HIPAA NOTICE OF PRIVACY PRACTICES

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XPRESS ORTHO CARE

Effective Date: February 1, 2017

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION

PLEASE REVIEW IT CAREFULLY

If you have any questions about this notice, please contact: HIPAA Information, Xpress Ortho Care, 875 Joliet Street, Dyer, IN 46311, (219) 233-2344.

WHO WILL FOLLOW THIS NOTICE:

This notice describes Xpress Ortho Care’s (“XOC”) privacy practices. All XOC clinics, entities, sites, and locations follow the terms of this notice. In addition, these clinics, entities, sites, and locations may share health information with each other for treatment, payment, or health care operations purposes described in this notice.

OUR PLEDGE REGARDING HEALTH INFORMATION:

XOC understands that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor, counselor or other staff members working in this office. This notice will tell you about the ways in which XOC may use and disclose health information about you. This notice also describes your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

XOC is required by law to:

  • make sure that health information that identifies you is kept private;
  • give you this notice of our legal duties and privacy practices with respect to health information about you; and
  • follow the terms of the notice that are currently in effect.

HOW XOC MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that XOC uses and discloses health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed; however, all of the ways we are permitted to use and disclose information will fall within one of the categories. Confidentiality rights for our patients are described in detail in the “Notice of Privacy Practices” form. In all cases, the written “Client Rights and Informed Consent” form takes precedent over the information posted on our website.

For Treatment. XOC may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices, at the hospital if you are hospitalized under our supervision, or at another doctor’s office, lab, pharmacy, or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We may also disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

If you transfer your care from our entities to another provider of care, we will ask that you fill out a request for release of information form.

For Payment. XOC may use and disclose health information about you so that the treatment and services you receive from us may be billed to, and payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. XOC may use and disclose health information about you for the operation of our health care practice. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services, and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning who our specific patients are.

Appointment Reminders. XOC may use and disclose health information to contact you as a reminder that you have an appointment. We will disclose as little health information as possible within this reminder. Be sure to inform your nearest XOC location of your correct contact information. This information should also be current on our confidential electronic medical records system.

Health-Related Services and Treatment Alternatives. With advance approval from you, XOC may use and disclose health information to tell you about health-related services, or recommend possible treatment options or alternatives that may be of interest to you. Please let us know if you do not wish us to send you this information, or if you wish to have us use a different address to send this information to you.

As Required By Law. XOC will disclose health information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety. XOC may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Military and Veterans. If you are a member of the armed forces or separated/discharged from military services, XOC may release health information about you as required by military command authorities, or the Department of Veterans Affairs, as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.

Workers’ Compensation. XOC may release health information about you to your employer’s workers’ compensation insurance carrier for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. XOC may disclose health information about you for public health activities.

These activities generally include the following:

  • to prevent or control disease, injury or disability;
  • to report deaths;
  • to report child abuse or neglect;
  • to report reactions to medications, or problems with products;
  • to notify people of recalls of products they may be using;
  • to notify a person or organization required to receive information on FDA-regulated products;
  • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree, or when required or authorized by law.

Health Oversight Activities. XOC may disclose health information to a health oversight agency for activities as authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, XOC may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. XOC may release health information if asked to do so by a law enforcement official:

  • in reporting certain injuries, as required by law, such as gunshot wounds, burns, or injuries to perpetrators of crime;
  • in response to a court order, subpoena, warrant, summons or similar process;
  • to identify or locate a suspect, fugitive, material witness, or missing person;
  • about a victim of a crime, if the victim agrees to disclosure, or under certain limited circumstances, if we are unable to obtain the person’s agreement;
  • about a death we believe may be the result of criminal conduct;
  • about criminal conduct at our facility; and
  • in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

Coroners, Health Examiners and Funeral Directors. XOC may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. XOC may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. XOC may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, XOC may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Research. XOC may use or disclose health information about you for the purposes of research, in accordance with the relevant federal HIPAA privacy regulations.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding health information XOC maintains about you:

Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billing records.

State law allows medical facilities to charge reasonable copying fees when information is requested for non-healthcare related purposes.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to HIPAA Information, Xpress Ortho Care, 875 Joliet Street, Dyer, IN 46311, (219) 233-2344. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that health information XOC has about you is incorrect or incomplete, you may ask XOC to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing, submitted to HIPAA Information, Xpress Ortho Care, 875 Joliet Street, Dyer, IN 46311, (219) 233-2344, and must be contained on one page of paper legibly handwritten or typed in at least 10 point font size. In addition, you must provide a reason that supports your request for an amendment.

XOC may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, XOC may deny your request if you ask us to amend information that:

  • was not created by XOC, unless the person or entity that created the information is no longer available to make the amendment;
  • is not part of the health information kept by or for our practice;
  • is not part of the information which you would be permitted to inspect and copy; or
  • is accurate and complete.

Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosures of your health information XOC has made, except for uses and disclosures for treatment, payment, and health care operations, as previously described.

To request this list of disclosures, you must submit your request in writing to HIPAA Information, Xpress Ortho Care, 875 Joliet Street, Dyer, IN 46311, (219) 233-2344. Your request must state a time period which may not be longer than six years and may not include dates before January 1, 2017.

The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information XOC uses or discloses about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we restrict a specified nurse from use of your information, or that we not disclose information to your spouse about a surgery you had.

XOC is not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance, or we believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to HIPAA Information, Xpress Ortho Care, 875 Joliet Street, Dyer, IN 46311, (219) 233-2344.. In your request, you must outline specifically what information you want to limit and to whom you want the limits to apply; for example, use of any information by a specified nurse, or disclosure of specified surgery to your spouse.

Right to Request Confidential Communications. You have the right to request that XOC communicates with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, or by mail to a post office box. To request confidential communications, you must make your request in writing to HIPAA Information, Xpress Ortho Care, 875 Joliet Street, Dyer, IN 46311, (219) 233-2344. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from HIPAA Information, Xpress Ortho Care, 875 Joliet Street, Dyer, IN 46311, (219) 233-2344, or download it here. We cannot respond to requests made electronically (i.e. email). We will not comply with your request for a paper copy of this notice if it is sent electronically.

CHANGES TO THIS NOTICE

XOC reserves the right to change this notice. XOC reserves the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain on the first page, in the top right-hand corner, the effective date. You may obtain a copy of the revised notice in effect upon your request.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with XOC or with the Secretary of the Department of Health and Human Services in the state in which you received services from XPRESS ORTHO CARE. To file a complaint with us, contact HIPAA Information, Xpress Ortho Care, 875 Joliet Street, Dyer, IN 46311, (219) 233-2344. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to XOC will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that XOC is unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE

Through your use of this website, you are agreeing that you have reviewed this statement in full and agree with all the terms contained herein. If you request a paper copy, we will request that you sign a separate form acknowledging you have received a copy of this notice. If you choose, or are not able to sign, a staff member will sign his/her name and insert the date. This acknowledgement will be filed with your records.

XPRESS ORTHO CARE

Effective Date: February 1, 2017

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION

PLEASE REVIEW IT CAREFULLY

If you have any questions about this notice, please contact: HIPAA Information, 3089 Maple Ave, Zanesville, OH 43701.

WHO WILL FOLLOW THIS NOTICE:

This notice describes Xpress Ortho Care’s (“XOC”) privacy practices. All XOC clinics, entities, sites, and locations follow the terms of this notice. In addition, these clinics, entities, sites, and locations may share health information with each other for treatment, payment, or health care operations purposes described in this notice.

OUR PLEDGE REGARDING HEALTH INFORMATION:

XOC understands that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor, counselor or other staff members working in this office. This notice will tell you about the ways in which XOC may use and disclose health information about you. This notice also describes your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

XOC is required by law to:

  • make sure that health information that identifies you is kept private;
  • give you this notice of our legal duties and privacy practices with respect to health information about you; and
  • follow the terms of the notice that are currently in effect.

HOW XOC MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that XOC uses and discloses health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed; however, all of the ways we are permitted to use and disclose information will fall within one of the categories. Confidentiality rights for our patients are described in detail in the “Notice of Privacy Practices” form. In all cases, the written “Client Rights and Informed Consent” form takes precedent over the information posted on our website.

For Treatment. XOC may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices, at the hospital if you are hospitalized under our supervision, or at another doctor’s office, lab, pharmacy, or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We may also disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

If you transfer your care from our entities to another provider of care, we will ask that you fill out a request for release of information form.

For Payment. XOC may use and disclose health information about you so that the treatment and services you receive from us may be billed to, and payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. XOC may use and disclose health information about you for the operation of our health care practice. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services, and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning who our specific patients are.

Appointment Reminders. XOC may use and disclose health information to contact you as a reminder that you have an appointment. We will disclose as little health information as possible within this reminder. Be sure to inform your nearest XOC location of your correct contact information. This information should also be current on our confidential electronic medical records system.

Health-Related Services and Treatment Alternatives. With advance approval from you, XOC may use and disclose health information to tell you about health-related services, or recommend possible treatment options or alternatives that may be of interest to you. Please let us know if you do not wish us to send you this information, or if you wish to have us use a different address to send this information to you.

As Required By Law. XOC will disclose health information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety. XOC may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Military and Veterans. If you are a member of the armed forces or separated/discharged from military services, XOC may release health information about you as required by military command authorities, or the Department of Veterans Affairs, as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.

Workers’ Compensation. XOC may release health information about you to your employer’s workers’ compensation insurance carrier for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. XOC may disclose health information about you for public health activities.

These activities generally include the following:

  • to prevent or control disease, injury or disability;
  • to report deaths;
  • to report child abuse or neglect;
  • to report reactions to medications, or problems with products;
  • to notify people of recalls of products they may be using;
  • to notify a person or organization required to receive information on FDA-regulated products;
  • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree, or when required or authorized by law.

Health Oversight Activities. XOC may disclose health information to a health oversight agency for activities as authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, XOC may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. XOC may release health information if asked to do so by a law enforcement official:

  • in reporting certain injuries, as required by law, such as gunshot wounds, burns, or injuries to perpetrators of crime;
  • in response to a court order, subpoena, warrant, summons or similar process;
  • to identify or locate a suspect, fugitive, material witness, or missing person;
  • about a victim of a crime, if the victim agrees to disclosure, or under certain limited circumstances, if we are unable to obtain the person’s agreement;
  • about a death we believe may be the result of criminal conduct;
  • about criminal conduct at our facility; and
  • in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

Coroners, Health Examiners and Funeral Directors. XOC may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. XOC may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. XOC may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, XOC may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Research. XOC may use or disclose health information about you for the purposes of research, in accordance with the relevant federal HIPAA privacy regulations.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding health information XOC maintains about you:

Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billing records.

State law allows medical facilities to charge reasonable copying fees when information is requested for non-healthcare related purposes.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to HIPAA Information, Xpress Ortho Care, 3089 Maple Ave, Zanesville, OH 43701. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that health information XOC has about you is incorrect or incomplete, you may ask XOC to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing, submitted to HIPAA Information, Xpress Ortho Care, 3089 Maple Ave, Zanesville, OH 43701, and must be contained on one page of paper legibly handwritten or typed in at least 10 point font size. In addition, you must provide a reason that supports your request for an amendment.

XOC may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, XOC may deny your request if you ask us to amend information that:

  • was not created by XOC, unless the person or entity that created the information is no longer available to make the amendment;
  • is not part of the health information kept by or for our practice;
  • is not part of the information which you would be permitted to inspect and copy; or
  • is accurate and complete.

Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosures of your health information XOC has made, except for uses and disclosures for treatment, payment, and health care operations, as previously described.

To request this list of disclosures, you must submit your request in writing to HIPAA Information, Xpress Ortho Care, 3089 Maple Ave, Zanesville, OH 43701. Your request must state a time period which may not be longer than six years and may not include dates before January 1, 2017.

The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information XOC uses or discloses about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we restrict a specified nurse from use of your information, or that we not disclose information to your spouse about a surgery you had.

XOC is not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance, or we believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to HIPAA Information, Xpress Ortho Care, 3089 Maple Ave, Zanesville, OH 43701. In your request, you must outline specifically what information you want to limit and to whom you want the limits to apply; for example, use of any information by a specified nurse, or disclosure of specified surgery to your spouse.

Right to Request Confidential Communications. You have the right to request that XOC communicates with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, or by mail to a post office box. To request confidential communications, you must make your request in writing to HIPAA Information, Xpress Ortho Care, 3089 Maple Ave, Zanesville, OH 43701. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from HIPAA Information, Xpress Ortho Care, 3089 Maple Ave, Zanesville, OH 43701, or download it here. We cannot respond to requests made electronically (i.e. email). We will not comply with your request for a paper copy of this notice if it is sent electronically.

CHANGES TO THIS NOTICE

XOC reserves the right to change this notice. XOC reserves the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain on the first page, in the top right-hand corner, the effective date. You may obtain a copy of the revised notice in effect upon your request.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with XOC or with the Secretary of the Department of Health and Human Services in the state in which you received services from XPRESS ORTHO CARE. To file a complaint with us, contact

HIPAA Information, Xpress Ortho Care, 3089 Maple Ave, Zanesville, OH 43701. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to XOC will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that XOC is unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE

Through your use of this website, you are agreeing that you have reviewed this statement in full and agree with all the terms contained herein. If you request a paper copy, we will request that you sign a separate form acknowledging you have received a copy of this notice. If you choose, or are not able to sign, a staff member will sign his/her name and insert the date. This acknowledgement will be filed with your records.