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AMERICAN KIDNEY STONE MANAGEMENT, LTD. NOTICE OF PRIVACY PRACTICES
(Revised February 26, 2014)

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

American Kidney Stone Management, Ltd. (“AKSM”) understands that your protected health information (“PHI”) is very important to you and we are committed to protecting it. In order to provide you with quality care and to comply with legal requirements, on occasion we do use and disclose your PHI. This notice will describe how and when we use your PHI. We are legally required to give you this Notice and to follow the terms of this Notice that are currently in effect. We are also obligated to notify you following a breach of unsecured PHI. This Notice only applies to the privacy practices of AKSM. Your physicians and/or procedure facilities may have different privacy practices and may give you other privacy notices. If you are under eighteen (18) years of age, your parent, guardian or other responsible party may be required to sign for and handle your privacy rights for you.

HOW AKSM MAY USE OR DISCLOSE YOUR PHI. In certain situations described in the following section, AKSM must obtain your written authorization to use or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:

  1. For Treatment: We may use and disclose your PHI to provide you with treatment and services. For example, we may disclose your PHI to other health care providers involved in your treatment.

  2. Payment/Insurance: We may use and disclose your PHI to bill and obtain payment for the services we provide you. For example, we may give information to your health insurer to verify that it will pay for your health care.

  3. For Health Care Operations: We may use and disclose your PHI for our health care operations, which include internal administration and planning and activities that improve the quality and cost effectiveness of the care we deliver to you. For example, we may use your PHI to evaluate the performance of our staff in caring for you and in connection with quality assessment and improvement initiatives. We may also disclose PHI to your other health care providers when such PHI is required to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities or health care fraud and abuse compliance.

  4. Disclosure to Relatives and Other Caregivers: We may use and disclose your PHI to a family member or other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure. If you are not present, or the opportunity to agree or object to a use or disclosure of PHI cannot practically be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interest.

  5. Legal Matters:We will give out PHI about you when required to do so by federal, state, or local law. We may disclose PHI about you for public health reasons for the purpose of preventing or controlling disease, injury or disability. We may give out PHI to a health oversight agency authorized by law, such as for audits, investigations, inspections, and licensure.

  6. Health or Safety: We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

  7. Research: We may use or disclose your PHI for medical research if a special review process determines that your privacy is protected.

USE AND DISCLOSURES OF PHI REQUIRING YOUR WRITTEN AUTHORIZATION. We must obtain your written authorization for most uses and disclosures of psychotherapy notes (which AKSM does not use), uses and disclosures of PHI for marketing purposes, and disclosures that constitute the sale of PHI. Additionally, other uses and disclosures of PHI not described in this Notice will be made only when you give us your written permission on an authorization form. For example, you will need to complete and sign an authorization form before we can send your PHI to your life insurance company or to your attorney. You may withdraw (revoke) your authorization by delivering a written statement to the Privacy Officer identified below.

YOUR RIGHTS REGARDING YOUR PHI. This section explains your rights and some of our responsibilities. Please submit any requests related to your rights below in a signed, dated writing to the Privacy Officer at the address at the end of this notice.

  1. Right to Inspect and Copy: You have the right to inspect and obtain a copy of PHI that we maintain in a designated record set. Under limited circumstances, we may deny you access to a portion of your records. We may charge a cost based fee, consistent with applicable law, for processing your request.

  2. Right to Amend: If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend this information if you tell us the reason for the request. We may deny your request for amendment if we believe the information that would be amended is accurate and complete or other special circumstances apply. If we do, we will tell you why in writing in 60 days and explain your options.

  3. Right to an Accounting of Disclosures: You may request a list of the times we have shared your PHI (“accounting of disclosures”) for six years prior to the date you asked (except for those about treatment, payment and health care operations), who we shared it with and why. We will give you the first listing within any 12-month period free, but we will charge you a reasonable cost based fee, consistent with applicable law, for all other accountings requested within the same 12 months.

  4. Right to Request Additional Restrictions: You have the right to ask us to restrict the uses or disclosures we make of your PHI (1) for treatment, payment, or healthcare operations and (2) to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you have the right to request that we not disclosure your PHI to a health plan for payment or health care operations purposes, if that PHI pertains solely to a health care item or service for which we have been involved and which has been paid out of pocket in full. Unless otherwise required by law, we are required to comply with your request for this type of restriction. For all other requests for restrictions on use and disclosures of your PHI, we are not required to agree to your request, but will attempt to accommodate reasonable requests when appropriate. We will tell you if we agree with your request or not.

  5. Right to Request Confidential Communications: You have the right to request that we communicate with you in a specific way (for example, home or office phone) or to send mail to a different address. We will agree to all reasonable requests.

  6. Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice even if you have agreed to receive this Notice electronically. We will provide you with a paper copy promptly following your request to the Privacy Officer.

  7. Further Information; Complaints: If you would like more information about your privacy rights, if you are concerned that we have violated your privacy rights, or if you disagree with a decision that we made about access to your PHI, you may contact our Privacy Officer. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Officer will provide you with the correct address for the Director. We will not retaliate against you for filing a complaint.

CHANGES TO THIS NOTICE. The effective date of the Notice is on the first page. AKSM may change this Notice at any time. Any change in the Notice could apply to PHI we already have about you, as well as any information we receive in the future. If we change this Notice, we will post a copy of the current Notice on our web site, www.aksm.com. You may also obtain any new notice by contacting the Privacy Officer.

PRIVACY OFFICER. If you have any questions about this Notice, you may contact the Privacy Officer at: Privacy Officer, AKSM, Ltd., 100 W. Third Ave., Suite 350, Columbus, OH 43201 Phone: 614-298-8150.