PATIENT NOTICE OF PRIVACY PRACTICES

EFFECTIVE DATE: June 26, 2009

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

I. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

Your health record is the physical property of Blue Bell Surgery Center. The information contained in the record, however, belongs to you. You have the right to:

A. Request a restriction or limitation on the medical information we use or disclose about you for your treatment, payment or health care operations. For example, you may request that a particular procedure be kept confidential and not shared with other providers. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend or when we notify a family member, personal representative or other person responsible for your care to inform them of your location and general condition. We are not required to agree to your requested restrictions. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

B. Obtain a copy of this Notice by requesting one from the administrator of the surgery center.

C. Inspect and obtain a copy of your health care record by submitting a request in writing to the administrator of the surgery center.

D. Amend your healthcare record if you feel that medical information that we have about you is incorrect or incomplete by requesting, in writing, that an amendment be made. You must provide a reason that supports your request.

E. Obtain a report of all of the disclosures of your health information that we have made.

F. Request that we communicate with you about your medical information in a certain way or at a certain location within reasonable limits.

G. Revoke your authorization to use and disclose medical information about you, except to the extent that we have already used or disclosed your medical information.

II. OUR RESPONSIBILITIES REGARDING YOUR MEDICAL INFORMATION

We are required by law to:

A. Maintain the privacy of your health information.

B. Provide you with this Notice, which describes our legal duties and privacy practices with respect to information we collect about you and a revised copy of the Notice if it is amended or otherwise changes.

C. Abide by the terms of this Notice.

D. Notify you if we are unable to agree to a requested restriction.

E. Accommodate reasonable requests that you have made to have us communicate your health information to you in a certain way or at a certain location.

WE RESERVE THE RIGHT TO CHANGE THIS NOTICE. We reserve the right to make the revised and changed notice effective for medical information that 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 the surgery center. The notice will contain the effective date on the first page. Each time you register at the surgery center for health care services, we will offer you a copy of the current notice in effect.

III. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

Each time you visit us, a record of your visit is made. We may use or disclose the health information contained in this record to certain employees and staff members of the surgery center or certain persons or entities outside the surgery center in certain situations without first obtaining your authorization. The following categories describe the different ways that we may use and disclose your medical information. We must obtain your prior written authorization before using or disclosing your medical information in all other situations which are not listed below.

A. Treatment. We may use medical information about you to provide you with medical treatment and services. We may disclose medical information about you to doctors, nurses, technicians, or other surgery center personnel who are involved in taking care of you at the surgery center.

For example, information obtained by a nurse, physician, or other member of your health care team will be recorded in your medical record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health team. Members of your health care team will then record the actions that they took and their observations. By reading your medical record, the physician will know how you are responding to treatment.

B. Payment. We may use and disclose medical information about you so that the treatment and services you receive at the surgery center may be billed to and payment may be collected from you, an insurance company, or third party.

For example, we may need to give your insurance company information about surgery you received at the surgery center so that the insurance company will pay us or reimburse you for the surgery.

C. Health Care Operations. We may use and disclose medical information about you for the operations of the surgery center.
For example, members of the medical staff, the risk manager or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will be used in a way to improve the quality and effectiveness of the healthcare and services that we provide.

D. Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the surgery center.

E. Treatment Alternatives. We may use and disclose medical information about you to contact you about or recommend possible treatment options or alternatives that may be of interest to you.

F. Health-Related Benefits and Services. We may use and disclose your medical information to inform you about health-related benefits or services that may be of interest to you.

G. Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care. We must inform you that we are going to use or disclose your information for this purpose and provide you with an opportunity to agree to, restrict or object to the disclosure or use.

H. Notification. We may use or disclose your medical information to notify or assist in notifying a family member, personal representative, or other person responsible for your care of your location and general condition. We must inform you that we are going to use or disclose your information for this purpose and provide you with an opportunity to agree to, restrict or object to the disclosure or use.

I. As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law.

J. Avert Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. The surgery center, however, will only disclose the information to someone able to help prevent the threat.

K. Organ and Tissue Donation. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

L. Business Associates. Some of the services provided at the surgery center are provided by business associates. For example, we contract with certain laboratories to perform lab tests. When we contract for these services, we may disclose your health information to our business associates so that they can perform the job we have hired them to do. To protect your health information, we require our business associates to appropriately safeguard your information.

M. Workers' Compensation. We may release medical information about you to the extent authorized and to the extent necessary to comply with the laws relating to workers' compensation or other similar programs established by law.

N. Public Health Risks. As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

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

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

Q. Law Enforcement. We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

R. Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner for purposes of identifying a deceased, determining a cause of death, or other duties authorized by law. We may also disclose health information to funeral directors consistent with applicable law to carry out their duties.

S. Food and Drug Administration. We may disclose to the FDA health information related to adverse events with respect to food, supplements, products and product defects, or post marketing surveillance information or to enable product recalls, repairs, or replacement.

T. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.

U. Victims of Abuse, Neglect or Domestic Violence. We may release medical information to a government authority if we reasonably believe that you are a victim of abuse, neglect or domestic violence, to the extent authorized or required by law. We must inform you or your personal representative that we have disclosed information for this purpose unless we believe that telling you or your personal representative would place you in risk of serious harm or otherwise not be in your best interest.

V. Child Abuse. We may release medical information to a government authority authorized by law to receive reports of child abuse or neglect.

IV. OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only upon a specific written authorization that you provide to us. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. The revocation, however, will not have any effect on any action the surgery center took before it received the revocation.

V. QUESTIONS OR COMPLAINTS

If you have questions and would like additional information, you may contact
Vicki R. Edelman, RN BSN, Administrator, 610-862-9565, at the surgery center.

If you believe your privacy rights have been violated, you can submit a written complaint describing the circumstances surrounding the violation to Vicki R. Edelman, RN, BSN, Administrator, 610-862-9565, at the surgery center or to the Secretary of Health and Human Services in Washington, D.C. You will not be penalized for filing any complaint.