclose your protected health information, as needed, if your health care provider or another health care provider in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the health care provider determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.

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 written authorization. These situations include:

By Law: We may use or disclose your protected health information without your written authorization to the extent that the use or disclosure is permitted or required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
Public Health: We may disclose your protected health information without your written authorization for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information without your written authorization, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Communicable Diseases: We may disclose your protected health information without your written authorization, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information without your written authorization to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Abuse or Neglect: We may disclose your protected health information without your written authorization to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information without your written authorization if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information without your written authorization to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose your protected health information without your written authorization in the course of any judicial or administrative proceeding, in response to an order of a court or an administrative tribunal or, under certain circumstances, in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information without your written authorization for law enforcement purposes. These disclosures may be made under the following reasons or circumstances: (1) compliance with legal process or as otherwise required by law, (2) limited information requests for identification and location purposes, (3) suspected criminal victim information, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on our premises) involving suspected criminal conduct.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information without your written authorization to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your protected health information without your written authorization to researchers when their research has been approved by an institutional review or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Limited Data Sets: We may disclose protected health information by removing directly identifying information (i.e., a limited data set) for research purposes or for public health purposes. If we do so, a "data use agreement" will be required from the recipient of this information that precludes the recipient from re-identifying this information (i.e., making its relationship to you identifiable) and/or disclosing it.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information without your written authorization if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

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 without their written authorization (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.

Workers' Compensation: Your protected health information may be disclosed by us without your written authorization as authorized to comply with workers' compensation laws and other similar legally-established programs.

Inmates: We may use or disclose your protected health information without your written authorization if you are an inmate of a correctional facility and your health care provider created or received your protected health information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

2. Your Rights

The following is a summary of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in your designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records and any other records that your health care provider and the practice uses for making decisions about you.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. We may deny your request to inspect or copy your protected health information. Depending on the circumstances, you may have the right to a review by a licensed health care professional who did not participate in the original decision to deny access. Any requests for inspection and copying of your protected health information or for review of a denial of access shall be submitted in writing to our Privacy Contact. We retain the right to charge you fees for copying and postage (if applicable) and may require advancement payment, in accordance with applicable laws and regulations. We will not charge a fee to retrieve the records for copying. A request for review of a denial of access shall be provided to our Privacy Contact. Generally, we will provide our responses to any of these requests within sixty (60) days after receipt by our Privacy Contact. If another health care provider requires these records to render care or treatment, please have that provider contact us; so we may make every reasonable effort to get your records to that provider within the time that he or she requires your records.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. It must be provided to the Privacy Contact or your health care provider.

We are not required to agree to a restriction that you may request. If your health care provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your health care provider does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Further, we may terminate our agreement to a restriction under certain circumstances.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.

You may have the right to request your health care provider amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us; and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Regardless, your request for an amendment shall remain part of your designated record set. Your request and any statement of disagreement shall be printed or typewritten, shall not exceed two (2) pages and shall state the basis for the request. It must be provided to our Privacy Contact. Generally, we will provide our responses to any of these requests within sixty (60) days after receipt by our Privacy Contact.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations, as described in this Notice of Privacy Practices. It excludes disclosures pursuant to your written authorization and disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for certain other disclosures that we are permitted to make without your authorization. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. We also shall not supply an accounting of disclosures for more than the most recent six (6) years. The right to receive this information is subject to certain exceptions, restrictions and limitations. Your request for an accounting shall be provided in writing to our Privacy Contact. Generally, we will provide our responses to any of these requests within sixty (60) days after receipt by our Privacy Contact. We will provide the first accounting during a twelve (12) month period without charge; but we reserve the right to charge a reasonable cost-based fee for additional accountings during that period of time.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. If we revise this Notice of Privacy Practices, we will make it available at our offices upon your request and will post a notice in a clear and prominent location that it has been amended.

3. Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

You may contact our Privacy Contact at 610-927-2939 or patwagner@msn.com for further information about the complaint process.

This notice was published and becomes effective on April 14, 2003.

I acknowledge receipt of the Notice of Privacy Practices of ______________________ for the patient identified below on the date specified below.

1. Print patient name: _______________________________

2. If the patient is a minor or incompetent, complete this section; otherwise, move onto Section 3.

Print name of person signing acknowledgement: _______________________________

Print authority to sign for patient (e.g., custodian or parent): _______________________



3. Signature of Recipient of Notice of Privacy Practices: _________________________


4. Date: ______________________________

5. If the patient or his or her custodian refused to sign the acknowledgement, employee who witnessed refusal shall set forth the following below: (1) summary of efforts made to obtain signature (with identification of person(s) refusing to sign), (2) date, and (3) print and sign name.