Urology Centers of Alabama

Privacy Policy

HIPAA 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 Carefully
UROLOGY CENTERS OF ALABAMA, P.C., (“PC”)

is required to maintain the privacy of your protected health information and to provide you with notice of our legal duties
and privacy practices with respect to your protected health information. We will not use, release or disclose your health
information except as described in this Notice of Privacy Practices (“Privacy Notice” or “Notice”), unless specifically
authorized by you in writing. We are also required by law to notify you following a breach of unsecured protected health
information. In providing professional medical services to you, we will create, maintain, and store your protected health
information.

WHAT HEALTH INFORMATION IS PROTECTED

We are committed to protecting the privacy of health information we gather about you while providing health-related services.
Some examples of protected health information are information about your health condition; information about health care
services you have received or may receive in the future; information about your health care benefits under an insurance
plan; geographic information; demographic information; unique numbers that may identify you; and other types of information
that may identify who you are.

EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS

The following categories describe the ways that we may use, release, and disclose your health information for treatment,
payment, and health care operations without the need for a signed authorization from you.

Treatment

We will use your protected health information in the provision and coordination of your health care. For example, we may
disclose all or any portion of your medical record information as part of your care and continued treatment to your attending
physician and other health care providers who have a legitimate need for such information.

Family/Friends

The PC may release protected health information about you to a friend or family member who is involved in your medical
care. We may also give information to someone who helps pay for your care, and we may also tell your family or friends
of your condition and that you are at the PC. We will give you an opportunity to agree or object to these disclosures.

Payment

The PC may release protected health information about you for the purposes of determining coverage, billing, claims management,
medical data processing, and reimbursement. For example, the information may be released to an insurance company, third
party payor or other entity (or their authorized representatives) involved in the payment of your medical bill and may
include copies of your medical record needed to pay your account.

Healthcare Operations

The PC may use and disclose your protected health information during routine healthcare operations. These operations may
include quality assurance, utilization review, medical review, internal auditing, accreditation, certification, licensing
or credentialing activities, management and administration of the PC, and educational purposes.

Appointment Reminders

The PC may use and disclose protected health information to contact you via phone, email or text to remind you that have
an appointment for treatment, medical care or follow-up at the PC and may leave a message for you at the number that PC
has listed for you.

The Practice may also use and disclose your protected health information without your authorization for the following purposes:
Health Related Business, Services and Treatment Alternatives

– Your medical information may be used or disclosed to tell you of health-related benefits or services provided by the
PC that may be of interest to you and your particular medical condition.

Alternatives

– Your medical information may be used or disclosed via phone, email or text to tell you of health-related benefits or
services provided by the PC that may be of interest to you and your particular medical condition.

Regulatory Agencies

– Your medical information may be disclosed to a health oversight agency for activities authorized by law including, but
not limited to, licensure, certification, audits, investigations and inspections.

Law Enforcement/Litigation

– Your medical information may be disclosed to a law enforcement official for law enforcement purposes as required by law
or in response to a valid subpoena or court order.

Public Health

– Your medical information may be disclosed to public health or legal authorities charged with preventing or controlling
disease, injury or disability.

Serious Threat to Health or Safety

– Your medical information may be used or disclosed to reduce or prevent a serious threat to your health and safety or
the health and safety of another individual or the public.

Military/Veterans/National Security

– Your medical information may be disclosed, as required by military command authorities, if you are a member of the armed
forces. In addition, the PC may disclose your medical information to federal officials for intelligence and national security
activities authorized by law.

Required by Law

– Your medical information may be used or disclosed when required to do so by law.

Coroners, Medical Examiners, Funeral Directors

– Your medical information may be disclosed to a coroner, medical examiner, or to funeral directors as necessary to carry
out their duties.

Research

– Your medical information may be used or disclosed for research purposes in certain limited circumstances.

Workers Compensation

– Your medical information may be used or disclosed to release medical information about you for workers’ compensation
or similar programs as required under Alabama law.

YOUR AUTHORIZATION IS NEEDED FOR OTHER USES AND DISCLOSURES

We will not use or disclose your health information for any other purpose not described in this Notice unless you give us written
authorization to do so. A signed authorization is necessary for most uses and disclosures related to psychotherapy notes
(where appropriate). Uses and disclosures of protected health information for marketing purposes and disclosures that constitute
a sale of protected health information also require an authorization. If you give us written authorization to use or disclose
your health information for a purpose that is not described in this Notice, then you may revoke it in writing at any time.
Your revocation will be effective for all your health information that we maintain, unless we have taken action in reliance
on your authorization. We may engage in fundraising activities from time to time. You have the right to opt out of receiving
any communications from us regarding fundraising.

YOUR INDIVIDUAL RIGHTS

You have the following rights concerning your medical information. Please note that to exercise any of the privacy rights described
below, you must complete a written request and send it to the PC’s Privacy Officer at

UROLOGY CENTERS OF ALABAMA, P.C.

You have the right to:

  1. Request that the PC communicate with you about your health and related issues in a particular manner or at certain locations;
  2. Inspect and copy your health record as provided by the HIPAA Privacy Rule in 45 C.F.R. § 164.524;
  3. Obtain an accounting of the use or disclosure of your health information as provided in 45 C.F.R. § 164.528;
  4. Request restrictions on certain uses and disclosures of your medical information. The PC may not agree to honor your request
    for restrictions. We are not required to agree to your request for a restriction, and in some cases the restriction
    you request may not be permitted under law. If we do agree to your request to restrict the use and disclosure of health
    information, we will be bound by our agreement unless the information is needed to provide you with emergency treatment
    or comply with the law. Please note that we must agree to your request to restrict disclosure of your health information
    to a health plan if (a) the request is for the purpose of carrying out payment or health care operations and is not
    otherwise required by law; and (b) the information pertains solely to a health care item or service for which you have
    already paid us in full.
  5. Receive a paper copy of this Privacy Notice, upon request;
  6. Revoke any authorization allowing the PC to use or disclose your medical information except to the extent that action has
    already been taken by the PC; and
  7. Amend your health record as provided in 45 C.F.R. § 164.526.
  8. FOR MORE INFORMATION OR TO REPORT A PROBLEM: If you have questions and would like additional information or if you believe
    your privacy rights have been violated, please contact our Privacy Officers, Paula McContha or Wayne Spainhoward at
    205-930-0920 or at 3485 Independence Drive, Homewood, Alabama 35209. All complaints must be submitted in writing. There
    will be no retaliation for filing a complaint or expressing a concern. You may also file a complaint with to the Region
    IV, Office of Civil Rights, Department of Health and Human Services, Sam Nunn Atlanta Federal Center, Suite 16T70,
    61 Forsyth Street, SW., Atlanta, GA 30303-8909. Voice Phone 800-368-1019, Fax 404-562-7881, TDD 800-537-7697 or via
    http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html.

CHANGES TO THIS NOTICE: The PC reserves the right to change the terms of its Privacy Notice and to make the new Notice provisions
effective for all individually identifiable health information that it maintains.

EFFECTIVE DATE: The effective date of the Privacy Notice is September 14, 2015.

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