Effective Date: April 14, 2003

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 Judith Lash, RN at 215-790-1788.

WHO WILL FOLLOW THIS NOTICE

This notice describes Philadelphia FIGHT and the Jonathan Lax Center's privacy practices and that of:

• All employees, staff, students and other FIGHT personnel who work in the following programs of FIGHT: the Jonathan Lax Treatment Center, the Family Planning Clinic at YHEP, Case Management at YHEP, the Diana Baldwin Clinic, the Case Management Department, and Care Outreach Department.
• Any health care professional including physicians, nurse practitioners, physician assistants, and psychotherapists authorized to enter information into your Lax Center chart.
• Any health care professional including physicians, nurse practitioners, physician assistants and psychotherapists authorized to enter information into your Family Planning Clinic chart.
• Psychotherapists, counselors, or other providers authorized to enter information into your Diana Baldwin Clinic chart.
• The Case Management department of the Lax Center.
• The Care Outreach department of Philadelphia FIGHT
• Volunteers we allow to help you while you are in the Lax Center, or a client of Care Outreach, Case Management, the Diana Baldwin Clinic, or the Family Planning Clinic at YHEP.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at Philadelphia FIGHT. This is usually referred to as your “chart”. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Philadelphia FIGHT and the Lax Center, whether made by FIGHT or Lax Center personnel or your personal provider.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Make sure that medical information that identifies you is kept private (with certain exceptions);
• Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical 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 medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. For example, your provider may need to tell another provider at the Lax Center that you have been hospitalized so that we can effectively coordinate your care. In another example, the doctor may need to tell the nutritionist if you have diabetes so that we can advise you about appropriate diets. Staff of the Lax Center also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.

We also may disclose medical information about you to people outside the Lax Center or FIGHT who may be involved in your medical care. Some examples are specialists such as dermatologists, oncologists, dentists, or psychotherapists.

For Payment.

We may use and disclose medical information about you so that the treatment and services you receive at the Lax Center or the Family Planning Clinic may be billed to and payment may be collected from an insurance company or a third party. For example, we may need to give your HMO information about care you received at the Lax Center so your HMO will pay us for this visit. 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.

To comply with requirements of our funders

We may use and disclose medical information about you to comply with requirements of our funders such as government agencies. Our major funding sources require that we provide medical information about a sample of our patients for monitoring purposes. We obtain your consent for this disclosure at your first visit.

For access to income support, social services and other programs.

We may use and disclose medical information about you for social service, entitlements, and other programs. Some examples are applications for social security disability payments, Medicaid or HealthChoices, HOPWA housing programs, or MANNA food deliveries. However, before we disclose medical information about you to anyone outside of Philadelphia FIGHT, we obtain your written consent.

For Health Care Operations.

We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run Philadelphia FIGHT programs including the Lax Center and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many Lax Center patients to decide what additional services FIGHT and the Lax Center should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Lax Center personnel for review and learning purposes.

Appointment Reminders.

We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at Philadelphia FIGHT and the Lax Center. We may use and disclose medical information to contact you as a reminder that you have an appointment for a research study in which you have enrolled at FIGHT. We obtain your consent for these reminders. This means that we do not contact you unless you have informed us that it is all right to do so, and we do not leave messages from Philadelphia FIGHT or the Lax Center unless you have told us that it is all right to do so.

Fundraising Activities .

We do not use medical information about you to raise money for Philadelphia FIGHT or its programs.

Individuals Involved in Your Care or Payment for Your Care.

Except in emergencies, we do not release medical information about you to a friend or family member who is involved in your medical care without your permission. We do not give information to someone who helps pay for your care unless you specifically request that we do so.

Research.

We always obtain your consent before we use and disclose medical information about you for research purposes. At your first visit, we obtain your consent for employees of Philadelphia FIGHT to look at your medical information to see if you are eligible for a research study. Before you enroll in a research study you will be asked to sign an informed consent, which will describe the purpose of the study, the study procedures, its potential risks and benefits, alternatives to participating in the research study, the study's procedures for keeping your information confidential, and any compensation you might receive. You might also be asked to sign an additional authorization for us to use and disclose information about you obtained during the research study, if you join a study after April 14, 2003, or if you sign a new informed consent after that date. You have the right to decline to participate in any research study and you have the right to withdraw at any time. If you withdraw from the study, we will stop collecting medical information on you for the study; however information collected before you withdrew will still be part of the study record

As Required By Law.

We will disclose medical information 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 medical information about you when necessary to prevent a serious threat to your health and safety consistent with Pennsylvania Act 148. This means that information may be disclosed to a health care provider to provide emergency care or treatment appropriate to the individual.

SPECIAL SITUATIONS

Organ and Tissue Donation.

We may release medical information 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. This information will only be released with your permission.

Military and Veterans.

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

Workers' Compensation.

We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. We will obtain your consent before we disclose medical information about you.

Public Health Risks.

We may disclose medical information about you for public health activities. These activities generally include the following:

• To report cases of CDC-defined AIDS and other reportable conditions as required by law;
• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report the abuse or neglect of children, elders and dependent adults;
• 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 medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes.

If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information 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 (which may include written notice to you) or to obtain an order protecting the information requested.

Law Enforcement.

We may release medical information if required 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 Philadelphia FIGHT 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.

Coroners, Medical Examiners and Funeral Directors.

We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the Lax Center to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities.

We may release medical information 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 medical information 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.

Inmates.

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information 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. We will attempt to obtain your consent before we disclose any information to the correctional institution .

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy.

You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing records, but may not include some mental health information.

To inspect and/or copy medical information that may be used to make decisions about you, you may ask your provider. It is our policy that this information should be provided to you upon request. If you feel you are having a problem obtaining medical information about you, you may also submit your request in writing to Karam Mounzer, MD, Medical Director. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and/or copy in certain very limited circumstances. A reason for the denial will be provided to you. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Lax Center 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 Amend.

If you feel that medical information 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 or for Philadelphia FIGHT and the Lax Center.

To request an amendment, your request must be made in writing and submitted to

Karam Mounzer, MD, Medical Director. In addition, you must provide a reason that supports your request.

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 medical information kept by or for the Lax Center;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Even if we deny your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you indicate in writing that you want the addendum to be made part of your medical record we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

Right to an Accounting of Disclosures.

You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you other than our own uses for treatment, payment and health care operations, (as those functions are described above) and with other expectations pursuant to the law.

To request this list or accounting of disclosures, you must submit your request in writing to Judith Lash, RN, Nurse Manager. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). 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.

Right to Request Restrictions.

You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information 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 surgery you had.

We are not required to agree to your request for a restriction and in some cases the restriction you request may not be permitted under law. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or comply with the law. Once we have agreed to the restriction you have the right to revoke the restriction at any time. Under some circumstances we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases we will need your permission before we can revoke the restrictions.

To request restrictions, you should inform your provider. You may also make your request in writing to your provider, or to Karam Mounzer, MD, Medical Director. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

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 a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you may inform your provider.. We will not ask you the reason for your request. We will accommodate all reasonable requests. Please specify in your request how or where you wish to be contacted. You may also make this request in writing to Karam Mounzer, MD, Medical Director, at the Jonathan Lax Center, 1233 Locust St. Philadelphia PA 19107.

Right to a Paper Copy of This Notice.

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

You may obtain a copy of this notice at our website: www.fight.org . To obtain a paper copy of this notice, please ask at the front desk of the Lax Center. Or you may call us at 215-985-4448.

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 medical information 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 the Lax Center. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, copies of the notice in effect will be available at the front desk and you have the right to request a current notice at any time.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Philadelphia FIGHT or with the Secretary of the Department of Health and Human Services. To file a complaint with Philadelphia FIGHT, contact Judith Lash, RN, Nurse Manager of the Lax Center. 215-790-1788. All complaints must be submitted in writing. No one will retaliate or take action against you for filing a complaint. To contact the Secretary of the Department of Health and Human Services, you can contact the Office for Civil Rights, U.S. Department of Health and Human Services, 150 S. Independence Mall West, Suite 372, Public Ledger Building, Philadelphia, PA 19106-9111. Main Line (215) 861-4441. Hotline (800) 368-1019. FAX (215) 861-4431. TDD (215) 861-4440 or visit www.hhs.gov/ocr/hipaa.

OTHER USES OF MEDICAL INFORMATION.

Other uses and disclosures of medical information 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 medical information about you, you may revoke that permission, in writing,

at any time. If you revoke your permission, this will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.