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. At LAKESHORE SURGERY CENTER, we believe individuals have a right to adequate notice of our policies, procedures and practices with respect to uses and disclosures of protected health information. LAKESHORE SURGERY CENTER is required by law to maintain the privacy of your health information and to provide you with a notice of our legal duties and privacy practices. We are required to and will abide by the terms in the Notice of Privacy Practices in effect at the time it is provided to you. You have the right to request a paper copy of this Notice of Privacy Practices even if we have provided a copy to you electronically by email. LAKESHORE SURGERY CENTER will not use or disclose your individually identifiable or protected health information other than to carry out health care treatment, payment, and/or operations for you, or as required by law. An example of treatment is a visit to our office for the purpose of surgery, diagnosis or care of a health issue wherein doctors, nurses, laboratory technicians and others will share the information about you in the course of your treatment. Payment includes sharing protected health information with an insurer or third party that may be responsible for collecting payment from a health plan. Healthcare operations means sharing protected health information for the purpose of quality review. LAKESHORE SURGERY CENTER will use and disclose protected health information to business associates in the course of providing treatment, securing payment for such treatment, and/or to facilitate health care operations of our practice, to facilitate the requirements of our business associates’ contracts, and to comply with requests from other covered entities to carry out treatment, payment or health care operations. Except for the purposes above, LAKESHORE SURGERY CENTER will only use or disclose protected health information with your express written authorization and you may revoke the authorization at any time in writing. The revocation will apply only to future uses and disclosures. Any information LAKESHORE SURGERY CENTER provides to a third party other than to our business associates or other health care providers with a treatment relationship with you will be de-identified or stripped of any and all personal data which could be used to identify a specific individual. LAKESHORE SURGERY CENTER may contact you to provide appointment reminders or to provide you with information about alternative treatments or heath care services we provided. When receiving communications from us, you may request that we communicate with you at an alternate location or by alternate means and we will make every effort to accommodate your request. You may request that certain uses and disclosures of your protected health information be restricted. To do so, you must provide a request in writing. LAKESHORE SURGERY CENTER will determine if the information constitutes required information to carry out treatment, payment or health care operations. If, in our sole opinion, your request does not involve information that is required by us to carry out treatment, payment or health care operations, we will accept your request for restrictions and will notify you if your request will be honored within 30 days or as required by law. With respect to your protected health information, you have the right to request and receive the following from LAKESHORE SURGERY CENTER: Inspecting and copying You may request a report containing your health information that has been collected by LAKESHORE SURGERY CENTER for you to inspect and copy. Such requests will be honored within 30 days or as required by law, and you will be notified in writing of LAKESHORE SURGERY CENTER’s receipt of the request and the date upon which the information will be available to you. Amendment or Correction You may request that we amend or correct your health information that has been collected by LAKESHORE SURGERY CENTER. Upon agreement by your health care provider, requests to amend health information will be honored within 30 days or as required by law, and you will be notified in writing of LAKESHORE SURGERY CENTER’s action taken. Accounting of the Disclosures You may request that we supply you with a listing of the disclosures of your protected health information which have been made by LAKESHORE SURGERY CENTER, except those made for treatment, payment or health operations, those required by the Final Privacy Rule or made pursuant to other law, and those made pursuant to your explicit authorization. Such requests will be honored within 30 days or as required by law, and you will be notified in writing of the date on which the accounting will be available to you. At a minimum, the accounting of disclosures will include the following information: Date of each disclosure Name and address of the organization that received the protected health information A brief description of the information disclosed LAKESHORE SURGERY CENTER has also required in our business associate contracts that they offer a means to provide a listing for you. If you believe that your rights have been violated, you may send questions or complaints about this notice or LAKESHORE SURGERY CENTER’s privacy practices to us and/or the Secretary of the Department of Health and Human Services (DHHS). Such communication with LAKESHORE SURGERY CENTER should be directed to: Office Manager, LAKESHORE SURGERY CENTER, The address of the Secretary of Health and Human Services is 7200 N. Western Avenue, Chicago, IL 60645. LAKESHORE SURGERY CENTER will not retaliate against you for filing a complaint with the Secretary of Health and Human Services. LAKESHORE SURGERY CENTER reserves the right to revise this Notice of Privacy Practices at any time without prior notification. You may request a copy of the revised notice and we will provide it to you. For additional information, please write to us at Office Manager, LAKESHORE SURGERY CENTER, 7200 N. Western Avenue, Chicago, IL 60645 or call (773) 761-6900. This Notice of Privacy Practices is effective as of July 1, 2005.