Privacy Practices

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NOTICE OF PRIVACY PRACTICES AND AUTHORIZATION FORM

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND AUTHORIZES THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI). THIS NOTICE ALSO DESCRIBES HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

ResponsiCare, Inc. is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have any questions about any part of this notice, or you want more information about the privacy practices at ResponsiCare, Inc. Facilities, please contact our privacy officer:

Dale J. Anderson,J.D., Privacy Officer
2424 Danville Rd, Suite K
Decatur, AL 35603
(256)355-0555

Effective date of this notice: May 3, 2004

I. How ResponsiCare, Inc. May Use or Disclose Your Health Information
ResponsiCare, Inc. collects health information from you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of ResponsiCare, Inc., but the information in the medical record belongs to you. ResponsiCare Inc. protects the privacy of your health information. The law permits ResponsiCare, Inc. to use or disclose your health information for the following purposes:

1. TREATMENT
2. PAYMENT
3. REGULAR HEALTH CARE OPERATIONS
4. INFORMATION PROVIDED TO YOU
5. NOTIFICATION AND COMMUNICATION WITH FAMILY We may disclose your health information to notify/assist in notifying a family member, your personal representative, or other party responsible for your care regarding your location, your general condition, or in the event of your death. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are not able or are unavailable to agree or object, our health professionals/staff
   will utilize their best judgment in communication with your family and others, as applicable.
6. REQUIRED BY LAW As required by law, we may use and disclose your health information.
7. PUBLIC HEALTH As required by law, we may disclose your health information to public health authorities for the purposes related to preventing or controlling disease, injury, or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the FDA, and reporting disease and/or infectious exposure.
8. HEALTH OVERSIGHT ACTIVITIES We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure, and proceedings.
9. JUDICIAL AND ADMINISTRATIVE PROCEEDINGS We may disclose your health information in the course of any administrative or judicial proceedings.
10. LAW ENFORCEMENT We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness, or missing person, complying with a court order or subpoena, and other law enforcement purposes.
11. DECEASED PERSON INFORMATION We may disclose your health information to Coroners, Medical Examiners, and Funeral Directors
12. ORGAN DONATION We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and/or tissues.
13. RESEARCH We may disclose your health information to researchers conducting research that has been approved by an institutional review board.
14. PUBLIC SAFETY We may disclose your health information to appropriate authorities in order to prevent or mitigate a serious or imminent threat to the health or safety of a person or the general public.
15. SPECIALIZED GOVERNMENT FUNCTIONS We may disclose your health information for military, national security, prisoner, and government benefits (only for health plans) purposes.
16. WORKER’S COMPENSATION We may disclose your health information as necessary to comply with worker’s compensation laws.
17. MARKETING We may contact you to provide appointment reminders or to give you information about other treatments or health-related benefits that may be of interest to you (we will not sell or disclose information to a third party for marketing purposes).
18. CHANGE OF OWNERSHIP In the event that ResponsiCare, Inc. is sold or is merged with another organization, your health information/records will become the property of the new owner.

II. When ResponsiCare, Inc. May Not Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, ResponsiCare, Inc. will not use or disclose your health information without your written authorization. If you do authorize ResponsiCare Inc. to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

III. Your Health Information Rights

1. You have the right to request restrictions on certain uses and disclosures of your health information. However, ResponsiCare is not required to agree to the restrictions so requested.
2. You have the right to receive your health information through a reasonable alternative means or at an alternative location within thirty (30) days of written request.
3. You have the right to inspect and copy your health information
4. You have the right to request that ResponsiCare, Inc. amend any health information that is deemed incorrect or incomplete. However, ResponsiCare, Inc. is not required to amend your health information, and will provide you with information on any denial to amend same as well as information about how you may disagree with such denial.
5. You have a right to receive an accounting of disclosure of your health information made by ResponsiCare, Inc., except that ResponsiCare, Inc. is not required to account for the disclosures described in parts (1), (2), (3), (4), (5), and (6) of Section I of this Notice of Privacy Practices.
6. You have a right to a paper copy of this notice of privacy practices.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or
more of these rights, you may contact the privacy officer as noted on the first page of this document.

IV. Changes to This Notice of Privacy Practices
ResponsiCare, Inc. reserves the right to amend this Notice of Privacy Practices at any time in the future and to make
new provisions effective for all information that it maintains, including information that was created or received prior to the date of such amendment. Until such amendment is made, ResponsiCare, Inc. is required by law to comply with this Notice.

V. Complaints
Complaints about this Notice of Privacy Practices or how ResponsiCare, Inc. acquires, maintains, or disseminates your health information should be directed to:

Dale J. Anderson, J.D.
Practice Administrator and Chief Operating Officer
ResponsiCare, Inc.
2424 Danville Road SW
Decatur, AL 35603
(256)355-0555

If you are not satisfied with the manner in which ResponsiCare, Inc. handles your complaint, you may submit a formal complaint to:

Department of Health and Human Services Office of Civil Rights
Hubert H. Humphrey Building
200 Independence Avenue SW
Room 509F HHH Building
Washington, DC 20201

By signing, I acknowledge the opportunity to receive a copy of these privacy practices and authorize ResponsiCare, Inc. to use and or disclose certain protected health information (PHI) about me to any appropriate personnel, or entity including, but not limited to: insurance companies, Medicare, Medicaid, hospitals, ancillary treatment facilities, and referral providers. I understand that I do not need to sign this authorization to receive treatment. ResponsiCare, Inc. affiliated clinics or other entities will not receive remuneration (payment) from a third party in exchange for disclosing PHI. This authorization permits ResponsiCare, Inc. and affiliated clinics to use and/or disclose individually identifiable health information about me (specifically described on my signed records release form to be used or disclosed). I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Officer as listed below:

Dale J. Anderson, J.D
Practice Administrator and Chief Operating Officer
ResponsiCare, Inc.
2424 Danville Road SW
Decatur, AL 35603