THIS NOTICE TELLS YOU HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

SUMMARY OF YOUR PRIVACY RIGHTS

We may share your health information to:

• treat you
• get paid
• run the clinic
• tell family and friends about you
• do research
• appointment reminders
• law enforcement requests
• worker's compensation requests

We may use your health information for:

• health and safety reasons
• organ & tissue requests
• military purposes
• lawsuits
• national security reasons
• coroner, medical examiner or funeral director use
• tell you about other health benefits & services
• raise funds

Under HIPAA you have the right to:

• get a copy of your medical record
• change your medical record if you think it's wrong
• get a list of whom we share your health information with
• ask us to limit the information we share
• ask for a copy of our privacy notice
• complain in writing to UHC using the contact information below, if you believe your privacy rights have been violated

Privacy Officer
Unity Health Care, Inc.
1220 12th Street S.E
Washington, DC 20003
202-667-0016
hipaa@unityhealthcare.org

Additional information on your Rights and Responsibilities as a Patient can be found at the end of this document.

NOTICE OF PRIVACY PRACTICES

Who will follow this notice?
Unity Health Care, Inc including all corporate entities and locations, our employees, volunteers, and contractors will comply with the protection of your privacy as described in this notice.

Our Pledge:
We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services that you receive at Unity to ensure that we care providing quality care and to comply with legal requirements. This notice applies to all of your health information that we maintain, whether created by our staff or others, and tells you about the ways in which we may use or disclose your personal health information.

We are required by law to give you this Notice of our Privacy Practices, follow the terms of this notice, and to ensure that your health information is kept private.

How We May Use and Disclose Your Health Information:

Below are examples of uses or disclosures for each category

For Treatment. We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to the doctors, nurses, technicians, medical students and others who are involved in your care. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow your healing. We may also disclose your information to healthcare professionals outside of Unity in order to coordinate the different services you need.

For Payment. We may disclose your medical information so that treatment and service you receive may be billed to a third party. For example, if you have health insurance, we may need to share information about your office visit with your health plan in order for them to pay us or to reimburse you for the visit. We may also tell your health plan about treatment that you need to obtain your health plan’s prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. We may use and disclose your medical information for our day-to-day operations and to ensure that all of our patients receive quality care. We may also use and disclose health information about you to other health care providers involved in your care or to your health plan for use in their day-to-day operations. We may also disclose information to doctors, nurses, technicians, and other personnel for review and learning purposes. We may remove information that identifies you from this set of information so others may use it to study healthcare and healthcare delivery without learning who the specific patients are.

Appointment Reminders. We may use and disclose health information about you to contact you as a reminder that you have an appointment at Unity Health Care.

Health-Related Services and Treatment Alternatives. We may use and disclose health information to tell you about health-related services or recommend treatment options or alternatives that may be of interest to you. Please let us know if you do not wish us to contact you with this information, or if you wish to have us use a different address when sending this information to you.

Fundraising Activities. We may use health information about you to contact you in an effort to raise money for our not-for-profit operations. We may disclose health information about you to a foundation related to Unity Health Care so that the foundation may contact you in raising money for Unity Health Care. We will only release contact information, such as your name, address and phone number and the dates you received treatment or services from us. Please let us know if you do not want us to contact you for fundraising efforts.

Individuals Involved in Your Care or Payment for Your Care. We may release health information about you to a friend or family member who is involved in your health care or the person who helps pay for your care.

Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process one aspect of which is to ensure the privacy of your health information. We may disclose your health information to researchers who are in the planning stages of a research project. For example, we may help potential researchers look for patients with specific health needs, so long as the health information they review does not leave our facility. We will almost always ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are or will be involved in your care.

Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Lawsuits and Disputes. We may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request or other lawful process that is not accompanied by a court or administrative order, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the corrections 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.

Miscellaneous. We may use or disclose your medical information without your prior authorization for several other reasons. Subject to certain requirements, we may give out your medical information without prior authorization for public health purposes, abuse or neglect reporting, health oversight audits or inspections, funeral arrangements, organ donation and emergencies. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders. Additional special rules may apply to mental health records

Your Rights:
You have certain rights with respect to your personal health information. This section of our notice describes your rights. To exercise any of your rights outlined below, submit a written request to our Privacy Contact Person identified on the first page of this notice:

Right to Inspect and Copy: You have the right to inspect and copy the personal health information in your medical and billing records, or in any other group of records that we maintain and use to make health care decisions about you. This right does not include the right to inspect and copy psychotherapy notes, although we may, at your request and on payment of the applicable fee, provide you with a summary of these notes.

We may charge a fee for the copying and mailing costs, and for any other costs associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If your request is denied, you may request that the denial be reviewed. We will designate a licensed health care professional to review our decision to deny your request. The person conducting the review will not be the same person who denied your request. We will comply with the outcome of this review. Certain denials, such as those relating to psychotherapy notes, however, will not be reviewed.

Right to Amend: If you feel that the health information we maintain about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for any information that we maintain about you. In your request, you must provide a reason that supports your request for an amendment.

We may deny your request under certain circumstances. If we deny it, we will advise you in writing of the reason(s) and explain your rights to submit a statement of explanation.

Any amendment we make to your health information will be disclosed to the health care professionals involved in your care and to others to carry out payment and health care operations, as previously described in this notice.

Right to Receive an Accounting of Disclosures. You have the right to a list of those instances where we have disclosed your medical information other than for treatment, payment, healthcare operations or where you specifically authorized a disclosure.

To request an accounting of disclosures, you must state a time period that may not be more than six (6) years and may not include dates before April 14, 2003. 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.

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. 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 for your care, such as a family member or friend. For example, you may request that we not disclose information about you to a certain doctor or other health care professional, or that we not disclose information to your spouse about certain care that you received.

We are not required to agree to your request for restrictions if it is not feasible for us to comply with your request or if we believe that it will negatively impact our ability to care for you. When making a request to restrict disclosure of your health information, you must tell us what information you want to limit and to whom you want the limits to apply.

Right to Receive Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way. For example, you can ask that we only contact you at work or by mail to a specified address.

When making a request, specify how or where you wish to be contacted. We will accommodate all reasonable requests.

Right to a Paper Copy of this Notice. You have the right to receive a paper copy of this notice at any time. To receive a copy, please request it from our privacy contact person identified on the first page of this notice. You may also obtain a copy of this notice at our website, at www.unityhealthcare.org.

Changes to this Notice:
We reserve the right to change this notice and to make the changed notice effective for all of the health information that we maintain about you, whether it is information that we previously received about you or information we may receive about you in the future. We will post a copy of our current notice in our facility. Our notice will indicate the effective date on the first page, in the top right-hand corner. We will also give you a copy of our current notice upon request.

Complaints:
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. You may file a complaint by mailing, faxing or e-mailing us a written description of your complaint or by telling us about your complaint in person or over the telephone:

Privacy Officer
Unity Health Care, Inc.
1220 12th Street S.E
Washington, DC 20003
202-667-0016
hipaa@unityhealthcare.org

Please describe what happened and give us the dates and names of anyone involved. Please also let us know how to contact you so that we can respond to your complaint. You will not be penalized for filing a complaint.

Other Uses and Disclosures of Your Protected Health Information:
Other uses and disclosures not described above or covered by applicable law will be made only with your written authorization. You may revoke your authorization, in writing, at any time. You understand that we are unable to take back any uses and disclosures that we have already made with your authorization, and that we are required to retain our records of the care that we have provided to you.

UNITY HEALTH CARE, INC.
PATIENTS' RIGHTS

All patients will receive quality medical services by licensed or certified professionals in an appropriate health care setting. Patients will be treated with dignity and respect by all staff and all services will be delivered with sensitivity to differences in language, culture and personal values and beliefs. Patients have a right to:

1. Confidential medical advice and treatment. Patients’ medical information will be released only in compliance with the law.
2. Privacy while receiving care.
3. Receive clinical evaluation, diagnostic testing, treatment and appropriate follow-up care and/or referral.
4. Have medical conditions, medications and treatments thoroughly explained and discussed in appropriate language for lay persons to understand.
5. Consent to OR refuse testing, medications and treatment.
6. Pre- and post-test counseling for HIV testing.
7. Refuse to participate in research projects. If you do participate, you have the right to a complete explanation of the purpose and use of the research information and to withdraw from the project at any time.
8. Information about patients' rights and responsibilities and the organization's code of ethical behavior.
9. Information concerning resolution of patient complaints.
10. Have family members participate in your health care decisions.
11. Designate a surrogate decision maker for health care decisions.
12. Information about fee schedules and payment policies.
13. Know the rules of behavior in all Unity Health Care, Inc. settings.
14. Appeal termination of services through the Clinical Administrator of each health center.
15. Security of self and property.
16. The right to physical access to the health center regardless of physical impairment.

All patients have the right to present grievances, either verbally or in writing, to the Clinical Administrator or supervisor who will respond directly or present the grievance to the Medial Director d/or the management team.

UNITY HEALTH CARE, INC.
PATIENTS' RESPONSIBILITIES

All patients have certain responsibilities to Unity Health Care, Inc. in order to help us provide the best possible care for each patient. Patients have a responsibility to:

1. Treat staff members and other patients within the health center with dignity and respect at all times.
2. Utilize the appointment system rather than the walk-in system except when you are in need of urgent care.
3. Keep your regularly scheduled appointments. When this is impossible, you have a responsibility to notify the clinic and reschedule your appointment.
4. Provide the health center with written authorization to contact other physicians and clinics where you have been seen. This will enable the staff to obtain previous medical history and render more effective treatment.
5. Raise questions about instructions that are given to you. If for any reason you feel you cannot comply with the instructions, speak with a staff member right away.
6. Furnish the health center with your complete current address and phone number and update it whenever there are changes.
7. Provide complete and truthful information to enrollment and to medical services to make certain that the information you give for inclusion in your medical record is accurate and complete.
8. Provide accurate information to Unity staff regarding entitlements (e.g. Medicaid, Medicare) or other third party insurance coverage that you have in order to enable Unity to bill appropriately.