CARE ALLIANCE
NOTICE OF PRIVACY PRACTICES

Effective Date: April 14, 2003.

THIS NOTICE DESCRIBES HOW PERSONAL HEALTH INFORMATION (PHI) ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respect patient confidentiality and only release personal health information about you in accordance with the Ohio and federal law. This notice describes our policies related to the use of records of your care generated by Care Alliance.

Privacy Contact. If you have any questions about this policy or your rights under this notice, contact the Director of Human Resources at 216-781-6228, Ext. 13.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

In order to effectively provide health care, there are times when we will need to share your personal health information with others outside Care Alliance.

Treatment. We may share personal health information about you with others to provide, coordinate, or manage your care or any related services. Payment. Personal health information will be used to obtain payment for the treatment and services provided. This may include contacting your health insurance company for prior approval of treatment or for billing purposes. Healthcare Operations. We may use information about you to coordinate certain business activities; for example, setting up appointments and reviewing your care.

INFORMATION ABOUT YOU ALSO MAY BE DISCLOSED IN THE FOLLOWING CIRCUMSTANCES:

Emergencies. Information may be shared to address the immediate emergency you are facing.

Follow Up Appointments/Care. We may contact you to remind you of future appointments or to provide information about treatment alternatives or other health-related benefits and services.

As Required by Law. This would include situations where we have a subpoena, court order or are mandated to provide public health information, such as information regarding communicable diseases or suspected abuse and neglect.

Coroners, Funeral Directors. We may disclose personal health information to a coroner, personal health examiner or funeral director for the purpose of carrying out their duties.

Governmental Requirements. We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure. There might also be a need to share information with the Food and Drug Administration related to adverse events or product defects. If requested we are required to share information with the Department of Health and Human Services to determine our compliance with federal health care laws.

Criminal Activity or Danger to Others. If a crime is committed on our premises or against our personnel, we may share information with law enforcement officials to assist in the apprehension of the criminal. Also, if we believe you present an immediate danger to yourself or others, we may share information with appropriate law enforcement officers.

PATIENT RIGHTS

You have the following rights under Ohio and federal law:

Copy of Record. You are entitled to inspect your personal health record. We may charge you a reasonable fee for copying and mailing your record.

Release of Records. You may consent, in writing to release your records to others, for any purpose you choose. This could include your attorney, employer, or others. You may revoke this consent at any time, but only to the extent that no action has been taken under your prior authorization.

Restriction on Record. You may ask us not to use or disclose part of your personal health information. This request must be in writing. Care Alliance is not required to agree to your request if we believe it is in your best interest to permit use and disclosure of the information.

Contacting You. You may request that we provide information to another address or by alternative means. We will honor such request as long as it is reasonable. We have a right to verify that the payment information you are providing is correct.

Amending Record. If you believe that something in your record is incorrect or incomplete, you may request that we amend it. To do so, contact the Director of Human Resources and ask for the Request to Amend Health Information form. In certain cases, we may deny your request. If we deny your request for an amendment, you have a right to file a response stating that you disagree with us. We will then submit our response, and your statement and our response will be added to your record.

Accounting for Disclosures. You may request a listing of any disclosures we have made related to your personal health information, except for information we were required to release, we used for treatment, payment or health care operations, that we shared with you or your family, or that you gave us specific consent to release. To receive information regarding disclosures made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to our Director of Human Resources. We will notify you of the cost involved in preparing this list.

Questions and Complaints. If you have any questions or complaints or wish a copy of this Policy, you may contact our Director of Human Resources at our administrative office. You also may file a complaint with the Secretary of Health and Human Services if you believe Care Alliance has violated your privacy rights. No action will be taken against you as a result of filing a complaint.

Changes in Policy. Care Alliance reserves the right to change its Privacy Policy based on the needs of Care Alliance or changes in state and federal law.



ACKNOWLEDGEMENT OF PRIVACY POLICY
AND CONSENT TO RELEASE OF INFORMATION

I have been informed of Care Alliance's "Notice of Privacy Policies". My rights, including the right to see and copy my record, to limit disclosure of my health care information, and to request an amendment to my record, are explained in the Policy. I consent to the release of my health care information as described in the Notice of Privacy Practices. I understand that I may revoke, in writing, my consent for release of personal health information, except to the extent Care Alliance has already made disclosures with my prior consent.

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Patient or Authorized Person Signature



_________________/_________
Relationship/Date



Patient unable/refused to sign.
Verbal acknowledgment/consent given.



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Staff Signature

4/08/03