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

If you have any questions about this notice, please call 713-885-9899 and ask to speak with the Patient Relations Department.

OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the hospital and clinic. 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 in the hospital and clinic, whether made by hospital/clinic personnel or your treating doctor.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Make sure that medical information that identifies you is kept private
• Give you this notice of our legal duties and privacy practices with respect to medical information about you
• Follow the terms of the notice that is currently in effect

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe several different ways that we use and disclose medical 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.

For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other hospital/clinic personnel who are involved in taking care of you. 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. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital or clinic also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. With your permission, we also may disclose medical information about you to individuals outside the facility who may be involved in your care.

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

For Hospital/Clinic Operations: We may use and disclose medical information about you for hospital/clinic operations. These uses and disclosures are necessary to run the hospital/clinic and make sure that all of our patients receive quality care. For example, we may use medical information to review the treatment and services in order to check on the performance of our staff in caring for you. We may also combine medical information about many hospital or clinic patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other hospital/clinic personnel for review and learning purposes. We may also combine the medical information we have with medical information from other health care providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

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 facility.

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

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

Hospital Directory: We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital and your general condition (e.g., fair, stable, etc.). If you give us your religious affiliation, this information would be included in the hospital directory. The directory information, but not your religious affiliation, may also be released to people who ask for you by name. This is so your family and friends can visit you in the hospital and generally know how you are doing.

Individuals Involved in Your Care: We may discuss medical information about you with a friend or family member who is involved in your medical care. We may also tell your family or friends your condition and that you are in the hospital. In addition, we may disclose medical 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.

Research: Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with people’s need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave our institution.

As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law. Example, law about reporting deaths.

To Avert a 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 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.

SPECIAL SITUATIONS

Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability
• To report births and deaths
• To report child abuse or neglect
• To report reactions to medications or problems with products
• To report elder and adult abuse, neglect and/or exploitation
• To notify people of recalls of products they may be using
• 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 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: 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. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil right laws.

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 or in the defense of a malpractice claim arising out of care provided by us. We may disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

Coroner, Medical Examiners and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identity a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to enable them to carry out their duties.

Law Enforcement: We may release medical information if asked by a law enforcement official for the following reasons:

• In response to a court order, subpoena, warrant, summons or similar process
• Limited information to identify or locate a suspect, fugitive, material witness, or missing person
• About the victim of a crime if, under certain limited circumstances, 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 the hospital or clinic
• 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

National Security and Intelligence Activities: We may release medical 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: We may disclose medical 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, we may release medical information about you to the correctional institution or law enforcement official. This release would be if 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) the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information that we maintain about you:

Right to Inspect and Copy: You have the right to inspect and request copies of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and receive copies of medical information that may be used to make decisions about you, you must submit your request in writing to:

Avanta Health Professionals
1302 N. Shepherd
Houston, TX 77008

If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the facility 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 medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the facility.

To request an amendment, your request must be made in writing and submitted to:

Avanta Health Professionals
1302 N. Shepherd
Houston, TX 77008

In addition, you must provide a reason that supports your request.

We 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, we may deny your request if you ask us to amend information:

• Not created by us
• Not part of the medical information kept by or for the hospital/clinic
• Not part of the information which you would be permitted to inspect and copy
• Information which is accurate and complete

Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you.

To request this list or accounting of disclosures, you must submit your request in writing to:

Avanta Health Professionals
1302 N. Shepherd
Houston, TX 77008

Your request must state a time period, which may not be longer than six years and may not include dates before February 26, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). 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.

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or hospital/clinic operations. 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. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to:

Avanta Health Professionals
1302 N. Shepherd
Houston, TX 77008

In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) what you want to limit, for example, disclosure to your spouse.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical 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 request confidential communications, you must make your request in writing to:

Avanta Health Professionals
1302 N. Shepherd
Houston, TX 77008

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 a paper copy of this notice. You may ask us to give you a copy of the notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, contact:

Avanta Health Professionals
1302 N. Shepherd
Houston, TX 77008

CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical 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 the hospital and clinic. The written notice will contain on the first page, in the top right-hand corner, the effective date. The effective date is listed under the main title of this electronic document.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with our institution or with the Secretary of the Department of Health and Human Services. To file a complaint with Avanta Health Professionals, contact:

Avanta Health Professionals
1302 N. Shepherd
Houston, TX 77008

All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

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 with your written permission. If you provide us permission to use or disclose medical 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 medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we already made with your permission, and that we are required to retain our records of the care that we provided to you.

WHO MUST FOLLOW THIS NOTICE
This notice describes our hospital’s and clinic’s practices and those of:

• Any health care professional authorized to enter information into your hospital/clinic chart
• All departments and units of the hospital and clinic
• Any member of a volunteer group we allow to help you while you are in the hospital
• All employees, staff and other hospital/clinic personnel

In addition, these entities, sites and locations may share medical information with each other for treatment, payment or hospital/clinic operations purposes described in this notice.