INVESTORS CAREERS CONTACT US LOGIN MyPay PRODUCTS, SERVICES & THERAPIES PATIENTS OUR COMPANY Notice of Privacy Practices 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. PROTECTING YOUR PRIVACY InfuSystem is committed to maintaining the privacy of your personal health information as required by law. In providing you with health care items and services, we will receive information and create records regarding you and the services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our privacy practices. The terms of this Notice of Privacy Practices apply to all records containing your individually identifiable health information (“IIHI” or “health information”) that are created or retained by InfuSystem. We reserve the right to revise or amend our privacy practices and to revise and amend this Notice of Privacy Practices. Any revision or amendment to our privacy practices and to this notice will be effective for all of your records that InfuSystem has created or maintained in the past, and for any of your records that InfuSystem may create or maintain in the future. InfuSystem will post a copy of our current notice in our offices in a visible location at all times, we will post a copy of our current notice on our website at InfuSystem.Com, and you may request a copy of our most current notice at any time. We will abide by the terms of the notice currently in effect. The effective date of this notice is July 12, 2013. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE Upon receipt of this Notice of Privacy Practices, please sign the attached Acknowledgement of Receipt of Notice and return it to our Privacy Officer at the address listed at the bottom of this notice. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION For Treatment Purposes.InfuSystem may use and disclose your health information to treat you. For example, we may ask your treating physician to send a copy of the Certificate of Medical Necessity or written order that he completed in order to provide you with the right equipment. By way of further example, our on-call nurses may review medical information regarding your use of our equipment if you should contact us about a question regarding the equipment. For Payment Purposes.InfuSystem may use and disclose your health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits, and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. By way of further example, we may use and disclose your health information to obtain payment from third parties that may be responsible for such costs. Also, we mayuse your health information to bill you directly for services and items. For Health Care Operations. InfuSystem may use and disclose your health information to operate our business. For example, InfuSystem may use your health information to evaluate the quality of care you received from us, or to conduct billing compliance activities for our business As Required by Law.InfuSystem will use and disclose your health information when we are required to do so by federal, state or local law. For Public Health Activities. InfuSystem may, in accordance with applicable laws, disclose your health information to public health authorities that are authorized by law to collect information for the purpose of: preventing or controlling disease, injury or disability maintaining vital records, such as births and deaths reporting child abuse or neglect to appropriate authorities reporting reactions to drugs or problems with products or devices notifying individuals if a product or device they may be using has been recalled notifying a person regarding potential exposure to a communicable disease as authorized by law notifying your employer in limited circumstances related mainly to workplace injury/illness or medical surveillance providing proof of immunization to schools required to obtain such information by state laws with the parent or guardian’s agreement As Related to Victims of Abuse, Neglect or Domestic Violence. InfuSystem may disclose your health information for the purpose of notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information. For Health Oversight Activities. InfuSystem may disclose your health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, audits; investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general. For Judicial and Administrative Proceedings.InfuSystem may use and disclose your health information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your health information in response to a discovery request, subpoena, or other lawful process by another party, but only if we have received assurances from the party seeking the information that reasonable efforts have been made to inform you of the request or we receive assurances from the party seeking the information that reasonable efforts have been made to obtain a protective order regarding the information the party has requested For Law Enforcement Purposes. InfuSystem may disclose your health information if asked to do so by a law enforcement official: As required by law, including laws that require the reporting of certain types of wounds or injuries•• • • • Regarding criminal conduct at our offices• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator) In response to a warrant, summons, court order, subpoena or similar legal process To identify/locate a suspect, material witness, fugitive or missing person Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement Concerning a death we believe has resulted from criminal conduct As to Deceased Persons.InfuSystem may disclose information regarding deceased individuals to coroners, medical examiners, or funeral directors as permitted by law. InfuSystem may also disclose information regarding deceased individuals to entities involved in organ, eye, or tissue donation. For Research Purposes InfuSystem may use and disclose your health information for research purposes in certain limited circumstances. We will obtain your written authorization to use your health information for research purposes except when: (a) our use or disclosure was approved by an Institutional Review Board or a Privacy Board; (b) we obtain the representations from the researcher that (i) the information being sought is necessary to prepare a research protocol, (ii) none of your health information will be removed from our offices, and (iii) the information is necessary for the research study; or (c) the health information sought by the researcher only relates to decedents and the researcher agrees either orally or in writing that the use or disclosure is necessary for the research and, if we request it, to provide us with proof of death prior to access to the health information of the decedents. To Avert Serious Threats to Health or Safety. InfuSystem may use and disclose your health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent or lessen the threat. We may also use and disclose your health information to law enforcement authorities to identify or apprehend an individual who has escaped from custody or to identify or apprehend an individual who has admitted participation in a violent crime. For Specialized Government Functions. InfuSystem may disclose your health information if you are a member of the armed forces (including veterans) and if required by the appropriate authorities. InfuSystem may disclose your health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. InfuSystem may also disclose your health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals. For Workers’ Compensation. InfuSystem practice may release your health information for workers’ compensation and similar programs that provide benefits for work-related injuries or illness. With Your AuthorizationMost uses and disclosures of your health information for marketing purposes and disclosures that constitute a sale of your health information require your written authorization. Should InfuSystem consider using or disclosing your information for these purposes, it will obtain your written authorization to do so. InfuSystem will also obtain your written authorization for other uses and disclosures that are not identified by this notice or permitted by applicable law. With limited exception, any authorization you provide to us regarding the use and disclosure of your health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION You have the following rights regarding the health information that we maintain about you: The Right to Request Restrictions. You have the right to request a restriction in our use or disclosure of your health information for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are required to comply with your requested restriction if the disclosure is to a health plan for purposes of carrying out payment or health care operations and the protected health information pertains solely to a health care item or service for which InfuSystem has been paid out of pocket in full. Otherwise, we are not required to agree to your request. If we do agree, we are bound by our agreement except in certain circumstances. For example, even if we have agreed to a restriction we may still use or disclose your health information if you need emergency treatment. Even if we have agreed to a restriction, we may still use or disclose your health information for specific purposes set forth in the Privacy Rule which include most of the uses and disclosures described in the section of this notice titled How We May Use and Disclose Your Health Information (they do not include those uses and disclosures for treatment, payment, and health care operations). In order to request a restriction in our use or disclosure of your health information, please contact our Privacy Officer at the address listed. Your request must describe in a clear and concise fashion: the information you wish restricted; whether you are requesting to limit our use, disclosure or both; and to whom you want the limits to apply. Once we agree to a request to restrict uses or disclosures, we may only terminate the agreement if you agree to or request the termination in writing, you orally agree to the termination and the oral agreement is documented, or we notify you that we are terminating our agreement. If we terminate the agreement by notifying you, the termination is effective with respect to health information that is created or received after we have notified you. The Right to Request Confidential Communications. You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to our Privacy Officer at the address listed below specifying the requested method of contact, or the location where you wish to be contacted. We will accommodate reasonable requests. You do not need to give a reason for your request. The Right to Access Your Health Information. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records. You must submit your request in writing to our Privacy Officer at the address listed below in order to inspect and/or obtain acopy of your health information. InfuSystem may charge a fee for the costs of copying, mailing, labor and supplies associated with your request, including a fee for the preparation of a summary of your information should you agree to accept a summary. If InfuSystem uses electronic health records, you can request and obtain a copy of your protected health information in electronic format. You can also request that the information be forwarded to another entity or individual in electronic format. The charge for transmission of protected health information in electronic format will not be greater than the labor costs in responding to the request for a copy of your protected health information. InfuSystem may deny your request to inspect and/or copy your health information in certain limited circumstances. In some of these circumstances you may request a review of our denial. Another licensed health care professional chosen by us will conduct the review. The Right to Request Amendments to Your Health Information. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for us. To request an amendment, your request must be made in writing and submitted to our Privacy Officer at the address listed below. You must provide us with a reason that supports your request for amendment. We will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) not created by our company, unless the individual or entity that created the information is not available to amend the information; (b) not part of the health information we keep; (c) not part of the health information which you would be permitted to inspect and copy under the Privacy Rule; or (d) is accurate and complete. We will notify you whether we will or will not make the amendment requested. If we do not make the amendment, we will notify you of your rights including your rights regarding submitting a statement of disagreement and how to file a complaint. The Right to an Accounting of DisclosuresYou have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain non-routine disclosures we have made of your health information which were not for treatment, payment, or our health care operations. No accounting of disclosures is required for health information that is disclosed as part of your routine patient care (i.e., disclosures for treatment, payment and health care operations). For example, there will be no accounting of disclosures if our on-call nurse provides information to your doctor; or the billing department using your information to file your insurance claim. There are other circumstances in which an accounting of disclosures is not required such as disclosures made to you or pursuant to your authorization. In order to obtain an accounting of disclosures, you must submit your request in writing to our Privacy Officer at the address listed below. All requests for an accounting of disclosures must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first accounting you request within a 12-month period is free of charge, but we may charge you for additional lists within the same 12-month period. We will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. The Right to Receive Notice of a Breach of Unsecured Health Information. We are required by law to maintain the privacy of your health information. We are required to provide notice of our legal duties and privacy practices with respect to your health information. We are required to notify you following a breach of your health information if it is unsecured. Health information is “unsecured” if it is not rendered unusable or unreadable to unauthorized individuals through the use of technology such as encryption. A breach of unsecured health information would occur if there was unauthorized access, use or disclosure of your health information which compromised the security or privacy of the unsecured information. The Right to Receive a Paper Copy of This Notice.You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact our Privacy Officer at the address listed below. The Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with InfuSystem or with the Secretary of the Department of Health and Human Services. To file a complaint with InfuSystem, contact our Privacy Officer at the address listed below. All complaints must be submitted in writing. You will not be penalized for filing a complaint. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Jan Skonieczny, Privacy Officer InfuSystem, Inc. 3851 W. 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