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. If you have any questions about this notice, please contact our Privacy Officer at (888) 873-8999.

Our Pledge Regarding Health Information:
We understand that PHI about you and your health care is personal and that as required by law, CSI is to maintain the privacy of your PHI. The medical information that we are committed to protecting is called protected PHI or ”PHI” for short. We create a record of the care and services you receive from us. This notice applies to all of the records of your care generated by CSI. This notice will tell you about the ways in which we may use and disclose PHI about you. We also describe your rights to the PHI we keep about you, and describe certain obligations we have regarding the use and disclosure of your PHI. Further, in keeping with federal and state laws and our own policy, CSI has a responsibility to protect the privacy of your information. We have physical, electronic and procedural safeguards in place to protect your information.

How We May Use and Disclose PHI about You
The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We may use PHI about you to provide you with health care treatment or services. We may disclose PHI about you to physicians, nurses, technicians, or other personnel who are involved in taking care of you. They may work at our offices, at the hospital if you are hospitalized, or at a physician’s office, lab, pharmacy, or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. For example, a doctor treating you for an infection may need to know if you have an allergic reaction to certain medication.

For Payment: We may use and disclose PHI about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your treatment so your health plan will pay us or reimburse you directly. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For healthcare Operations: We may use and disclose PHI about you for health care operations. These uses and disclosures are necessary to operate our business and make sure that all of our patients receive quality care. We may use PHI to review the quality of care and services you get. We may also use PHI to provide you with case management or care coordination services for conditions such as asthma, diabetes or traumatic injury. We may remove information that identifies you from this set of PHI so others may use it to study health care delivery without learning the identities of our patients.

To Schedule Deliveries: We will contact you by telephone to schedule delivery of medication and supplies.

As Required by Law: We will disclose PHI about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Disaster Relief Efforts: We may also disclose information to you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Military and Veterans: If you are a member of the armed forces or separated/discharged from military services, we may release PHI about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release PHI about foreign military personnel to the appropriate foreign military authorities.

Workers’ Compensation: We may release PHI about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Due to Public Health Risks: We may disclose PHI about you for public health activities. Examples of these activities include the following:
• To prevent or control disease;
• To report births and deaths;
• To report child abuse or neglect;
• To report reactions to medications or problems with products;
• To notify people of recalls of products they may be using;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities: We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example audits, investigations, inspections, and licensure. The activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release PHI if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at our facility; and
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

In Response to Coroners, Health Examiners and Funeral Directors: We may release PHI to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release PHI about patients to funeral directors as necessary to carry out their duties.

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

Protective Services for the President and Others: We may disclose PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

For Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI about you to the correctional institution or law enforcement official. This release would 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 and security of the correctional institution.

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

Right to Inspect and Copy: You have the right to inspect and copy PHI that may be used to make decisions about your care. Usually, this includes health and billing records.

To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to PHI, you may specify a physician or chiropractor to which we may release your records. We will comply with the outcome of the review.

Right to Amend: If you feel 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 we keep the information. To request an amendment, you must complete a form entitled, Form to Request Amendment to PHI Retained in Designated Record Sets, which can be obtained by contacting our Privacy Officer. The completed form must be submitted to our Privacy Officer and must provide a reason that supports your request for an amendment. We may deny your request for an amendment if it is not in writing or 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 or for our business;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Any amendment we make to your PHI will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures: You have the right to request a list accounting for any disclosures of your PHI we have made, except for uses and disclosures for treatment, payment, healthcare operations, and business associates, as previously described. To request this list of disclosures, you must submit your request on a form entitled Request for Accounting for Disclosures of Health Information. This form may be obtained by contacting our Privacy Officer. Return the completed form to the Privacy Officer’s attention. Your request must state a time period, which may not be longer than six years and may not include dates before April 1, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.

Right to Request Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, and 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, such as a family member or friend. For example, you could ask that we restrict a specified nurse from use of your information, or that we not disclose information to your spouse about a surgery you had. To request a restriction or limitation, please contact our Privacy Officer to obtain the form entitled Form to Request Restrictions on Use and Disclosures of Protected Health Information. In your request, you must tell us what information you want to limit and to whom you want limits to apply; for example, use of any information by a specified nurse, or disclosure of specified surgery to your spouse. Return the completed form to the Privacy Officer’s attention. We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box. To request confidential communications, complete the form entitled Request for Confidential Handling of Health Information, which can be obtained by contacting our Privacy Officer. Submit the completed form to the attention of our Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a list of disclosures: You have the right to request a list of certain disclosures CSI may have made about you, such as disclosures of health information to government agencies that license CSI. Your request must be in writing. If you request such an accounting more than once in a 12-month period, we may charge a reasonable fee.

Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please contact our Privacy Officer.

Changes To This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for PHI we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain the effective date. In addition, each time you register for treatment or health care services, we will offer you a copy of the current notice in effect.

Complaints
If you believe your privacy rights haven been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact our Privacy Officer to obtain a Privacy Complaint Form. Submit the completed form to the attention of our Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of PHI
Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us 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 about you for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your permission, and are required to retain our records of the care that we provided to you.


Effective Date of This Notice: April 1, 2003.
Rev. 6/09, 9/10

For more information, please call CSI toll-free at: 1.888.873.8999.