Effective July 2014

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. We also will be obtaining your written acknowledgement that you had the opportunity to review this Notice of Privacy Practices (“Notice”). This Notice applies to Dr. Steven Chudik, the Steven Chudik Shoulder, Knee and Sports Medicine Clinic, the Orthopaedic Surgery and Sports Medicine Teaching and Research Foundation (OTRF) and its affiliated member organizations hereafter referred to as just the Steven Chudik Shoulder and Knee Injury Clinic (“we” or “us”).

Understanding Your Medical Record/Health Information

Each time you visit a healthcare provider, a record of your visit is made. This information is often referred to as your medical record. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. Understanding what is in your record enables you to ensure its accuracy. Understanding how your health information is used helps you to better understand who, what, when, where and why others may access your health information and allows you to make more informed decisions when authorizing disclosure to others. By reading this Notice and signing the Acknowledgement and/or Receipt of Notice of Privacy Practices section on the Universal Consent, you are allowing us to use, access and disclose your health information for treatment, payment and healthcare operations.

Uses and Disclosures for Treatment, Payment and Healthcare Operations

We may use and share health information in order to provide “Treatment,” obtain “Payment” for treatment provided to you, and perform our “Healthcare Operations.” These three terms are defined as:

Treatment: We use and share your health information to provide other services to you, for example, to diagnose and treat your injury or illness. In addition, we may also share your health information with physicians, nurses, other caregivers or organizations involved in your present or future treatment.

Privacy: We may use and share your health information to obtain payment for services that were provided to you. For example, we may share your health information to request payment and receive payment from Medicare, Medicaid, your health insurer, HMO, other company or program that arranges or pays the cost of some or all of your health care. As another example, we may share your health information with the person who you told us is primarily responsible for paying for your treatment, such as your spouse, parent or personal representative.

Healthcare Operations: We may use and share your health information for our healthcare operations, which includes management, planning and activities that continually improve the quality and effectiveness of health care and services we provide. For example, members of the medical staff, risk or quality improvement teams may use information in your medical record to assess the care and its outcomes.

Uses or Disclosures the Steven Chudik Shoulder, Knee and Sports Medicine Clinic May Make Without Your Authorization

Notification and Disclosure to Relatives, Friends and Your Caregivers: We may use or disclose information to notify or assist in notifying a family member, personal representative or another person responsible for your care, your location and general condition. Caregivers, using their judgment, may disclose to a family member, other relative, friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Privacy: We will almost always ask for your specific authorization (permission) if the researcher(s) will have access to your name, address or other information that reveals your identity. However, under rare circumstances we may use or share your health information if the group that oversees our research, approves a waiver of authorization for disclosure or for a researcher to begin the research process. Limited Data Set: We may use or disclose a limited data set (i.e., in which certain identifying information has been removed) of your health information for purpose of research, public health or healthcare operations. Any recipient of that limited data set must agree to appropriately safeguard your information. Incidental Uses and Disclosures: Reasonable steps will be taken to ensure your privacy is protected; however, while providing your treatment, your information could be incidentally disclosed. Medical Examiners, Coroners and Funeral Directors: We may disclose health information to medical examiners, coroners and funeral directors consistent under applicable law to carry out their duties.

Research: Research: Dr. Steven Chudik’s outcome research is used to measure and improve his patient care and to help him provide the highest standard of care. Your personal health information (PHI), responses to questions and other information obtained during Dr. Chudik’s research will be kept private using reasonable measures and to the standards required by the Health Insurance Portability and Accountability Act (HIPAA).

Marketing: We may contact you to provide appointment reminders, case management, information about treatment alternatives, other health-related benefit, and services that may be of interest to you. Fund Raising: We may contact you as part of a general fund-raising effort in support of The Orthopaedic Surgery and Sports Medicine Teaching and Research Foundation (OTRF). Workers’ Compensation: We may disclose health information to the extent authorized by and necessary to comply with laws relating to workers’ compensation.

Health Oversight Agencies: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

As Required by Law: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Should you be an inmate of a correctional institution, we may disclose to the institution, or agents thereof, health information necessary for your health and the health and safety of other individuals.

Confidentiality of Mental Health, Alcohol and Drug Abuse Information

The confidentiality of mental health, alcohol and drug abuse medical records maintained by our program is protected by federal law and regulations. Generally, Dr. Steven Chudik or the Steven Chudik Shoulder, Knee and Sports Medicine Clinic may not acknowledge to anyone outside the program that a patient attends the program or disclose any information identifying that a patient is receiving treatment for alcohol or drug abuse unless one of the following conditions is met:

• The patient gives written consent for disclosure.
• The disclosure is allowed by a court order.
• The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation.

The conditions above generally apply as long as the patient is not a threat to self or others. Further, protection does not apply to the disclosure of information to the authorities for suspected abuse or neglect (child or adult).

Your Health Information Rights

Your medical record is the physical property of the organization that compiled it; however, the information within your medical record belongs to you. You have the right to:

• Obtain a Copy of This Notice of Privacy Practices: We will provide you with a paper copy of the current Notice if you request it.
• Request a Restriction on Certain Uses and Disclosures: You have the right to request restrictions on uses and disclosures of your health information for the purposes of treatment, payment or healthcare operations. We are not required to allow your request in all instances. If we do agree with the request, we will comply with your request except to the extent that disclosure has already occurred or if you are in need of emergency treatment.
• Request a Copy of Your Medical Record: You have the right to inspect and obtain a copy of your medical record, except in limited circumstances defined by federal regulations. If you are denied access to your medical record for certain reasons, the denial may be appealed. There may be a fee associated with providing you a copy of your medical record(s). It is your responsibility to inquire about the fee amount and for the payment of the fee prior to receiving your medical record copy.
• Request an Amendment to Your Medical Record: You may make a written request to amend your health information. You must give us a reason for the amendment. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement. We will provide you with a copy of any such rebuttal.
• Obtain an Accounting of Disclosures of Your Health Information: You may request an accounting of certain disclosures of health information made by us on or after April 1, 2002. Such disclosures will not include those made by Dr. Steven Chudik or the Steven Chudik Shoulder, Knee and Sports Medicine Clinic for purposes of treatment, payment or healthcare operations or disclosures to you or authorized by you.
• Request Alternate Communication of Your Health Information: You have the right to request that confidential communications be made by alternate means, for example, fax versus mail or at alternate locations. Your request must be in writing. We must honor your request if it is reasonable.

Our Responsibilities

Dr. Steven Chudik or the Steven Chudik Shoulder, Knee and Sports Medicine Clinic is required to:

• Maintain the privacy of your health information.
• Provide you with this Notice of our legal duties and privacy practices.
• Abide by the terms of this Notice.

We reserve the right to change our practices and to make the new provisions effective for all health information we maintain. If this Notice is changed, it will be displayed at common entry points and on our Internet site at www.stevenchudikmd.com.

For More Information or to Report a Privacy Concern

If you have any questions or would like additional information, you may contact Dr. Chudik at 630-324-0402. Additional information about filing a complaint with the Office for Civil Rights can be found at http://www.hhs.gov/ocr/privacy/.

Dr. Steven Chudik, the Steven Chudik Shoulder, Knee and Sports Medicine Clinic and the Orthopaedic Surgery and Sports Medicine Teaching and Research Foundation (OTRF) maintains a policy of non-retaliation on behalf of any individual who in good faith files a complaint.

DISCLOSURE

Dr. Chudik Industry Relationship Disclosure

Dr. Chudik is active in the research and development of new surgical techniques, instruments and implants, as well as new rehabilitation, injury prevention and performance programs. As part of this work, he collaborates with other healthcare businesses, including orthopaedic implant, physical therapy and sports performance companies, and provides expert consultation to support the research and development required to bring these new methods and technology to patients. In some instances, Dr. Chudik receives compensation for his time and expertise.

Dr. Chudik uses products and/or services from these companies, as well as others, in the care of his patients. You can be assured the selection of a product or service Dr. Chudik uses in the care of his patients is based solely on what is best for the patient and not on a particular company’s product or service.

Dr. Chudik occasionally seeks funding and/or assistance for his foundation in order to provide unbiased orthopaedic research and educational opportunities to pre-med students and athletic trainers. Dr. Chudik also provides instructional lectures on orthopaedic conditions, implants and surgical techniques to other doctors and medical personnel.

Dr. Chudik is a member of the American Academy of Orthopaedic Surgeons (AAOS) which holds its members to extremely high ethical standards to ensure that even the appearance of a conflict of interest does not jeopardize the trust patients place in AAOS doctors.

AAOS adopted Standards of Professionalism requiring orthopaedic surgeon members to identify and disclose potential conflicts of interest to their patients, the public and colleagues. These standards clearly articulate how and under what circumstances AAOS members may work with and be compensated by industry, as well as the penalties for failure to comply. You can learn more about these Standards of Professionalism to which Dr. Chudik stringently adheres at the AAOS website, www.aaos.org/industryrelationships/.

Full disclosure of his relationships with healthcare professions is very important to Dr. Chudik because he always puts the interests of his patients first and is open to answering any questions about his practice and professional relationships. Please do not hesitate to contact him if you have any questions or concerns.