SOUTHERN COLORADO CLINIC P.C

I.     Understanding Your Health Information

Each time you visit Southern Colorado Clinic, a record of your visit is created. This record usually contains your name and other information that may identify you, your symptoms, examination and test results, diagnoses, treatment, plan for future health care and financial information. This record is sometimes referred to as your medical record or medical chart. This record allows:

• Doctors, nurses, and other health professionals to plan your treatment;
• Our Medical Clinic to obtain payment for services we provide to you, such as from health plans, Medicaid, or you; and
• Our Medical Clinic Practice to measure the quality of care provided to you.

As we have in the past, we are committed to keeping your health information confidential. We will not use or give to others your health information without your written permission, except as stated in this Notice.

II.     How We Will Use and Give Out Your Health Information

a. Treatment, Payment and Health Care Operations

We will use and give out your health information to provide you with health care treatments, to get paid for our services, and help us operate our Physician Practice. For example:

• We will give your health information to health care professionals not on our staff, such as other doctors and hospital staff, who help care for you;
• We may send a bill to your health insurance plan or to you; and
• Our clinic may use your medical record to review our performance and make sure you receive quality health care.

b. Other Uses and Disclosures Allowed or Required by Law

We may use or give out your health information for the following purposes under limited circumstances:

• To people who are involved in your care or who help pay for your care, such as your family, your close personal friends, or any other person chosen by you to notify them of your location, general health, and to assist you in your health care (such as to pick-up medicine or help with follow-up care);
• To government agencies that oversee our Physician Practice (such as license and certification inspectors);
• To government agencies that have the right to receive and collect health information (such as to control disease outbreaks);
• When we are ordered by a court or judge;
• To workers’ compensation programs when your health problems is from a work-related injury;
• When law enforcement requests information (such as to prevent danger or injury);
• To coroners and funeral directors to allow them to carry out their duties;
• To organ donor agencies (subject to applicable laws);
• For research studies that meet all privacy law requirements (such as research to stop a disease);
• To avoid a serious threat to the health or safety of others;
• To contact you about new treatments or medicines that may help you;
• To business associates of the Physician Practice that help us perform required tasks, such as our accountants, computer consultants, and billing companies (only if the business associate agrees in writing to keep your health information confidential as required by law); and
• For any other purpose required or allowed by law.

c. Other Uses and Dicloses Requiring Your Written Permission

Except as stated above, we will use or give out your health information only after getting your written permission on an Authorization form. You may revoke your authorization at any time by notifying us in writing that you wish to do so.

III.     Your Rights Regarding Your Health Information

Subject to certain legal limits, you have rights regarding the use and disclosure of your health information, including the rights to:

• Request limits on uses of your health information
• Receive confidential communications of your health information
• Inspect and copy your health information
• Request a change to your health information
• Receive a record of how we have used and given out your health information
• Obtain a copy of this Notice of Privacy Practices

IV.     Questions, Concerns, and Changes to this Notice

If you have any questions or want to talk about any of the information in this Notice of Privacy Practices, please contact Kim Garnett, Director of Operations Southern Colorado Clinic, 3676 Parker Blvd., Pueblo, Colorado 81008, 719/253-7000.

If you believe your privacy rights have been violated, you may file a complaint with Southern Colorado Clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with Southern Colorado Clinic, contact Kim Garnett, Director of Operations Southern Colorado Clinic, 3676 Parker Blvd., Pueblo, Colorado 81008, 719-553-2200. All complaints must be submitted in writing. We will not retaliate against you for filing a complaint.

We may change our Notice of Privacy Practices in the future. Such changes will apply to your health information that we created or received before the effective date of the change. We will notify you of any changes to our Notice of Privacy Practices by posting the changed notice at your physician’s office at Southern Colorado Clinic and on our web site.