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COMconnect

COMconnect™ is web based technology that offers current and past medical and drug screen records on line. Through a secure and password protected web access point COM clients can obtain medical documents from your desk top. COM Connect™ will provide valuable data, appointment schedules and communications to save you time. COM Connect can be also utilized by insurance carriers to stream line information for claims adjusters. The trending and cost analysis features will provide critical information to eliminate or minimize costly risk.

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.

Please review before continuing to COMconnect™.

If you have any questions about this notice, please contact the Operations Officer at 574-389-1231.

WHO WILL FOLLOW THIS NOTICE

This notice describes Community Occupational Medicine, LLC practices and that of:

Any health care professional authorized to enter information into your medical

record(s).

All employees, staff, contract employees, interns, externs and other health system personnel.

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 Community

Occupational Medicine, LLC. 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 at this facility, whether made

by health system personnel or your physician.

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;

give you this notice of our legal duties and privacy practices with respect to medical information about

you; and;

to 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, or other health

system personnel who are involved in taking care of you at this, or any of our affiliated sites. For

example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes

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may slow the healing process. Different departments of the hospital and health system 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 health system who may be involved in your medical care after you leave our facility such as

employers, family members, or others we use to provide services that are part of your care.

For Health Care Operations - We may use and disclose medical information about you for health

system operations. These uses and disclosures are necessary to run the health system, to 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 health system patients to decide what additional services the

hospital or health system should offer, what services are not needed, and whether certain new treatments

are effective. We may also disclose information to doctors, nurses, technicians, and other health system

personnel for review and learning purposes. We may also combine the medical information we have

with medical information from other hospitals and health systems to compare how we are doing and see

where we can make improvements in the care and services we offer. We may remove information that

identifies you, from the medical information others may use, to study health care and health care

delivery without learning who the specific patients are.

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 within the health system.

Treatment Alternatives - We may use and disclose medical information to tell you about or

recommend possible treatment options or alternatives that may be of interest to you.

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 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.

Organ and Tissue Donation - If you are an organ donor, 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.

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.

Minors - Parents and/or legal guardians have a right to protected health information regarding their

minor children except when prohibited by law.

Public Health Risks - We may disclose medical information about you for public health activities.

These generally include the following:

o to prevent or control disease, injury or disability;

o to report births and deaths;

o to report child abuse or neglect;

o to report reactions to medications or problems with products;

o to notify people of recalls of products they may be using;

o 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;

o 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.

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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 Dispute - 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 or to obtain

an order protecting the information requested.

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 health

system 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 official for intelligence, counterintelligence and other national security activities

authorized by the 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.

Law Enforcement - We may release medical information if asked to do so by a law enforcement

official

o in response to a court order, subpoena, warrant, summons or similar process;

o to identify or locate a suspect, fugitive, material witness or missing person;

o about the victim of a crime if, under certain limited circumstances, we are unable to obtain the

person’s agreement;

o about a death we believe may be the result of criminal conduct;

o about criminal conduct at this medical 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.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT

AND OPT

Individuals Involved in Your Care or Payment for Your Care - Unless you object, we may disclose

to a member of your family, a relative, a close friend or any other person you identify, your Protected

Health Information that directly relates to that person’s involvement in your health care., If you are

unable to agree or object to such a disclosure, we may disclose such information as necessary if we

determine that it is in your best interest based on our professional judgment.

Disaster Relief - We may disclose your Protected Health Information to disaster relief organizations

that seek your Protected Health Information to coordinate your care, or notify family and friends of your

location or condition in a disaster. We will provide you with an opportunity to agree or object to such a

disclosure whenever we practically can do so.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

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

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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. Usually, this includes medical and billing records, but does not include

psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your

request in writing to the medical records department of Community Occupational Medicine, LLC. 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 copy in certain very limited circumstances. If you are denied access to

medical information, you may request that the denial be reviewed. Another licensed health care professional

chosen by this facility 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 the health system.

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

department of Community Occupational Medicine, LLC. 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 this facility;

is not part of the information which you would be permitted to inspect and copy; or

is accurate and complete

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. To request this list or accounting of

disclosures, you must submit your request in writing to the medical records department of Community

Occupational Medicine, LLC. Your request must state a time period which may not be longer than six years and

may not include dates before April 1997. 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 Health

Information we use or disclose for treatment, payment, or health care operations. You also have the right to

request a limit on the Health Information we disclose to someone involved in your care or the payment for your

care, like a family member or friend. For example, you could ask that we not share information about a

particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in

writing, to The Operations Manager. We are not required to agree to your request unless you are asking us to

restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care

operation purposes and such information you wish to restrict pertains solely to a health care item or service for

which you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the

information is needed to provide you with emergency treatment.

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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 must make your request in writing to the medical records

department of Community Occupational Medicine, LLC. 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 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.

Breach notification requirements – The obligation to notify patients if there is a breach of their PHI is

expanded and clarified under the new rules. Breaches are now presumed reportable unless, after completing a

risk analysis applying four factors, it is determined, that there is a “low probability of PHI compromise.”

Also the new rules do not modify the definition of unsecured PHI—that is, PHI that has not been properly

secured. Electronic PHI that is encrypted is secured, and thus not subject to the breach notification

requirements.

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 clinic. The notice will contain on the first

page, in the top right-hand corner, the effective date. In addition, each time you register at this facility you will

be offered a copy of the current notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Operations Officer of

Community Occupational Medicine, LLC or with the Secretary of the Department of Health and Human

Services. To file a complaint directly with this facility the Operations Manager can be reached at 574-389-1231.

All complaints must be submitted in writing. You will not be penalized for filing a complaint.

You may contact our office at Community Occupational Medicine, LLC at 22818 Old US 20, Elkhart IN 46516

or 574-389-1231.

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, we will no

longer use or disclose medical information about you for the reasons covered by your written authorization.

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.

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