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.

Notice of Privacy Practices

PURPOSE AND EFFECTIVE DATE

The purpose of this notice (“Notice”) is to inform you of how your patient information will be handled as a result of new privacy regulations required under a federal law, the Health Insurance Portability and Accountability Act of 1996. This law protects information about you or your medical condition that identifies you as a patient (sometimes referred to as “protected health information” or “PHI”). This Notice describes the privacy practices that will be followed by Fallon Clinic and its member organizations set forth under Section 5 below (collectively, “Fallon Clinic”), and others who are permitted to use or disclose your medical information, as well as Fallon Clinic’s legal obligations regarding the use or disclosure of your health information and your rights with respect to Fallon Clinic’s use and disclosure of such information. This Notice will be effective on April 14, 2003.

OUR LEGAL OBLIGATIONS TO YOU

Fallon Clinic is required by law to: (a) maintain the privacy of your PHI; (b) provide you with notice of Fallon Clinic’s legal duties and privacy practices with respect to PHI; and (c) abide by the terms described in this Notice.

1. Uses and Disclosures of Protected Health Information

A. Description of Uses and Disclosures of Protected Health Information for Treatment, Payment or Fallon Clinic Health Care Operations

You will be asked by Fallon Clinic to sign a consent form and an acknowledgement of receipt of this Notice. When we obtain your consent, and you acknowledge in writing your receipt of this Notice, or you fail to acknowledge receipt but we make a good faith effort to obtain a written acknowledgement (which we document along with the reasons for the failure), and in certain other circumstances, we are permitted by law to use or disclose your PHI for treatment, payment and Fallon Clinic health care operations. Some examples of the ways in which we may use and disclose PHI for these purposes are described below. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by Fallon Clinic once you have provided consent or acknowledged receipt of this Notice.

Treatment . We may use and disclose your PHI to provide treatment for your medical condition, coordinate or manage your health care and provide related services. Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. This includes the treatment for your medical condition and the coordination or management of your health care with another health care provider. For example, we may disclose your PHI, as necessary, to a home health agency that provides care to you. We may also disclose PHI to other physicians who may be treating you or otherwise assisting in the provision of care to you. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to treat you. In addition, we may disclose your PHI from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your treatment.

Payment . We may also use and disclose PHI about you to obtain payment for the health care services that we provide to you. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, we may tell your health plan about a treatment recommended for you in order to obtain prior approval or to determine whether your plan will cover the treatment. We may need to give your health plan information about treatment you received so your health plan will pay us or reimburse you for that treatment. We may also disclose PHI about you to a third party for the payment activities of such party. For example, we may be asked to disclose your PHI to another provider in order to support the medical necessity of that provider’s care to you for purposes of payment to the provider.

Health Care Operations . We may use and disclose your PHI in order to support the business activities and operations of Fallon Clinic. For example, we may use PHI to review our treatment and services and the performance of our staff in caring for you. We may also, under limited circumstances, disclose your PHI to a third party caring for you, which is necessary to support its health care operations. For example, the disclosure of PHI to a third party may be necessary for such third party’s quality assessment and improvement activities or a review of the competence of its providers treating you.

We may also disclose your PHI to third party “business associates” that perform various activities (e.g., billing, insurance, accounting and medical transcription services) for or on behalf of Fallon Clinic. Whenever an arrangement between Fallon Clinic and a business associate involves the use or disclosure of your PHI, we will have a written agreement with the business associate that is intended to protect the privacy of your PHI.

Treatment Alternatives . We may use or disclose your PHI, as necessary, to provide you with information about treatment options or alternatives that may be of interest to you, including communications about member organizations listed in Section 5 of this Notice.

Health-Related Benefits and Services .We may send you information about products or services that we believe may be beneficial to you. Under certain circumstances, we may use and disclose your PHI for other marketing activities as well. For example, your name and address may be used to send you a newsletter about our services we offer.

Fundraising Activities .We may use your PHI to contact you in an effort to raise money for Fallon Clinic. We may disclose your name and address and the dates you received services to a foundation that is affiliated with Fallon Clinic or a third party business associate so that either party may contact you in raising money for Fallon Clinic. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.

Training Purposes . We may use and disclose your PHI for purposes of providing training and education to medical school students and/or residents who treat patients at our clinics.

Appointment Reminders . We may use or disclose your PHI, as necessary, to contact you as a reminder that you have an appointment at Fallon Clinic. This may be done via an automated calling system.

Emergencies . We may use or disclose your PHI in an emergency treatment situation. Under these circumstances, Fallon Clinic will try to obtain your consent and acknowledgement of this Notice as soon as reasonably practicable after the delivery of treatment to you. If your physician or another physician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to do so, he or she may still use or disclose your PHI to treat you.

Communication Barriers . We may use and disclose your PHI if your physician or Fallon Clinic attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician or Fallon Clinic determines, in the exercise of professional judgment, that your consent to receive treatment is clearly inferred from the circumstances.

B. Uses and Disclosures of Protected Health Information Requiring an Opportunity For You to Agree or Object

We may use or disclose your PHI without your consent or authorization in limited circumstances when you are informed in advance of the use and disclosure and you have the opportunity to agree, object, or limit the use or disclosure. Unless you advise us of your objection to these uses, we will assume that you agree that we may use your PHI as described in this section. The types of uses or disclosures that require us to provide you with an opportunity to agree or object are set forth below.

Individuals Involved in Your Health Care . We may disclose PHI about you to a family member, relative, close friend or anyone you identify who is involved in your medical care or to someone who helps pay for your care. These disclosures will be limited to the PHI that is directly relevant to the individual’s involvement in your care or payment for your care.

Notification Identification and Location of Others and Disaster Relief .We may use or disclose PHI to notify, identify or locate relatives and personal custodians to inform them of your health status, condition, or death. We may disclose your PHI to a public or private entity authorized by law to assist in disaster relief efforts. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in connection with your family and others.

C. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object

In certain circumstances, we may use or disclose your PHI without your consent, authorization or agreement. Some of the types of uses or disclosures that may be made without your permission are set forth below, but not every use or disclosure of this type is listed.

Required By Law . We will disclose PHI about you to the extent that we are required to do so by federal, state or local law.

Public Health and Health Oversight Activities . As required by law, we may disclose to a public health authority PHI about you for public health activities that may include:

• prevention and control of disease, injury or disability;
• providing notice to a person who may be at risk for contracting or spreading a disease or condition; and
• reporting and prevention of neglect, domestic violence or abuse, consistent with applicable federal and state law.

We may disclose PHI to an agency responsible for overseeing health care activities authorized by law. Health oversight activities include audits, investigations, inspections, proceedings, and licensure and disciplinary actions or other activities necessary for appropriate oversight of the health care system, government benefit programs, and entities subject to government regulatory programs or civil rights laws.

FDA Reporting . We may disclose your PHI to non-government entities subject to regulation by the Food and Drug Administration regarding the quality, safety and effectiveness of FDA-regulated products and activities, including:

• reporting of reactions to medications or problems with medical devices; and
• providing notice of drug or medical device recalls.

Legal Proceedings . We may disclose your PHI as part of a judicial or administrative proceeding, in response to a court or administrative order. In response to a subpoena, discovery request or other lawful process that is not accompanied by a court or administrative order, we may only produce the information if we receive satisfactory assurance from the party seeking the information that reasonable efforts have been made to tell you about the request for your PHI or to obtain an order protecting the information requested. If we do not receive this satisfactory assurance, we will not disclose any PHI under these circumstances unless we make reasonable efforts to notify you of the request for your PHI or we seek a qualified protective order from a court or administrative tribunal to protect the information requested. In any case, we will only disclose the amount and type of information that is expressly required or authorized by the request or order.

Law Enforcement . We may release PHI to law enforcement officials under limited circumstances for purposes of: (1) responding to a court order, subpoena, warrant, summons or similar process, (2) identifying or locating a suspect, fugitive, material witness or missing person, (3) responding to a request for information about the victim of a crime, (4) responding to a request for information about a death we believe may be the result of criminal conduct, (5) responding to a request for information about criminal conduct on the premises of Fallon Clinic, and (6) in emergency circumstances to report a crime.

Coroners, Medical Examiners and Funeral Directors . We may release PHI to a coroner or medical examiner for the purpose of identifying a deceased person, determine the cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI about patients of Fallon Clinic to funeral directors as necessary to carry out their duties.

Organ and Tissue Donation . We may release PHI to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

To Prevent a Serious Threat to Health or Safety . We may disclose your PHI when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person.

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

National Security and Intelligence Activities . We may disclose PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protected Services for the President and Others . We may disclose PHI about you to authorized federal officials so they may provide protection to the President, certain other governmental persons or foreign heads of state.

Workers’ Compensation . We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs that provide benefits for work-related injuries or illnesses.

Correctional Institutions . Under certain circumstances, we may use or disclose protected information of patients who are inmates of a correctional facility.

Research . In the absence of an authorization, we may disclose PHI to researchers:

• If the research has been approved by the Institutional Review Board after reviewing the research proposal and establishing protocols to ensure the privacy of your PHI. This might be used, for example, to conduct records research, when researchers are unable to use de-identified information and it is not practicable to obtain research participants’ authorization; or
• If we have received representations from the researcher, either in writing or orally, that the use or disclosure of the PHI is solely to prepare a research protocol or for similar purposes preparatory to research, that the researcher will not remove any PHI from Fallon Clinic, and that PHI for which access is sought is necessary for the research purpose. This provision might be used, for example, to design a research study or to assess the feasibility of conducting a study; or
• If we have received representations from the researcher, either in writing or orally, that the use or disclosure being sought is solely for research on the PHI or decedents, that the PHI being sought is necessary for the research, and, at the request of Fallon Clinic, documentation of the death of the individuals about whom information is being sought.

D. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

We may make other uses and disclosures of your PHI not covered by this Notice. Unless otherwise permitted or required by law, these uses and disclosures will be made only with your written authorization. For example, most uses and disclosures of PHI for the purpose of research will require your written permission, except as otherwise described in this Notice or as permitted by law.

If you give permission to use or disclose PHI about you, you may revoke that permission in writing at any time. If you revoke your permission, we will no longer use or disclose PHI as had been permitted by your written authorization. However, we are unable to take back any disclosures we have already made with your permission.

2. Your Rights Regarding Your Protected Health Information

You have the following rights regarding the PHI we maintain about you:

Right to Request Restrictions . You have the right to request that we restrict the use or disclosure of PHI about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a medication prescribed to you. However, Fallon Clinic is not required to agree to any restriction requested by you under this paragraph. If we agree, we will comply with your request unless the information is needed to provide you emergency treatment, or as otherwise permitted by law.

To request restrictions, you must make your request in writing to Fallon Clinic’s Privacy Officer. In your request, you must tell us: (a) what information you want to limit; (b) whether you want to limit our use, disclosure or both; and (c) to whom you want the limits to apply – for example, disclosures to your spouse.

Right to Inspect and Copy . You have the right to inspect and copy PHI that may be used to make decisions about your care. This includes medical records, but does not include psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits your access to such information.

To inspect and copy PHI, you must submit your request in writing to our Medical Records Department. If you request a copy of the information, we may charge you a reasonable fee for the costs of copying, mailing or other costs associated with your request.

We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI, you may be able to request a review of that decision. Depending on the circumstances, the decision to deny access may or may not be reviewable. If you make such a request, we will notify you as to whether the decision is reviewable. If reviewable, another health care professional chosen by Fallon Clinic will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Request Confidential Communications . You have the right to request that we communicate with you about medical matters in a certain way or at an alternate location. For example, you may ask that we only contact you at the office or only by mail. If your request is reasonable, we will make every effort to accommodate it.

To request confidential communications from us by an alternate means or at an alternative location, you must complete an Alternative Communication Request form from any Fallon Clinic location . Your request must specify how and/or where you wish to be contacted.

Right to Amend . If you believe that PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by Fallon Clinic.

To request an amendment, you must complete the Amendment Requst form from Medical Records. The completed form must be submitted to the Medical Records Department. In addition, we will require you to provide us with a reason in support of your request.

We may deny your request for amendment if it is not in writing. We may also deny your request if it does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the PHI kept by Fallon Clinic;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete

If your request to amend your medical information is denied, you may file a statement of disagreement with us. You also have a right to a copy of our rebuttal statement, if we choose to prepare one.

Right to an Accounting of Disclosures . Subject to certain limitations, you have the right to request an accounting of disclosures of your PHI to third parties made by Fallon Clinic during the six (6) years prior to the date of your request. However, you are not entitled to any disclosures made:

• related to treatment, payment or health care operations of the Fallon Clinic;
• to you;
• for the Fallon Clinic’s directory or to persons involved in your care or as otherwise permitted under Section 1.B. above;
• pursuant to an authorization;
• for national security or intelligence purposes;
• to correctional institutions or law enforcement officials;
• as part of a limited data set; or
• prior to April 14, 2003.

To request an accounting of disclosures, you must submit your request in writing to our Medical Records Department. Your request must state a time period not longer than six years, and the time period cannot extend to dates before April 14, 2003. The first list you request within a twelve (12) month period will be free. For additional lists, we may charge you for the costs of providing the list.

Right to a Paper Copy of this Notice . You have the right to receive a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. To obtain a paper copy of this Notice, please contact our Medical Records Department or Privacy Office.

An electronic copy of this Notice is also posted at our website, www.Fallon-Clinic.com.

3. Changes to this Notice

Fallon Clinic reserves the right to change this Notice and to make the revised Notice effective for PHI currently in our possession and for any PHI we receive in the future. We will post a copy of the current Notice at Fallon Clinic and each of its member organizations. The effective date will be noted in the top right-hand corner of the first page of the Notice. Unless and until changes to the Notice are made, Fallon Clinic is required by law to comply with this Notice of Privacy Practices. You will be able to tell when changes have been made to the Notice of Privacy Practices by referring to the upper right-hand corner of the Notice, which will include the rvision date of that Notice.

4. Complaints

If you believe that we have violated your privacy rights, you may file a complaint with us or the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact our Privacy Officer at (508) 852-0600 or e-mail the Privacy Officer at Privacy.Officer@Fallon-Clinic.com. All complaints must be submitted in writing. There will be no retaliation against you for filing a complaint.

5. Member Organizations

This Notice applies to the following Fallon Clinic organizations:

• Fallon Clinic, Inc.
• Lakeview Medical, Inc.
• New England SCOPE, LLC
• Precision Medical Imaging at Fallon Clinic
• SEE New England, LLC

6. Associated organization

• Fallon Community Health Plan

If you want additional information or have any questions about this notice
please contact Charlyn Feeney, privacy officer, at 1-508-368-5494.
Call 1-800-283-2556 and ask to speak with our Fallon Clinic Medical
Records Department.