Consultants in Laboratory Medicine of Greater Toledo, Inc. Statement of Privacy Practices

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

Consultants in Laboratory Medicine of Greater Toledo, Inc. on behalf of itself and its affiliated covered entities (“CLM”), in the course of its business practice and, in some cases, as required by law, collects, uses and maintains confidential information about CLM’s patients. This information includes but is not limited to:

Patient demographics Patient information Patient/member financial information Patient/member medical insurance information Third party payor’s of patient/member medical bills

We respect the privacy of our patients and the confidentiality of personal information. This information belongs to the patient and patients have the right to:

Request confidential communications be mailed or telephoned to an alternative address or alternative telephone number Request an accounting of disclosures of your health information Request restrictions on certain protected health information (“PHI”) uses and disclosures Revoke your authorization to use or disclose health information except to the extent that action has already been taken Right to inspect and copy their PHI Right to amend PHI Right to receive a paper copy of the notice upon request

At no time will confidential information be knowingly shared or disseminated to unauthorized parties. To attain this standard, CLM has committed significant resources to ensuring the safety and confidentiality of our patients’ information. This is done through:

Business Associate Agreements Vendor Data Security and Confidentiality Agreements Individual employee computer Ids and passwords Employee training regarding privacy and Protected Health Information Designated facsimile numbers for the transfer of Protected Health Information

When we share information whether inside or outside the company, as part of our commitment to your privacy, certain policies have been established to protect your information. Employees of CLM who are authorized to have access to patient information have received specific instruction in issues of information confidentiality. In those cases where confidential information might be shared with health-plan providers, governmental agencies and other third-party vendors, specific written agreements regarding confidentiality are established and monitored with these organizations.

We will use your health information for payment. For example: A bill may be sent to you or a third party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have supplied us.

In all other cases in which information might be shared with individuals or organizations that may not have specific policies or agreements in place, CLM will obtain permission from any affected patient prior to releasing the information, unless the law prescribes otherwise.

If you have questions and/or would like additional information, you may contact the HIPAA Compliance and Privacy Officer of Consultants in Laboratory Medicine of Greater Toledo, Inc. at (419) 534-9629.

If you believe your privacy rights have been violated, you can file a complaint by contacting Consultants in Laboratory Medicine of Greater Toledo, Inc. or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

My Signature below indicates that I have been provided with a copy of the notice of privacy practices.

__________________________________________________      _____________ Signature of Patient or Legal Representative                           Date If signed by legal representative, relationship to patient ___________________________ Effective Date: