Text Box: NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. The goal of Synergy Orthotics & Prosthetics (Synergy O & P) is to take appropriate steps to attempt to safeguard any medical or other personal information that is provided to us. We are required to: (i) maintain the privacy of medical information provided to us; (ii) provide notice of our legal duties and privacy practices; and (iii) abide by the terms and Notice of Privacy Practices currently in effect. WHO WILL FOLLOW THIS NOTICE This notice describes Synergy O & P’s practices of our employees and staff at all locations: Synergy Orthotics and Prosthetics, Plano Synergy Orthotics and Prosthetics, at Dallas Synergy Orthotics and Prosthetics, at Fort Worth All offsite clinics provided by Synergy O & P All of these locations will follow the terms of this notice and may share medical information with each other for treatment, payment, or healthcare operation purposes described in this notice. INFORMATION COLLECTED ABOUT YOU In the ordinary course of receiving treatment and healthcare services from us, you will be providing us with personal information such as: Your name, address, and phone number. Information relating to your medical history. Your insurance information and coverage. Information concerning your doctor, nurse or other medical providers. In addition, we will gather certain medical information about you and will create a record of the care provided to you. Some information also may be provided to us by other individuals or organizations that are part of your “circle of care” - such as your doctors, your health plan, and close friends or family members. Text Box: HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe different ways that we use and disclose medical information. Not every use or disclosure in a category is listed. For Treatment: We will use health information about you to furnish services and items to you, in accordance with the policies and procedures. For example, we will use your medical history, such as any presence of diabetes, to determine the orthotics or prosthetic device you might need. For Payment: We will use and disclose health information about you to bill for our services and collect payment from you or your insurance company. For example, we may need to give a payer information about your current medical condition in order to pay us for devices or other services that we have provided to you. We may also need to inform your payer of the treatment you are going to receive in order to obtain prior approval or to determine whether the device or services are covered. For Health Care Operations: We may use and disclose information about you for the general operation of our business. For example, we sometimes arrange for auditors or other consultants to review our practices, evaluate our operations, and inform us on how to improve our operations. Individuals Involved in Your Care or Payment for Your Care: We may disclose information to individuals involved in your care or in the payment for your care, but we will obtain your consent before doing so. This includes people and organizations that are part of your “circle of care”, such as your spouse, your doctors, or an aide who may be providing services to you. Although we must be able to communicate with your physicians or health care providers, you can let us know if we should not communicate with other individuals, such as your spouse or family. Our Business Associates: We sometimes work with outside individuals and businesses who help us to operate our business successfully. We may disclose your health information to these business associates so that they can perform the tasks that we hire them to do. Our business associates must guarantee to us that they will respect the confidentiality of your personal and identifiable health information. Other Public Policy Uses and Disclosures: There are a number of public policy reasons why we may disclose information about you. We will or may disclose health information about you when we are required to do so by federal, state , or local law, in connection with certain public health reporting activities, and in connection with certain health oversight activities of licensing and other agencies. We will disclose information in response to warrant, subpoena, or other order of the court or administrative hearing body, and in connection with certain government investigations and law

Privacy Practices (page 1)

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