Comprehensive In-Home
Geriatric Medical Assessments
for Seniors and Their Families

Geriatrics Consulting Services HIPAA NOTICE OF PRIVACY PRACTICES Effective Date April 28, 2003

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU, AS A PATIENT OF GERIATRICS CONSULTING SERVICES OF GREENSBORO, P.A. (GCS) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

GCS is dedicated to maintaining the privacy of your individually identifiable, protected health information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in GCS concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

How we may use and disclose your PHI? Your privacy rights in your PHI? Our obligations concerning the use and disclosure of your PHI:

The terms of this notice apply to all records containing your PHI that are created or retained by GCS. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that GCS has created or maintained in the past, and for any of your records that we may create or maintain in the future. You may request a copy of our most current Notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Dr. Michele A. Haber, PO Box 4529, Greensboro, NC 27404, Phone: 336-292-7622.

C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS.

The following categories describe the different ways in which we may use and disclose your PHI.

1. Treatment. GCS may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.

2. Payment. GCS may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

3. Health Care Operations. GCS may use and disclose your PHI to operate our business. For example, GCS may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for GCS. We may disclose your PHI to other health care providers and entities to assist in their health care operations.

4. Release of Information to Family/Friends. GCS may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you.

5. Disclosures Required By Law. GCS will use and disclose your PHI when we are required to do so by federal, state or local law.

D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public Health Risks. GCS may disclose your PHI to public health authorities that are authorized by law to collect information for purposes such as: maintaining vital records, such as births and deaths; reporting child abuse or neglect; preventing or controlling disease, injury or disability; notifying a person regarding potential exposure to a communicable disease; notifying a person regarding a potential risk for spreading or contracting a disease or condition; reporting reactions to drugs or problems with products or devices; notifying individuals if a product or device they may be using has been recalled; notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information; notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health Oversight Activities. GCS may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. GCS may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain a court or administrative order protecting the information the party has requested.

4. Law Enforcement. We may release PHI if asked to do so by a law enforcement official: regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement; concerning a death we believe has resulted from criminal conduct; in response to a warrant, summons, court order, subpoena or similar legal process; to identify/locate a suspect, material witness, fugitive or missing person; in an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

8. Serious Threats to Health or Safety. GCS may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

9. Military. GCS may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

10. National Security. GCS may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

11. Inmates. GCS may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

12. Workers Compensation. GCS may release your PHI for workers compensation and similar programs.

E. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding the PHI that we maintain about you:

1. Confidential Communications. You have the right to request that GCS communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Dr. Michele A. Haber, PO Box 4529, Greensboro, NC 27404 specifying the requested method of contact, or the location where you wish to be contacted. GCS will accommodate reasonable requests. You do not need to give a reason for your request.

2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Dr. Michele A. Haber, PO Box 4529, Greensboro, NC 27404. Your request must describe in a clear and concise fashion:

(a) the information you wish restricted; (b) whether you are requesting to limit GCSs use, disclosure or both; and (c) to whom you want the limits to apply.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Dr. Michele A. Haber, PO Box 4529, Greensboro, NC 27404 in order to inspect and/or obtain a copy of your PHI. GCS may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. GCS may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for GCS. To request an amendment, your request must be made in writing and submitted to Dr. Michele A. Haber, PO Box 4529, Greensboro, NC 27404. You must provide us with a reason that supports your request for amendment. GCS will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by GCS, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain non- routine disclosures GCS has made of your PHI for non- treatment, non-payment or non-operations purposes. Use of your PHI as part of the routine patient care in GCS is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Dr. Michele A. Haber, PO Box 4529, Greensboro, NC 27404. All requests for an accounting of disclosures must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but GCS may charge you for additional lists within the same 12-month period. GCS will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Dr. Michele A. Haber, Phone: 336-292-7622.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with GCS or with the Secretary of the Department of Health and Human Services. To file a complaint with GCS, contact Dr. Michele A. Haber, PO Box 4529, Greensboro, NC 27404. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to Provide an Authorization for Other Uses and Disclosures. GCS will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the purposes described in the authorization. Please note, we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact Dr. Michele A. Haber MD