Effective Date: January 1, 2004

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.

Our Pledge Regarding Health Information

We are required by law to make sure that protected health information is kept private, to provide you with this notice of our legal duties and privacy practices relating to your protected health information, and to follow the terms of the Notice that is currently in effect.

Who Will Follow This Notice?

How We Protect Your Personal Information

Statement of Your Rights

You have the right to know how we use or disclose your personal medical information. There are certain uses and disclosures of your personal medical information that we are permitted or required to make by law without your permission.

In addition, you have:

• The right to request that we place additional restrictions on our uses and disclosures of your personal medical information, but we are not obligated to agree to any such restrictions.
• The right to access, to inspect and to copy the protected information pertaining to you that we maintain in our files. Our files may include prescription, treatment, and billing records. You may make the request either at our office or by sending a written request to our Privacy Officer. We may deny your request to inspect and copy in certain limited circumstances. Our policy is to personally deliver or send the requested records to the patient at the address on record for the patient. We may charge a reasonable fee for copies, postage, and supplies that are necessary to fulfill your request.
• The right to request that we correct or amend any personal medical information that we have about you if you feel that the information is incomplete or incorrect. In certain circumstances, we may deny your request for amendment. All denials will be made in writing. If we deny your request, you have the right to file a statement of disagreement with the decision and we may give a rebuttal to your statement.
• The right to receive an accounting of the disclosures of your personal medical information that we make for purposes other than activities related to your treatment, or our payment functions or other health care operations.
• The right to request that you receive communications of personal medical information in a confidential manner. For example, you may request that we call you at your work telephone number when your orthosis is ready. You must state how or where you would like to be contacted. We will accommodate all reasonable requests that we may require to be in writing.
• The right to obtain a paper copy of this notice from us on request.

Please, contact us if you have any question about your rights or about this notice.

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How We May Use and Disclose Health Information about You

The following are examples of ways we use and disclose protected health information.

Treatment: We will use and disclose your protected health information to provide you with treatment or services. For example, information obtained by us may be used to dispense orthopedic shoes or inserts to you. We also may use your protected health information, as necessary, to contact you to provide maintenance to our products and/or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We will also maintain records related to the care and services provided to you.

Payment: We may use and disclose health information about you so that the treatment and services you receive from us may be billed and payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain approval or to determine whether your plan will cover the treatment.

For Health Care Operations: We might use and disclose health information about you during any of the following activities:

• Quality assessment and improvement activities, including case management and care coordination;
• Competency assurance activities, including performance evaluation, credentialing, and accreditation of our facility;
• Conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs;
• Business planning, development, management and administration of our facility;
• Business management and general administrative activities of our facility, including but not limited to: de-identifying protected health information, creating a limited data set, etc.

Communication with Individuals Involved in Your Care or Payment for Your Care: Using our best judgment, we may disclose your protected health information to a family member, other relative, or any person you identify relevant to that person's involvement in your care or payment related to your care. For example, if you send a friend or relative to pick up your orthosis, we may disclose your protected health information to him or her.

Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an appointment. We may leave relevant appointment information on your home answering machine to assure that you are given information regarding items that you may need to bring to your appointment (such as X-rays, insurance cards, photo ID, etc.) Please, let us know if you do not wish to have us contact you concerning your appointment or if you wish to have us use a different telephone number or address to contact you for this purpose.

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Disclosure of Your Health Information as Required by Law

We will disclose health information about you when required or permitted to report your health information by federal, state, or local law. Some of these disclosures include:

Public Health Activities: Our facility may disclose protected health information to:

• Public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive report of child abuse and neglect;
• FDA adverse event reporting, tracking of products, product recalls, and post marketing surveillance;
• Individuals who may have contacted or been exposed to a communicable disease when notification is authorized by law;
• Employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or work-place related medical surveillance, because such information is needed by the employer to comply with the Occupational Safety and Health Administration (OSHA) or similar statute law.

To Avert a Serious Threat to Health or Safety: We may use or disclose your protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Victims of abuse, neglect, or domestic violence: We may disclose your protected health information to public authorities, as allowed, to report suspected abuse, neglect or domestic violence.

Health oversight activities: We may disclose protected health information about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations and inspections, licensure and other activities for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.

Worker's Compensation: We may disclose protected health information about you as authorized by law and as necessary to comply with laws relating to worker's compensation or similar programs established by law.

Judicial and Administrative Proceedings: Our facility may disclose protected health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurance regarding notice to the individual or a protective order is provided.

Correctional Institutions: If you are or become an inmate of a correctional institution, we may disclose protected health information to the institution or its agents when necessary for your health or the health and safety of others.

Law Enforcement: We may release health information if asked to do so by a law enforcement official:

• In reporting certain injuries, as required by law, gunshot wounds, burns, injuries to perpetrators of crime;
• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person:
• Name and address;
• Date of birth or place of birth;
• Social security number;
• Blood type and/or Rh factor;
• Type of injury;
• Date and time of treatment and/or death, if applicable;
• A description of distinguishing physical characteristics.
• About the victim of a crime, if the victim agrees to disclosure or under certain limited circumstances even if we are unable to obtain the person's agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at our facility;
• In emergency circumstances to report a crime, the location of the crime or victims, the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors: We may release protected health information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also disclose protected health information consistent with applicable law to funeral directors to carry out their duties.

Organ or Tissue Procurement Organizations: Consistent with applicable law, we may disclose protected health information about you to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Research: We may disclose protected health information about you to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Military and Veterans: If you area member of the armed forces, we may release protected health information about you as required by military command authorities. We may also release protected health information about foreign military personnel to the appropriate military authority. In addition, we may release your protected health information to help determine eligibility for benefits by the Department of Veterans Affairs.

National Security, Intelligence Activities, and Protective Services for the President: We may release protected health information about you to authorized federal officials for intelligence, counterintelligence, protective services to the President, other national security activities authorized by law.

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Other Uses of Your Health Information

We will obtain your written authorization before using or disclosing your protected health information for purposes other than those listed in this Notice or as otherwise permitted by law. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing protected health information about you, except to the extent that we have already taken action in reliance on your authorization or required by law.

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Changes to This Notice

We reserve the right to change this notice and the supporting policies and procedures. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility and on our web site at www.triumphpo.net . The notice will contain the effective date on the first page. In addition, each time you register for an appointment to benefit from our services, we will have available copies of the current notice in effect.

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Requesting Information or Reporting a Problem

If you have any questions about this notice, please contact our Privacy Official at (402) 434-5080. If you believe your privacy rights have been violated, you may complain either directly to us or to the Secretary of Health and Human Services in writing or verbally at the following addresses:

You will not be retaliated against in any way for filing a complaint. We know that your trust in us is very important and we are committed to protecting your privacy rights.