COLLEGE HILL WOMEN'S HEALTH CENTER

PRIVACY POLICIES

It is the policy of our practice that all the physicians and staff preserve the integrity and the confidentiality of protected health information (PHI) pertaining to our patients. The purpose of this policy is to ensure that our practice and its physicians and staff have the necessary medical and PHI to provide the highest quality medical care possible while protecting the confidentiality of the PHI of our patients to the highest degree possible. Patients should not fear providing information to our practice and its physicians and staff for purposes of treatment, payment and healthcare operations (TPO). To that end, our practice and its physicians and staff will:

• Adhere to the standards set forth in the Notice of Privacy Practices.
• Collect, use and disclose PHI only in conformance with state and federal laws and current patient covenants and/or authorizations, as appropriate. Our practice and its physicians and staff will not use or disclose PHI for uses outside of practice's TPO, such as marketing, employment, life insurance applications, etc. without an authorization from the patient.
• Use and disclose PHI to remind patients of their appointments only with their consent.
• Recognize the PHI collected about patients must be accurate, timely, complete and available when needed. Our practice and its physician and staff will:
  • Implement reasonable measures to protect the integrity of all PHI maintained about patients.
• Recognize that patients have a right to privacy. Our practice and its physicians and staff respect the patient's individual dignity at all times. Our practice and its physicians and staff will respect patient's privacy to the extent consistent with providing the highest quality medical care possible and with the efficient administration of the facility.
• Act as responsible information stewards and treat all PHI as sensitive and confidential. Consequently, our practice and its physicians and staff will:
• Treat all PHI data as confidential in accordance with professional ethics, accreditation standards and legal requirements.
• Not disclose PHI data unless the patient (or his/her authorized representative) has properly consented to or authorized the release or the release is otherwise authorized by law.
• Recognize that, although our practice "owns" the medical record, the patient has a right to inspect and obtain a copy of his/her PHI. In addition, patients have a right to request an amendment to his/her medical record if he/she believe his/her information is inaccurate or incomplete. Our practice and its physicians and staff will:
• Permit patients access to their medical records when their written requests are approved by our practice. If we deny their request, then we must inform the patient that they may request a review of our denial. In such cases, we will have an on-site healthcare professional review the patients' appeals.
• Provide the patient an opportunity to request the correction of inaccurate or incomplete PHI in their medical records in accordance with the law and professional standards.
• All physicians and staff of our practice will maintain a list of all disclosures of PHI for purposes other than TPO for each patient. We will provide this list to patients upon request, so long as their requests are in writing.
• All physicians and staff of our practice will adhere to any restrictions concerning the use or disclosure of PHI that patients have requested and have been approved by our practice.
• All physicians and staff of our practice must adhere to this policy. Our practice will not tolerate violations of this policy. Violation of this policy is grounds for professional sanctions in accordance with our practice's personnel rules and regulations.
• Our practice may change this privacy policy in the future. Any changes will be effective upon the release of a revised privacy policy and will be made available to patients upon request.

COLLEGE HILL WOMEN'S HEALTH CENTER

Patient Consent for Use and Disclosure of Protected Health Information

With my consent, College Hill Women's Health Center may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to College Hill Women's Health Center's Notice of Privacy Practices for more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. College Hill Women's Health Center reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to College Hill Women's Health Center, Privacy Officer at 3000 College Drive, Rock Springs, WY 82901.

With my consent, College Hill Women's Health Center may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carryi8ng out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, College Hill Women's Health Center may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

With my consent, College Hill Women's Health Center may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request the College Hill Women's Health Center restrict how it uses or discloses my PHI to carry out TPO.

However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to College Hill Women's Health Center's use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, College Hill Women's Health Center my decline to provide treatment to me.

COLLEGE HILL WOMEN'S HEALTH CENTER

Privacy Policies

Date:______________

I, (patient name printed):_______________________________________have received the Notice of Privacy Policies and Practices from College Hill Women's Health Center.

Patient