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

Consulting Radiologists Corporation ( CRC ) uses health information about you to obtain payment for treatment or testing, for administrative purposes, and to evaluate the quality of care that you receive. Your health information relating to medical services rendered to you by CRC and its staff is contained in a medical record that is the physical property of CRC.

How CRC May Use or Disclose Your Health Information
Without Your Authorization

For Treatment or Testing. CRC may use your health information to provide you with medical treatment or tests. For example, information obtained by a health care provider, such as a physician, nurse, or other person providing health services to you on behalf of CRC will be recorded in your file. Health care providers will record actions taken by them in the course of your treatment or testing and note how you respond to the actions. The results of your treatment or tests may be disclosed to other health care providers involved in your health care.

For Payment. CRC may use and disclose your health information to others for purposes of receiving payment for services which you receive from CRC. For example, a bill may be sent to you or a third-party payer, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, or supplies used for your treatment or test(s).

For Health Care Operations. CRC may use and disclose health information about you for its operational purposes. For example, your health information may be disclosed to members of CRC s management, risk or quality improvement personnel, and others to:

• evaluate the performance of our staff;
• train members of our staff;
• assess the quality of care and outcomes in your case and similar cases;
• cooperate with outside organizations that evaluate or certify health care providers or facilities;
• learn how to improve our facilities and services;
• determine how to improve the quality and effectiveness of the health care we provide; and
• assist those persons who review our activities, such as our lawyers, accountants and business managers who assist us in complying with laws and regulations.

CRC may use your information to provide appointment remind≠ers or information about treatment alternatives or other health-related benefits and ser≠vices that may be of interest to you.

CRC is permitted, and in some cases, obligated by law, to use and disclose information about you. For example, CRC may disclose, if appropriate, information for the following purposes:

• for judicial and administrative proceedings pursuant to legal authority;
• to report information related to victims of abuse, neglect or domestic violence;
• to assist law enforcement officials in their law enforcement duties;
• to assist health oversight agencies, such as governmental auditors and the Ohio Department of Health; and
• in the case of emergency.

Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or other health oversight activities.

Your health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.

Research. CRC may use your health information for research purposes when an institutional review board or privacy board (which has reviewed the research proposal and established protocols t ensure the privacy of your health information) has approved the research.

Health and Safety. Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

Government Functions. Specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.

Workers Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to workers compensation matters.

CRC will not use your health information for any other purpose without your written authorization. Any authorization which you provide to CRC may be subsequently revoked by you, but only to the extent CRC has not already processed a disclosure. No further disclosures may be made without a change in your authorization.
Your Health Information Rights

You have the right to:

• request a restriction on certain uses and disclosures of your information as provided by 45 CFR ß164.522; however, CRC is not required to agree to a requested restriction;
• obtain a paper copy of this Notice of Privacy Practices upon request;
• inspect and obtain a copy of your health record as provided for in 45 CFR ß164.524; however, we reserve the right to charge you a reasonable fee;
• seek amendment of your health record as provided in 45 CFR ß164.526;
• request confidential communications of your health information by alternative means or at alternative locations;
• revoke your authorization to use or disclose health information except to the extent that action has already been taken; and
• receive an accounting of disclosures made of your health information as provided by 45 CFR ß164.528.

These rights may be exercised by requesting such action from CRC. Depending upon the specific right sought to be exercised, you may be required to complete and sign a written form provided by CRC. Please direct all requests of this nature to the CRC receptionist, who will refer you to the proper CRC staff member.

Complaints

You may complain to CRC and to the United States Department of Health and Human Services if you believe your privacy rights have been violated by use or disclosure in violation of this Notice. If you wish to file a complaint with CRC, please contact the Privacy Officer at the address and telephone number listed below. You will not be retaliated against for filing a complaint.

Obligations of CRC

CRC is required to:

• maintain the privacy of protected health information;
• provide you with this Notice of its legal duties and privacy practices with respect to your health information;
• abide by the terms of this notice;
• notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;
• accommodate reasonable requests you may make to communicate health information in a confidential manner by alternative means or at alternative locations; and
• obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law.

CRC reserves the right to change its information practices and to make the new provisions effective for all protected health information it maintains. Revised notices will be made available to you, unless an emergency treatment situation exists. In the event of an emergency treatment situation, CRC will provide such notice as soon as practicable following any emergency situation which may occur.

Contact Information

If you have any questions or complaints or wish to revoke any authorization for the use or disclosure which you have granted or seek additional information as to our privacy practices, please contact:

Privacy Officer
Regency Imaging Center
3000 Regency Court, Suite 105
Toledo, Ohio 43623
Telephone