General Surgeons, Inc. is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about the privacy practices at General Surgeons please contact:

General Surgeons, Inc. (765) 962-6053

Attn: Cathy Jarvis csj@gsirichmond.com

1250 Chester Blvd.

Richmond, IN 47374

1. How General Surgeons may Use or Disclose Your Health Information

General Surgeons collects health information from you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of General Surgeons, but the information in the medical record belongs to you. General Surgeons protects the privacy of your health information. The law permits General Surgeons to use or disclose your health information for the following purposes:

1. Treatment. We will use and disclosed 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 your permission to have access to your protected health information. For example, we will disclose protected health information to other physicians who may be treating you when we the necessary permission from you to disclose your protected health information. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you.

2. Payment. Your protected health information will be used, as needed, to obtain payment for your health care services. This may included 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 surgery may require that your relevant protected health information be disclosed to the health plan to obtain approval for the surgery.

3. Regular 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. The activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing activities, and conducting or arranging for other business activities.

For example, we may disclose your protected health information to medical school students that see patients at our office. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary to contact you to remind you of your appointment. We will share you protected health information with third party "business associates" that perform various activities (e.g. transcription, services, billing) 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.

4. Information provided to you.

5. Notification and communication with family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

6. Required by law. As required by law, we may use and disclose your health information.

7. Public health. As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.

8. Health oversight activities. We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings.

9. Judicial and administrative proceedings. We may disclose your health information in the course of any administrative or judicial proceeding.

10. Law enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying of locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.

11. Deceased person information. We may disclose your health information to coroners, medical examiners and funeral directors.

12. Organ donation. We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

13. Research. We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board or General Surgeons’ privacy board.

14. Public safety. We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

15. Specialized government functions. We may disclose your health information for military, national security, prisoner and government benefits <only for health plans> purposes. <Note that disclosures for government benefits purposes are limited to health plans only.>

16. Worker’s compensation. We may disclose your health information as necessary to comply with worker’s compensation laws.

17. Marketing. We may contact you to provide appointment reminders or to give you information about other treatments or health-related benefits and services that may be of interest to you.

18. Change of Ownership. In the event that General Surgeons is sold or merged with another organization, your health information/record will become the property of the new owner.

Except as described in this Notice of Privacy Practices, General Surgeons will not use or disclose your health information without your written authorization. If you do authorize General Surgeons to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

1. You have the right to request restrictions on certain uses and disclosures of your health information. General Surgeons is not required to agree to the restriction that you requested.

2. You have the right to receive your health information through a reasonable alternative means or at an alternative location. <Add information re: requests in writing; specification of method; payment for method, as applicable.>

3. You have the right to inspect and copy your health information.

4. You have a right to request that General Surgeons amend your health information that is incorrect or incomplete. General Surgeons is not required to change your health information and will provide you with information about General Surgeons’ denial and how you can disagree with the denial.

5. You have a right to receive an accounting of disclosures of your health information made by General Surgeons, except that General Surgeons does not have to account for the disclosures described in parts 1 (treatment), 2 (payment), 3 (health care operations), 4 (information provided to you), and 15 (certain government functions) of section I of this Notice of Privacy Practices.

6. You have a right to a paper copy of this Notice of Privacy Practices.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact Cathy Jarvis at (765) 962-6053.

General Surgeons reserves the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, General Surgeons is required by law to comply with this Notice.

Complaints about this Notice of Privacy Practices or how General Surgeons’ handles your health information should be directed to:

General Surgeons, Inc.

Attn: Cathy Jarvis

1250 Chester Blvd.

Richmond, IN 47374

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: