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NOTICE OF HEALTH CARE PRIVACY PRACTICES
Effective April 14, 2003

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

As a patient, it is your right to be informed of the privacy practices of your health care provider and to be informed of your privacy rights with respect to your personal health information. Your personal health information is information that constitutes "protected health information" as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996. This Notice of Privacy Practices is intended to provide you information regarding your rights and Midwest Bariatric Solutions' privacy practices.

DUTIES OF MIDWEST BARIATRIC SOLUTIONS
Midwest Bariatric Solutions is required by law to maintain the privacy of your health information and to provide to you and your representative of this Notice of Duties and privacy practices regarding you health information. Midwest Bariatric Solutions is required to abide by the terms of this Notice as may be amended from time to time. Midwest Bariatric Solutions will not use or disclose your health information without your authorization, except as described in this Notice. Midwest Bariatric Solutions reserves the right to change the terms of its Notice to make the new Notice provisions effective for all health information that it maintains. Midwest Bariatric Solutions also reserves the right to change the terms of its Notice with respect to any applicable more limited uses and disclosure. If Midwest Bariatric Solutions makes a material change to this Notice, Midwest Bariatric Solutions will distribute a copy of the revised Notice.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that Midwest Bariatric Solutions maintains:

Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information, even if the restriction affects your treatment or Midwest Bariatric Solutions' Payment of health care options. For example, disclosing protected health information to a family member, relative or a close personal friend of the patient, or any person identified by the patient directly relevant to that patient's care, or disclosing information to notify or assist in notification of a family member, a personal representative of the patient, or another person responsible for the care of the patient, the patient's locations, general condition, or death. However, Midwest Bariatric Solutions is not required to agree to your request. If you wish to make a request for restrictions, please contact Julie Scott at (920) 725-4527.

Right to Receive Confidential Communications. You have the right to request that Midwest Bariatric Solutions communicate with you about your health information by alternative means or at alternative locations and Midwest Bariatric Solutions shall accommodate reasonable requests. For example, you may ask that Midwest Bariatric Solutions contact you at work rather than at home. If you wish to receive confidential communications, your request must be in writing and addressed to Julie Scott, Midwest Bariatric Solutions, 100 Theda Care Medical Plaza, Suite 400, Neenah, Wisconsin 54956.

Right to Inspect and Copy Your Health Information. You have the right to inspect and copy your health information , including billing records. This right may not apply to certain types of psychotherapy notes. A request to inspect and copy records containing your health information must be submitted in writing to Julie Scott, Midwest Bariatric Solutions, 100 Theda Care Medical Plaza, Suite 400, Neenah, WI 54956. If you request a copy of your health information, Midwest Bariatric Solutions may charge a reasonable fee for copying costs associated at your request. For example, you may request a copy of your health care record from your surgeon.

Right to Amend Your Health Information. You have the right to request that Midwest Bariatric Solutions amend your records, if you believe your health information records are incorrect or incomplete. That request may be made as long as the information is maintained by Midwest Bariatric Solutions. A request for an amendment of records must be made in writing and include a reason to support the requested amendment to Julie Scott, Midwest Bariatric Solutions, 100 Theda Care Medical Plaza, Suite 400, Neenah, WI 54956. Midwest Bariatric Solutions may deny the request if the health information you wish to amend 1) was not created by Midwest Bariatric Solutions; 2) is not part of Midwest Bariatric Solutions' records; 3) is not part of the health information you are permitted to inspect and copy; or 4) is, in the opinion of Midwest Bariatric Solutions, accurate and complete. For example, if you believe information in your medical history, such as your birth date, is incorrect, you may request that this information be amended.

Right to an Accounting. You have the right to request an accounting of disclosures of your health information made by Midwest Bariatric Solutions for certain purposes, which may include disclosures authorized by law. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. The accounting shall include the date of the disclosure, the name of the entity or person who received the health information, a brief description of the health information disclosed, and the reason for the disclosure. Midwest Bariatric Solutions will provide the first accounting you request during any 12-month period without charge. Subsequent accounting request may be subject to a reasonable cost-based fee. For example, you may request an accounting of disclosure made from your health care record in the last year to the state for disease reporting.

Right to a Paper Copy of this Notice. You have the right to a separate copy of this Notice at any time even if you received this Notice previously. To obtain a separate paper copy, please contact Julie Scott at 725-4527. For example, if you received the notice electronically, you may request Midwest Bariatric Solutions to provide a paper copy of the notice.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Midwest Bariatric Solutions may use your health information for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Midwest Bariatric Solutions has established a policy to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Provide Treatment. Midwest Bariatric Solutions may use or disclose your health information in the provision, coordination or management of your health care. For example, your health information may be disclosed to other physicians involved in your care and treatment.

To Obtain Payment. Midwest Bariatric Solutions may use or disclose your health information to obtain reimbursement from third parties of the care you may receive from Midwest Bariatric Solutions. The bill may include information that identifies you, your diagnosis and your treatment. For example, Midwest Bariatric Solutions may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Midwest Bariatric Solutions.

To Conduct Health Care Operations. Midwest Bariatric Solutions may use and disclose health information for its own operations in order to evaluate the function of Midwest Bariatric Solutions and as necessary to provide quality care to all of Midwest Bariatric Solutions' patients. Health care operations include activities such as: Quality assessment and improvement activities, activities designed to reduce health care costs, professional review and performance evaluation, business management and general administrative activities of Midwest Bariatric Solutions and certain marketing activities. For example, Midwest Bariatric Solutions may use your health information to evaluate its staff performance.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION PERMITTED WITHOUT YOUR AUTHORIZATION

For Appointment Reminders. Midwest Bariatric Solutions may use and disclose your health information to contact you as a reminder that you have an appointment for treatment or medical care with Midwest Bariatric Solutions.

When Legally Required. Midwest Bariatric Solutions will disclose your health information when it is required to do so by any Federal, State or local law.

When there are Risks to Pubic Health. Midwest Bariatric Solutions may disclose your health information for the following public activities and purposes:
Midwest Bariatric Solutions may disclose your health information, excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result, to a state or federal public health agency to prevent or control disease, injury or disability.
Midwest Bariatric Solutions may disclose your health information, excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result, to report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.
Midwest Bariatric Solutions may disclose your health information to notify a person who has been exposed to a communicable disease or who may be at risk or contracting or spreading a disease.
As required by law, Midwest Bariatric Solutions may disclose your health information to the State of Wisconsin for the purpose of statutory reporting.
Midwest Bariatric Solutions may disclose your health information, excluding your HIV test result without your authorization to a county agency investigating child abuse or if Midwest Bariatric Solutions reasonably believes that an individual is a victim of elder or child abuse.
Midwest Bariatric Solutions may disclose your health information, excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result to a state or federal public health agency for the purpose of preventing or controlling disease, injury or disability.
Midwest Bariatric Solutions may disclose your HIV test result without your authorization to a person that may have sustained a contact that carries a potential for transmission of HIV.
 
For Worker's Compensation. Midwest Bariatric Solutions may release your health information for worker's compensation or similar programs.

To Conduct Health Oversight Activities. Midwest Bariatric Solutions may disclose your health information to a health oversight agency for activities including audits; civil, administrative or criminal investigations; inspections; licensure or disciplinary action. Midwest Bariatric Solutions, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of or it not directly related to your receipt of health care or public benefits.

Judicial and Administrative Proceeding. Midwest Bariatric Solutions may disclose your health information in response to a court order. Midwest Bariatric Solutions may disclose your health information in response to a subpoena if Midwest Bariatric Solutions is a party to a court action, Midwest Bariatric Solutions has reviewed your authorization to disclose and had not complied within two business days or Midwest Bariatric Solutions failed to respond to a request for worker's compensation records. Midwest Bariatric Solutions may disclose your health information excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result in response to a subpoena from a state or federal agency.

For Law Enforcement. Midwest Bariatric Solutions may disclose your health information, excluding HIV test results to county law enforcement officials for the reporting and investigation of elder and/or child abuse. Midwest Bariatric Solutions may disclose your health information except for mental health, alcohol or drug abuse or developmental disabled or HIV test results to state and federal law enforcement officials. Midwest Bariatric Solutions may disclose mental health, alcohol or drug abuse or developmental disable health information for limited law enforcement purposes required by law. Midwest Bariatric Solutions may disclose your health information in response to a court order.

To Funeral Directors. Midwest Bariatric Solutions may use or disclose your HIV results to a funeral director.

For Cadaveric Organ, Eye or Tissue Donation Purposes. Midwest Bariatric Solutions may use or disclose your HIV test result to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation or Cadaveric organs, eyes or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.

In the Event of a Serious Threat to Health or Safety. Midwest Bariatric Solutions may, consistent with applicable law and ethical standards of conduct, disclose your health information if Midwest Bariatric Solutions, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

For Specified Government Functions. In certain circumstances, the Federal regulations authorize Midwest Bariatric Solutions to use or disclose your health information excluding mental health, alcohol or drug abuse or developmental disabled or HIB test result to facilitate a specified governmental functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.

AUTHORIZATION TO USE OR DISCLOSE YOUR HEALTH INFORMATION

Other than as stated above, Midwest Bariatric Solutions will not disclose your health information other than with your written authorization. If you or your representative authorizes Midwest Bariatric Solutions to use or disclose your health information, you may revoke that authorization in writing at any time by submitting your written withdrawal to Julie Scott, Midwest Bariatric Solutions' privacy compliancy officer at 100 Theda Care Medical Plaza, Suite 400, Neenah, WI 54956.

IF YOU HAVE A COMPLAINT
You have the right to express complaints to Midwest Bariatric Solutions or the secretary of Health and Human Services if you believe that your privacy rights have been violated. Any complaints to Midwest Bariatric Solutions should be made in writing to Julie Scott, Midwest Bariatric Solutions, 100 Theda Care Medical Plaza, Suite 400, and Neenah, WI 54956. Midwest Bariatric Solutions encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

IF YOU HAVE ANY QUSTIONS REGARDING THIS NOTICE, PLEASE CONTACT

Midwest Bariatric Solutions has designated Julie Scott privacy compliance officer and as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact her at Surgical Associates of Neenah, S.C., 100 Theda Care Medical Plaza, Suite 400, Neenah, WI 54956, (920) 725-4528.