Persons Who Will Abide by This Notice

Any health care professional authorized to discuss your medical information with North Shore Gastroenterology, Inc. and North Shore Endoscopy Center (collectively North Shore) all departments of North Shore, all employees of North Shore, all business associates of North Shore, all personnel of North Shore's clearinghouse.

The duties of North Shore are legally required and are as follows:

• To maintain the privacy of your protected health information.
  
• To provide a notice to our patients describing our legal duties and privacy practices.
  
• To abide by the current terms of the notice.
  
• We reserve the right to revise the terms of this Notice and to make the new Notice provisions effective for all protected health information that we maintain.

How North Shore Gastroenterology May Use and Disclose Information about You

For Treatment. We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you or your health.

For Payment. We may use and disclose health information about you so that the treatment and services you receive at this office may be billed to and payment can be collected from you, an insurance company or a third party.

For Health Care Operations. We may use and disclose health information about you in order to operate the facility and make sure that you and all of our patients receive quality care.

Appointment Reminders. We may contact you as a reminder that you have an appointment for treatment or medical care at the office.

Treatment Alternatives. We might tell you about or recommend possible treatment alternatives that may be of interest to you.

Health Related Products and Services. We may tell you about health related products or services that may be of interest to you.

Special Situations. We may use and disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations: To avert a serious threat to health or safety; when required by federal, state or local law; for research purposes; organ and tissue donation; military, veterans, national security and intelligence; Worker's Compensation, public health risks; health oversight activities; lawsuits and disputes; law enforcement; coroners, medical examiners and funeral directors; information not personally identifiable.

Other Uses and Disclosures of Health Information. We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. If you give us Authorization to use and disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your Authorization, but we can not take back any uses or disclosures already made with your permission.

Your Rights Concerning Your Medical Information

The following are your rights concerning medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your health care. This usually includes medical and billing records but does not include psychotherapy notes. In order to obtain a copy of your medical information or to review it, you must submit a request in writing to the Privacy Officer or the Acting Director at that time. We may charge a fee for the cost of copying or otherwise processing your request. We can also deny your request to copy and inspect under limited circumstances and if such denial is made, you may request to review that denial. A separate North Shore employee will review the request and denial and we will comply with the result of the review.

Right to Paper Copy of Notice. You have the right to receive a paper copy of this notice and may request one from us at any time. Those patients receiving copies electronically may still receive a paper copy of the notice. Please contact the Privacy Officer or the Acting Director
Right to Amend. You may request that we amend the medical information that we have about you if you believe it is incorrect or incomplete. This right to request amendment remains as long as North Shore keeps the information or it is kept for North Shore. Requests to amend medical information must include a supporting reason for the request, must be made in writing and submitted to the Privacy Officer or the Acting Director of North Shore. We may deny your request if the above requirements are not met. We may also deny you're your request for the following reasons:

• The information was not created by North Shore, unless the said creator of said information is no longer available to amend it.
• The information is not part of the medical information maintained by North Shore.
  
• The information is not part of the medical information you are otherwise allowed to copy or inspect.
  
• The information is already complete or accurate.

Right to Accounting. You have the right to request an accounting, or a list of disclosures we made of medical information about you. A written request must be submitted to the Privacy Officer, or the Acting Director of North Shore before any list of disclosures can be processed. Such request must include a time period no longer than six years and may not include any dates before February 26, 2003. The first list requested for a 12 month period will be provided free of charge, however, we may charge you a fee for subsequent lists. We will inform you of the costs of processing such a request before fulfilling your request in case you wish to withdraw your request.

Right to Request Restrictions. You have the right to request that a limitation be placed on your medical information for treatment, payment or healthcare operations. You can also request limits on the medical information we disclose about you to someone involved in your care, like family or friends. Although we are not required to comply with your request, we will if we agree, unless you need emergency treatment and the information is needed for that purpose. Requests for restrictions must be made in writing to the Privacy Officer, or the Acting Director of North Shore and must include:

The information you wish us to limit;
Whether it is the use or disclosure or both you wish us to limit; and
To whom the limits should apply, for example,
Right to Request Confidential Communications. You have the right to request that we may communicate with you about medical issues in a specific manner and at a specific location such as at work or by e-mail. You must submit a written request for confidential communications to the Privacy Officer or the acting Director of North Shore. We will do our best to fulfill all reasonable requests. You may indicate how and where you wish us to contact you.

Changes to the Notice. We reserve the right to amend this notice. Those patients receiving copies electronically may still receive a paper copy of the notice. Please contact the Director in order to obtain a copy.

Complaints. If you have a concern or complaint about how your protected health information is being used, please first contact the Privacy Officer of North Shore in writing to solve your concerns or you may contact the Office of Civil Rights or the Ohio Medicare Carrier, Palmetto GBA. You will not be retaliated against for filing a complaint.

Privacy Officer
North Shore Gastroenterology
850 Columbia Road, Suite 200
Westlake, Ohio 44145
440-808-1212

Office of Civil Rights
Department of Health and Human Services
233 North Michigan Avenue, Suite 240
Chicago, Illinois 60601

Palmetto GBA
Part B Operations-HIPAA Compliance Concerns
P.O. Box 18957
Columbus, Ohio 43218

Other uses of Medical Information. We will only disclose medical information about you not described in this notice or covered by laws that apply to us with your written permission. You may revoke your written permission to use or disclose your medical information by doing so in writing at any time. At that time, we will no longer use or disclose your medical information for those reasons specified in your authorization. You understand that disclosures already made with your permission cannot be reclaimed and that we are required to keep records of your healthcare provided to you.