If you have questions about this notice or want more information, please contact Sharon Andree at 724-542-4990. The effective date of this notice is April 14, 2003 .

Northland Open MRI, L.L.C. (“Northland”) may use and disclose your information to treat you, to get paid, and for its own management and quality purposes. Northland has entered into an arrangement (called an organized health care arrangement) with the physicians and the allied health professionals that may provide care to you while you are at Northland. Your providers may share information about you to get paid, to treat you, and for their management and quality purposes. This arrangement does not affect in any way how your physician medically treats you or your physician’s medical decisions about your care; it only affects how information about you is shared with your providers. This arrangement does not make your physicians or allied health professionals employees or agents of Northland; they make their own independent medical decisions about your care. This Notice only covers your information at Northland; it does not cover your information in a provider’s office that is not employed by Northland or facility that is not owned by Northland. You will receive another notice when you go to other facilities not associated with Northland and offices of providers who are not employed by Northland.

The following individuals and entities are part of the organized health care arrangement:

• Northland Open MRI and its Members
• Physicians and other individuals providing care in the facility

This notice describes how your providers may use and disclose your information. It only provides examples of how your information may be used and disclosed. It also gives examples of when your providers are required by law to disclose your information. This notice also explains your rights (and the limits on those rights) to:

• Have access to your information;
• Request changes to your information;
• Request limits on disclosing your information;
• Request a different phone number or address be used; and
• Request to review who has received your information.

To appropriately treat you and receive payment for the services we provide, we need to obtain information from you including your full name and address, insurance company, family medical history, current medical history, and current medical condition. We will use and disclose this information and other information we collect in the ways described below. To help you understand how we will use and disclose your information we have put the different uses and disclosures into categories and give examples of each. All of the ways we use or disclose your information will fit into one of the categories listed below, but we cannot list all of the uses and discloses in each category.

We may use and disclosure your health information for treatment, payment, and health care operations

Treatment
We may use and disclose your information to provide you with medical treatment and services. Your information may be disclosed to individuals providing care to you and different departments in the hospital. These individuals and departments need your information to provide care, and to coordinate and provide services (such as prescriptions, lab tests, meals, and x-rays). We may also disclose your information to individuals outside the hospital that may be involved in your care after you leave.

Payment
We may use and disclose your information to receive payment for the services and treatment provided to you. We use your information to create a bill and disclose your information when we send the bill to your insurance company, you , or a third party. The individual or entity paying the bill may request more information to determine whether the bill is covered by your insurance. We may tell your health plan about a treatment you are going to receive to get approval for payment or to determine whether your health plan will cover the treatment.

Health Care Operations
We may use and disclose your information for health care operation purposes. Health care operations includes review of the care you receive for quality assessment, educational, business planning, and compliance plan purposes. .

We may disclose and use your health information and you authorize us to use and disclose your information for:

Appointment Reminders
We may provide appointment reminders to you. You may request in writing that we send reminders to a confidential or alternative address.

Treatment Alternatives
We may provide you with information about treatment alternatives and other health related benefits and services.

We may also disclose your health information to outside entities without your consent or authorization in the following circumstances:

Required by Law
We disclose information as required by law. For example, we are required to report gunshot wounds to the police.

Public Health Purposes
We disclose information to health agencies as required by law for preventing or controlling disease. Examples are reporting of sexually transmitted, communicable, and infectious diseases.

To Prevent a Serious Threat to Health or Safety
We may disclose information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.

Research
Your information may be used by or disclosed to researchers for research approved by a privacy board or an institutional review board.

Health Oversight Activities
Your health information may be disclosed to governmental agencies and boards for investigations, audits, licensing, and compliance purposes.

Judicial and Administrative Proceedings
We may be required to disclose your health information to a court or for an administrative proceeding.

Law Enforcement Activities
We may be required to disclose your information as required by law, pursuant to a court order, warrant, subpoena, or summons.

In Emergency Circumstances
We may disclose information about you to providers to treat you in an emergency.

Deceased Individual
We may disclose information for the identification of the body or to determine the cause of death.

Military and Veterans
If you are a member of the armed forces we may release information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.

Inmates
If you are an inmate of a correctional institution or under the custody of a law enforcement official. This release must be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety or security of the correctional institution.

Protective Services for the President and Others

Organ and Tissue Donation
If you are an organ donor, we may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ bank, as necessary to facilitate organ or tissue donation.

Workers’ Compensation
We may release medical information about you for workers’ compensation or similar programs.

National Security and Intelligence Activities
We may release information about you to authorized Federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

We will give you the opportunity to object to the following uses and disclosure of your information:

Notification
We may tell your friends, relatives and other caretakers information which is relevant to their involvement in your care.

Disaster Relief
We may disclose information about you to public or private agencies for disaster relief purposes.

Facility Directory
We may disclose your room number and general condition to people who request this information about you by name. We may also disclose your religious affiliation to members of the clergy. You may request that your information not be included in our facility directory.

Your Rights:
You have the right to request a restriction on how information about you is used and disclosed. If you want to request a restriction of a use or disclosure of your information, contact Sharon Andree. We are not required to agree to any restriction on the use or disclosure of your information.

You have the right to request communications with you be made at an alternative address or phone number. To request that communication be made at a different address or phone number contact Sharon Andree at 724-542-4990 to obtain the form to make your request.

You have the right to inspect and copy your medical record. To inspect and copy your medical record a request must be made in writing on the form provided by Northland. To obtain a form contact Sharon Andree at 724-542-4990.

If you believe the information we have about you is incorrect or incomplete you may request that we amend your medical record. Your request must be made in writing on the form provided by Northland. To request a form contact Sharon Andree at 724-542-4990.

You have the right to receive an accounting of disclosures, a list of individuals and entities that received your health information. Your accounting will not include disclosures for reasons other than treatment, payment, and healthcare operations; disclosures made to you; disclosures made pursuant to an authorization; incidental disclosures; disclosures for notification purposes, disaster relief purposes and persons involved in the your care; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement officials having custody of you; disclosures as part of a limited data set; and disclosures made before April 14, 2003. You may receive one (1) free accounting during a twelve (12) month period. If you request more than one (1) accounting you will be charged a fee of $25.00 for a one (1) year accounting and $15.00 for each additional year up to six (6) years.

You have the right to request a paper copy of this Notice.

Our Duties
We are required by law to maintain the privacy of protected health information and to provide individuals with this Notice of our legal duties and privacy practices regarding health information.

We are required to follow the terms of the current Notice.

We may change the terms of this Notice and the revised Notice will apply to all health information in our possession. If we revise this Notice, a copy of the revised Notice will be posted at Northland Open MRI and a copy may be requested from Sharon Andree 724-542-4990.

Complaints
If you are provided with this Notice electronically you may request a paper copy by contacting Sharon Andree at sandree@mauhs.com.

If you believe your privacy rights have been violated you may contact:

Sharon Andree at 724-542-4990 or the Office for Civil Rights. You will not be penalized in any way for filing a complaint.

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