This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This policy also describes how the Granger Medical Clinic (GMC) and its affiliate clinic, Jordan Medical Arts (JMA), may use information about you. Further, this statement describes the privacy practices of GMC/JMA employees and providers.

State and Federal Laws and regulations require GMC/JMA to maintain the privacy of medical and health information about our patients. This notice describes our legal duties and privacy practices with respect to Protected Health Information. When we use or disclose Protected Health Information, we are required to follow the obligations described in this policy.

USES AND DISCLOSURES CONSENT AND AUTHORIZATION
In order to provide care, we will require you (our patient) to sign a consent to treat and consent to use and disclose your “Protected Health Information” for treatment provided, obtaining payment for services provided, and for our clinic operations (including administration of quality improvement and customer service).

TREATMENT
We use and disclose information that you provide us to treat and offer services to you. We may contact you to provide appointment reminders or offer information about treatment alternatives or other health–related information.

PAYMENT
We may use and disclose Protected Health Information to obtain payment for services that we provide to you. This may include such activities as claim processing and obtaining payment from your insurance carrier (or other company that arranges or pays the cost of some or all of your health care), verifying that your carrier will pay for health care, or coordinating your benefits from a secondary payer.

OPERATIONS
The GMC/JMA may use and disclose Protected Health Information for operations, which may include administration and planning programs that improve quality and effectiveness of the care that we provide. Such programs may include business planning, providing customer services, and conducting quality assessment and improvement activities.

USE OR DISCLOSURE WITH YOUR AUTHORIZATION
Your consent only permits us to use Protected Health Information for purposes of treatment, payment, and health care operations. We may use or disclose Protected Health Information for any reason other than treatment, payment, and health care operations only when (1) you give us your authorization by signing a GMC/JMA authorization form ("Your Authorization") or (2) there is an exception as noted in the following section.

USE AND DISCLOSURE WITHOUT CONSENT OR AUTHORIZATION
The GMC/JMA may use or disclose Protected Health Information for purposes of treatment, obtaining payment, and our health care operations without your consent or your authorization when you require emergency treatment; or when we try to obtain your consent but are unable to obtain it due to substantial barriers communicating with you and we reasonably infer that you would have consented in the absence of the barriers.

MARKETING COMMUNICATIONS
We may use or disclose Protected Health Information to identify health–related services and products that may be beneficial to your health and then contact you about those services and products available.

EMPLOYER SPONSORED HEALTH BENEFIT PLANS
We may disclose Protected Health Information to your employer so that your employer can monitor, audit, and otherwise administer your health plan. Your employer is not permitted to use your Protected Health Information for any purpose other than administration of your health plan. That means, among other things, that your employer cannot legally use your Protected Health Information in making employment decisions about you. Your health plan documents identify a contact person at your employer who receives, or can direct you to the person who receives Protected Health Information for the purpose of administration of your health plan.

PUBLIC HEALTH FUNCTIONS
The GMC/JMA may disclose Protected Health Information for the following public health activities and purposes: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability, as required by law and public health concerns; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk to contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work–related illnesses and injuries or workplace medical surveillance.

VICTIMS OF ABUSE, NEGLECT or DOMESTIC VIOLENCE
The GMC/JMA may disclose Protected Health Information without your consent or authorization to a government authority (social service or protective services agency), authorized by law to receive reports of such abuse, neglect, or domestic violence, if we reasonably believe that there may be abuse, neglect, or domestic violence issue.

HEALTH MONITORING FUNCTION
The GMC/JMA may disclose Protected Health Information to a health oversight agency that oversees the health care system and ensures compliance with the rules of government health programs such as Medicare or Medicaid.

AREAS OF POTENTIAL DISCLOSURES
The GMC/JMA may disclose Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
-We may disclose Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a
court order.
-We may disclose Protected Health Information to prevent or lessen a serious and imminent threat to a person's or the public's health or safety.
-We may disclose Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S.
Department of State.
-We may disclose Protected Health Information to a coroner or medical examiner as authorized by law.
-We may disclose Protected Health Information to organizations that facilitate organ, eye, or tissue procurement, banking, or transplantation.
-We may disclose Protected Health Information as necessary to comply with workers' compensation laws.

YOUR RIGHTS
If you would like more information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to Protected Health Information, you may contact the GMC/JMA administration office (801) 965-3417.

You may also file a written complaint with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services, which may be found in your local telephone directory. Should a complaint be filed, the GMC/JMA will not retaliate against you in any fashion.

YOU MAY SEEK FURTHER RESTRICTIONS
You may request restrictions on our use and disclosure of Protected Health Information (1) for treatment, payment, and health care operations, (2) to individuals (such as a family member, other relative, close personal friend, or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction.

CONFIDENTIAL COMMUNICATIONS
The GMC/JMA will follow your reasonable written request for you to receive Protected Health Information by alternative means of communication or at alternative locations.

ACCESS TO YOUR RECORDS
You may request access to your medical record file, as well as claims, claims payment, claims adjudication, case, medical management records, and your billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you request a copy or copies of your record, you may be charged a fee.

AMENDING YOUR RECORDS
You may request an amendment to your Protected Health Information retained in your medical record, payment, claims adjudication, case, medical management records, or billing records. We will agree to your request unless we believe that the amended information would not be accurate and complete, or other special circumstances may apply.

POSTING OF THIS NOTICE
This GMC/JMA Privacy Notice is available during the registration process when you come for an appointment. It is also posted in the GMC/JMA Business Office for your inspection.

DATE OF NOTICE, QUESTIONS OR COMPLAINTS
This Notice describes the Granger Medical Clinic privacy policy effective April 14, 2003 in accordance with the “Health Insurance Portability and Accountability Act 1996”, a federal law which specifies certain protections of your Protected Health Information. If a patient wishes to file a complaint related to this policy, you may contact: THE PRIVACY OFFICER, Granger Medical Clinic, 3725 West 4100 South, West Valley City, Utah 84120 or by writing to the Office of Civil Rights, U.S. Department of Health and Human Services.

RIGHT TO CHANGE TERMS
The GMC/JMA may change the terms of this Notice at any time. If a change is made the clinic may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. Should a change be required it will be posted in the GMC/JMA Business Office and made on future copies of this form.

HIPAA 4.14.03 v1