Notice of Privacy Practices

Effective Date: September 23, 2013

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.

I. What this is

This Notice describes the privacy practices of FORTÉ SPORTS MEDICINE AND ORTHOPEDICS (The “Practice”).

II. Our Privacy Obligations

We are required by law to maintain the privacy of medical health information about you (“Protected Health Information” or “PHI”), to provide you with this Notice of our legal duties and privacy practices with respect to PHI, and to notify you following a breach of your unsecured PHI. When we use or disclose PHI, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

III. Permissible Uses and Disclosures Without Your Written Authorization

In certain situation, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:

A. Use and Disclosure for Treatment, Payment and Health Care Operations. We may use and disclose PHI, but not your “Highly Confidential Information” (defined in Section IV. C below), in order to treat you, obtain payment for services provided to you and conduct our “health care operations” (e.g., internal administration, quality improvement and customer service) as detailed below:

 Treatment. We use and disclose PHI to provide treatment and other services to you –for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. We may also disclose PHI to other providers involved in your treatment. In some cases, the sharing of your PHI with other healthcare providers may be done electronically, including through an electronic health information exchange.

 Payment. We may use and disclose PHI to obtain payment for services that we provide to you – for example, to obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”), or to verify that Your Payor will pay for health care.

 Health Care Operations. We may use and disclose PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost-effectiveness of the care that we deliver to you and for conducting training programs in which students, trainers, or practitioners in areas of health care learn, under supervision, to practice or improve their skills as health care providers. For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose PHI to our Privacy Official in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.

We may also disclose PHI to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.

B. Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose PHI to a family member, other relative, a close personal friend, or any other person identified by you when you are present for, or otherwise available prior to, the disclosure. In efforts to obtain payment, the Practice will release billing information to the guarantor, spouse, or custodial parent after requesting appropriate identification. If you object to such uses or disclosures, please notify the Privacy Official.

If you are not present, you are incapacitated, or in an emergency circumstance, we may exercise our professional judgement to determine whether a disclosure is in your best interest. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that is directly relevant to the person’s involvement with your health care or payment related to your health care. We may also disclose PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.

C. Public Health Activities. We may disclose PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability, (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports, (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration, (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

D. Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect or domestic violence.

E. Health Oversight Activities. We may disclose PHI to a health oversight agency that oversees the health care system and is charged with the responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

F. Judicial and Administrative Proceedings. We may disclose PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

G. Law Enforcement Officials. We may disclose PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.

H. Descendants. We may disclose PHI to a coroner or medical examiner as authorized by law.

I. Organ and Tissue Procurement. We may disclose PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

J. Research. We may use or disclose PHI without your consent or authorization if an Institutional Review Board/Privacy Board approves a waiver of authorization for disclosure.

K. Health or Safety. We may use or disclose PHI to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

L. Specialized Government Functions. We may use and disclose PHI to units of the government with special functions, such as the U.S. Military or the U.S. Department of State under certain circumstances required by law.

M. Workers’ Compensation. We may disclose PHI as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.

N. As required by law. We may use and disclose PHI when required to do so by any other law not already referred to in the preceding categories.

IV. Use and Disclosures Requiring Your Written Authorization

A. Use or Disclosure with Your Authorization. For any purpose other than the ones described in Section III, we only may use or disclose PHI when (1) you give us your authorization on our authorization form (“Your Authorization”). For instance, you will need to execute an authorization form before we can disclose PHI to your life insurance company, to your child’s camp, or to the attorney representing the other party in litigation in which you are involved.

B. Marketing Communications. We must also obtain your written authorization (“Your Marketing Authorization”) prior to using PHI to send you any marketing materials. (We can, however, provide you with marketing materials in a face-to-face encounter, without obtaining Your Marketing Authorization.) In addition, we may communication with you about products or services relating to your treatment, case management or care coordination, or alternative treatment, therapies, providers or care settings. We may use or disclose PHI to identify health-related services and products that may be beneficial to your health, and then contact you about the services and products.

C. Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that: (1) is maintained in psychotherapy notes, (2) is about mental health treatment, (3) is about alcohol and drug abuse prevention, treatment and referral, or (4) is about certain communicable diseases such as HIV/AIDS, hepatitis, and gonorrhea. For example, we will not release such Highly Confidential Information in response to a Subpoena, but will follow state and federal requirements to provide you with notice and/or seek a court review of the request for your records. In the case of certain dangerous communicable diseases, state law requires us to report that data to the State Department of Health. In order for us to disclose your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written authorization.

D. Fundraising Communications. In connection with any fundraising, we may use or disclose to our fundraising staff your name, address and phone number, age, gender, dates and departments of service. If you do not want to receive any fundraising requests, you may contact the Privacy Official at the address and telephone number provided at the bottom of this Notice.

E. Sale of PHI. We will not sell your information without your written authorization. We will not use or share your information for the purpose of marketing the services or products of non-Practice entities without your written authorization.

V. Your Individual Rights

A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to PHI, you may contact our Privacy Official. You may also file written complaints with the Director at the Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Official will provide you with the correct address for the Director. We will not retaliate against you for filing a complaint with the Director or us.

B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, (3) to notify or assist in the notification of such individuals regarding your location and general condition; or (4) to your health plan for services for which you paid out-of-pocket in full, provided that such disclosure is not necessary for your treatment. All requests for such restrictions must be made in writing. Please obtain the appropriate form from the Practice. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction, except for disclosures to your health plan for services paid out-of-pocket in full.

C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable request for your receipt of PHI by alternative means of communication or at alternative locations. All requests for such communications must be made in writing. Please obtain the appropriate form from the Practice.

D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us. With the exception of laboratory/test results and copies of x-ray films for which oral requests may be honored, all requests for access must be made in writing. Please obtain the appropriate form from the Practice. You may obtain a copy of your PHI or a summary of you PHI, and we may impose a fee for such copy or summary. If we maintain PHI about you in electronic format, you have the right to a copy of your PHI in the electronic form or format you request, so long as the PHI is readily producible in that form or format. If it is not readily producible in the form or format you request, we will provide it to you in a reasonable alternative format. Under limited circumstances, we may deny your access to your records. Please know that if you are a parent or legal guardian of a minor, certain portions of the minor’s medical record will not accessible to you (for example, if the child had and exercised the right to confidential treatment without parental consent, such as testing for venereal disease or treatment for substance abuse).

E. Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Official identified below. Please obtain the appropriate form from the Practice.

F. Right to Amend Your Records. You may request that we amend PHI maintained in your medical record file or billing records, by delivering a written amendment statement to the Privacy Official. Please obtain the appropriate form from the Practice. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

G. Right to Receive an Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by us during any period of time prior to the date of your request, provided such period does not exceed six years and does not apply to disclosures that occurred prior to September 23, 2013. If you request an accounting more than once during a twelve (12) month period, we may impose a fee for this service.

H. Right to Receive Paper Copy of this Notice. Upon written request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

VI. Effective Date and Duration of This Notice

A. Effective Date. This Notice is effective on September 23, 2013. Last updated August 8, 2022.

B. Right to Change Terms of the Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new Notice. If we change this Notice, we will post the revised notice in the waiting areas of the Practice [and on our internet site at www.forteortho.com/privacy]. You may also obtain any revised notice by contacting the Privacy Official.

VII. Privacy Official

You may contact the Privacy Official at:

FORTÉ SPORTS MEDICINE AND ORTHOPEDICS

10767 Illinois St, Suite 3000B

Carmel, IN 46032

(317) 817-1200

Compliance@forteortho.com