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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.

Innovative Surgery Center is committed to protecting your medical information. Further, we are required by law to maintain the privacy of your protected health information (PHI) and to give you this notice, explaining our legal duties and privacy practices with regards to your protected health information. We are required to must abide by the terms set forth in this notice. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all protected health information we maintain. Any revisions will be posted in a prominent location in our office and, upon request, a copy will be provided to you of the revised notice. 

Uses and Disclosures of Your Protected Health Information:
1) Treatment: Your PHI may be used provide, coordinate, or manage your health care and any related services. We may also disclose your
PHI to other health care providers who may be treating you or involved in your health care to ensure they have the necessary
information to diagnose, treat or provide a service.

2) Payment: Your PHI may be used and disclosed to obtain payment for health care services provided by us or to determine whether we
may obtain payment for services recommended for you. Your PHI may be disclosed to obtain payment or for payment activities from
you, a health plan, healthcare clearinghouse, or a third party). As an example, we may need to include information that identifies you,
your diagnosis, procedures performed, with a bill to a third-party payer or your health plan to agree to payment for that treatment.

3) Health Care Operations: We may use and disclose your PHI to support the business activities of our office. The activities include, but are
not limited to, the evaluation of our team members in caring for you, quality assessment, the disclosure of information to physicians,
nurses, medical technicians, medical students and other authorized personnel for education and learning purposes. As an example, we
may use your protected health information to review and evaluate our treatment and services or to evaluate our staff’s performance
while caring for you. We may also disclose your protected health information to third party business associates who perform certain
activities for us (e.g., billing and transcription services). Finally, we may disclose to certain third parties a limited data set containing your
protected health information for certain business activities.

4) Appointment Reminders/Treatment Alternatives/ Health-Related Services: We may use and disclose your PHI to contact you to
remind you that you have a scheduled medical appointment or to advise you of treatment options or alternatives or health related
benefits and services which may be of interest to you.

5) Facility Directory: Unless you object, we may use and disclose in our facility directory your name, location in the facility, general
condition and religious affiliation. All of this information, except for your religious affiliation, will be disclosed to persons who ask for you
by name. Information in the facility directory may be shared with clergy.

6) Persons Involved in Your Care: We may use and disclose to a family member, a relative, a close friend, or any other person you identify,
your protected health information that is directly relevant to the person’s involvement in your care or payment related to your care,
unless you object to such disclosure. If you are unable to agree or object to a disclosure, we may disclose the information as necessary if
we determine that it is in your best interest based on our professional judgment.

7) Notification: We may use or disclose your protected health information to notify or assist in notifying a family member, personal
representative or other person responsible for your care, of your location, general condition or death.

8) As required by Law: We will disclose your PHI when required to do so by international, federal, state or local law. Examples include:
• Public health activities including reporting of certain communicable diseases
• Workers’ compensation or similar programs as required by law
• Authorities when we suspect abuse, neglect, or domestic violence
• Health oversight agencies, including the Food and Drug Administration and Department of Health and Human Services
• For certain judicial and administrative proceedings pursuant to an administrative order
• Law enforcement purposes, legal proceedings
• Medical examiner, coroner, or funeral director
• The facilitation of organ, eye, or tissue donation if you are an organ donor
• To avert a serious threat to your health and safety or that of others
• For governmental purposes such as military service or for national security; and
• In the event of an emergency or for disaster relief
• Inmates, during the course of providing care

9) Business Associates: We may share your PHI with other individuals or companies that perform various activities on behalf of, our office such
as after-hours telephone answering, quality assurance, or clinic research. Our Business Associates agree to protect the privacy of your

10) Marketing & any purposes which require the sale of your information: These disclosures require your written authorization.

11) Any other uses and Disclosures not recorded in this Notice will be made only with your written authorization. You may revoke the
authorization at any time by submitting a written revocation and we will no longer disclose your PHI, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

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