Updated: July 1, 2016 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO YOUR MEDICAL INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice describes the practices of Laurel Life in connection with the use and disclosure of your health information and certain obligations we have regarding the use and disclosure of your health information. It applies to the health care professionals who are involved in your care and/or are authorized to enter information into your health record, and all of our employees, staff, and other personnel working for Laurel Life. We are required by law to maintain the privacy of your health information and to provide you with this Notice describing our privacy practices. We are required to abide by the terms of this Notice, as it is modified from time to time. WE MAY MAKE CHANGES TO THIS NOTICE IN THE FUTURE, AND ANY OF THE TERMS OF THIS NOTICE THAT ARE CHANGED WILL APPLY TO ALL OF YOUR HEALTH INFORMATION. IF WE CHANGE OUR NOTICE, YOU MAY OBTAIN A COPY OF THE REVISED NOTICE BY REQUESTING IT IN PERSON OR BY SENDING A WRITTEN REQUEST FOR A COPY TO OUR PRIVACY OFFICER AT 7564 BROWNS MILL ROAD, CHAMBERSBURG, PA 17202. HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION We are permitted or required to use your health information for various purposes. We cannot describe every possible use or disclosure of your health information in this Notice. However, uses or disclosures that we are permitted or required to make will generally fall within one of the following categories: For Treatment. We may use and disclose health information about you in order to ensure that you receive proper health treatment. For example, we may disclose your health information to another physician or health care provider involved in your care. For Payment. We may use and disclose health information about you so that we obtain payment for the treatment and services we provide to you from you, an insurance company or another third party. For example, we may need to give your health insurance plan information about your diagnosis and a description of the care we provided to you in order to receive payment for your care. For Health Care Operations. We may use and disclose health information about you for our health care operations. Health care operations are activities that are necessary to run Laurel Life, maintain licensure, and to make sure that our patients and clients receive quality care. For example, we may use your health information to review our treatment of you and the services we provided and to evaluate the performance of our staff in caring for you. Appointment Reminders, Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose health information to contact you to remind you that you have an appointment with us. We also may use and disclose health information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. To Avert a Serious Threat to Health or Safety. We may use and disclose health 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 threatened harm. Organ and Tissue Donation. If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ transplantation. Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illness as required or permitted by law if you are injured at work. Health Oversight Activities. We may disclose your health information to a health oversight agency such as licensing boards for activities authorized by law. Public Health Risks. We may disclose your health information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; contact a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and 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. Individuals Involved in Your Care or Payment for Your Care. We may discuss your health care with family members or close personal friends who are involved in your health care or payment for that care. You have the right to restrict or refuse any of these uses or disclosures. As Required By Law. We will disclose health information about you when required to do so by federal, state, of local law. Lawsuits and Disputes. We may disclose health information about you in response to a court or administrative order, a subpoena, discovery request, or other lawful process, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement. Under certain circumstances, we may release information about you if asked to do so by a law enforcement official. Coroners, Health Examiners and Funeral Directors. Under certain circumstances, we may release health information to a coroner, health examiner or funeral director. Government Purposes. We may release your health information under limited circumstances if you are a member of the armed forces or foreign military personnel or for counter-intelligence and other national security activities authorized by law. Protective Services for the President and Others. We may disclose health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations. Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information to the correctional institution or law enforcement official. This release would be if 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) the safety and security of the correctional institution. Disaster Relief. We may disclose your health information to an organization assisting in a disaster relief effort. Incidental Uses and Disclosures. We may use or disclose your health information if it is a by-product of any of the uses or disclosures described above and it could not be reasonably prevented. Limited Data Sets. We may use or disclose certain information that does not directly identify you for research, public health care or health care operations if the recipient of that information agrees to protect the information. Certain types of health information are subject to more stringent protections under state law than those described above. For example, mental health records, HIV related information and drug and alcohol abuse or dependence information is subject to special protections. Business Associates. We may disclose health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. Data Breach Notification Purposes. We may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclosure of your health information. DISCLOSURES WITH YOUR AUTHORIZATION The following uses and disclosures of your protected health information will be made only with your written authorization: Uses and disclosures of protected health information for marketing purposes; Disclosures that constitute a sale of your protected health information; and Disclosures of psychotherapy notes, except for (a) treatment by the originator of the psychotherapy notes, (b) use in training programs in which students, trainees or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family or individual counseling, (c) defense of a legal action or proceeding brought by the you and (4) to an appropriate oversight agency. We are also required to obtain your authorization to use or disclose health information in those situations not otherwise described in this Notice. If you do authorize us to use or disclose your health information, you have the right to revoke that authorization at any time. However, disclosures made in reliance on your authorization before you revoked it will not be affected by the revocation. YOUR RIGHTS IN CONNECTION WITH YOUR HEALTH INFORMATION You have the following rights in connection with the health information we maintain: Right to Inspect and Copy. You have the right to inspect and copy your health information that is in our possession. You may not, however, have access to psychotherapy notes or information that is put together for use in a civil, criminal or administrative proceeding. To inspect or copy your health information, you must submit your request in writing to our HIPAA Privacy Officer. We have up to thirty (30) days to make your protected health information available to you and we may charge you a fee for the cost of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request to inspect or copy your health information in certain very limited circumstances. If you are denied access to your health information, you may be able to request the denial be reviewed. Right to an Electronic Copy of Electronic Medical Records. If your protected health information is maintained in an electronic format (known as electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your protected health information in the form or format you request, if it is readily producible in such form or format. If the protected health information is not readily producible in the form or format you request, your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record. Right to Request Amendment. If you feel that your health information is incorrect or incomplete, you may ask us to amend that information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, your request must be made in writing and submitted to our HIPAA Privacy Officer. You must explain why you believe that the health information is incorrect or incomplete. If we deny your request, you have the right to give us a short statement to be placed in your health information or to have us include your request for amendment with your health information. Right to an Accounting of Disclosures. You have the right to request, and we must provide you with, a list of our disclosures of your health information. We are not required to include on that disclosures to carry out your treatment, payment for your care, and our health care operations and certain other disclosures. To request this list or accounting of disclosures, you must submit your request in writing to our office. Your request must state a time period covered by your request. That time period may not be longer than six years. 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 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 about you for treatment, payment or health care operations. This restriction includes the right to restrict or limit health information disclosed for treatment, payment or health care operations related to self pay services. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. We are not required to agree to your request. To request restrictions, you must make your request in writing to our office. 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 may ask that we only contact you at work or by mail. Your request must specify how or where you wish to be contacted. To request confidential communications, you must make your request in writing to our office. We will not ask you the reason for your request, and we will accommodate all reasonable requests. Right to a Paper Copy of This Notice. You may ask us to give you a copy of this notice at any time by asking for it in person or in writing. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured protected health information. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with Laurel Life or with the Department of Health and Human Services, Office of Civil Rights. Complaints to Laurel Life must be submitted in writing to the HIPAA Privacy Officer at the address below. To file a complaint with the United States Secretary of Health and Human Services, send your written complaint to: Region III, 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. You will not be penalized for filing a complaint. Contact Information: Questions, Comments, or Requests If you have any questions or comments about this notice or if you wish to obtain further information, please contact our HIPAA Privacy Officer: HIPAA Privacy Officer Laurel Life, Inc. 7564 Browns Mill Road Chambersburg, PA 17202 (717) 375-4834 All communications to our HIPAA Privacy Officer must specify your name and contact information in order for us to efficiently address your request.