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Grilfin HosDital -i_ .._. ..."*. .^*s

GRIEFINTOSPITAL130 DIVISIONSTREET

I}ER3Y, CT 06418(203) 73s-7421

NOTICE OF PRIVACY PR.{CTICES

EIIS NOTICE DESG,IBES EOW MEX}ICALINT'ORMATION ABOTIT YOU MAY BE I]SEDAltD DXSCLOSED nr,m gow you cAI.[ cET

ACCESS TO IEIS II{F'ORMAIIONPI,EAS REVIEW IT CAREFI]LLY.

9Lff q$oNq'4B=,qgT THs NoTIcT: cdacrGriffaHospital t30 Divisio Srea,Derty, CT 06418,Arc Privrcy O6ceq (203) 732:2506, crothcDinctst, Mei.ical Records Deparbau4 130 DivisimStrcet, Derby, CT (203) 732-7390.

wEo WIIJ, FoI4oJ Es NoTrcE: Thisnshce dessdh Griffl Hoginl's practicgs end ltEtof auy health carc fdessi@d nihorizEd to cdrrinfo?i*im i6g6 ysnr ho*ital clar! all deparmadsnd -'ts sf tle hopial, aoy ncmbq og1 voludecr

' grorp *E 8llwto help you vrhile you arc in thchoqita! aII eqloyces, $atrad dErbosDiblpcrsomd md Grifia Eoryitl Occryatioal MeriicineCrcet, Gdffr F&ulty Praaicc pln, Valley Woueo's'Eealth Accxs ProgerD, Cemc ofExcellercc fcWomeu's Ecalt, GriEa Prwemion Research Ceuter,GriErEospiEt idegrdive Mediciue CEder, Giitrrphrt*rJ & Gifts AII these editicg sires EldlocCims followthe terms ofthis rstice. In adilitiom,these e,lcities, sites aad locatisns EEy $are DsdicaliEfGBstiotr wit! Fsch crther for tsFabeat, layE€d, Ghospial operatims purposes described h tlis !otic;.

OT'R PT,EDGT REGARDIr{G ti,trDIEALIIIFORMATION: We uldersand that EedisEljrforoatio aborr you aud yorrhealth is pelrsm{ Weate coEmitted to plotectiagmedical infontim sbouyoL We srEdte I reccrd of the sare ud services voureceive at the hospital We need this record to prvvideyou with qulity care ald to soEply with certain iegalrequiremeds This rotice applies to aII ofihe recordsofyorr care generatd by the hospital, whether madeLy horyital persmel oryowperscoal dostcr. yor.rpersonai doctor mey have diftrEnt poiicies cr noticesrcgardingthe doctor's.* and dsclosure ofvourmedical hfonnstiou created ilthe doctcds.{fice srcliuic. This lotice will tell you abord ttre vays in rrfiichwe may rse and disciose nedical inforruatiol abortyou- We also descn'be yourripits rnd certd!obiigaticns ue bave regardiug the use ald disclosure ofuedical idormatio-

We are reqqired by lawto uake srre thrt asdidiaformation

!h"t iileutifies you is kept private; give youthis nstice ofyour legd drties and privacy practioeiwith respect to medical idormztiou abori yorl anri{bllow the terms ofthe uqtice thst b cunerdly ia efect

followiag carcgories describe diE'ere$ wa5n fle weuse aud disclose medicai idorngtioE- Fcr eachcategory of uses u disclosr:reg we will e4laiu v&at*a sga! ftd ty to give some el:<a.qlies. Not every use

or disclosure ia a category witl be iisted llowever, allofthe vays we are pernited to tse and discloseiaformatim rvrll frll lpithin oue ofthe categorier.

'For Trtgfuent We may use aedicalirbmaricn abot yotr to provide you with medicaltrea&elf s services. We EEy disclose meficalinformaticn abort you to dostcs, nunes, tecbaicims,medical Sudeats, or other hospital perssuuel cfio lreinvolved in taking csre of you st the hospital Forexar4le, a doctorteating you fr a bmken leg mayueed to how ifyou bave iiiabetes because diabetesnay slow the healing pmcess h additim, tre doctornay need to tell the iiietitin ifyou bave diabetes sotbat ure cal anange for eppmprite meds DtrEr€rtdeparueub ofthe horyital also nay sharc EedicalinfcmatioF abolt yoB in orderto coordiDste thldiff'ercd rhihs you nee( such as prasctiptimr, labwort and x-rays We aiso oay disclosc meaiicalinforozticn gbou you to people ortside the hopital'whg oay be iuvolved in yorr oedical care aftsr you .

ierve the hospital such as finity meuberg clergr mothen we use io provide selvices rhrr at€ prrt ofyouC'IE.

For Pavment We may use ald di<closeneriical infornati@ abou you so thd the ucmed-d services you rEceive at the hospital may be brilled toand paymerf uay be cqllegted tm yo\ 8a irixEmrcecoqaly or r tbird party. Fcn oraryte, we mry aeedto give you health plan inforoatim. abort srgery youreceived at lhe hopital so yorr heallhpla will pry rsu rcimbuse you forthe surgery. We nay also tellyour hcalth plaa aborf a ftrrncc you rre goingtoreceivc ro obtringic approval cto daeruircuihether your plm will coycr thc testmeat

- For.rEealtt Carc Oocrations We meyurc-Jl-aad discie medical iofomltio abort you for h. oryitalcperrtiou. Thesc uses 8Dd disclo$nEs are necessrr5r tonn the horyital rnd rankc sure fht all of orr pcirmreseive qualig cara Fcex"-plq rrc uay use medicalhfmdim to rerriglp ottr' asd[:redt rnd services and toemluadc the perfqnsDra of ou saf ia caring fuyouWe may aiso comhine uedicsl idorn4i(E about --yhospital patieuts to decide n&at additimFt services thehoryital should oftr, nhat services are not needed, ald .

rtrether ceftaitnewtestElds arE eftetivc. We mavalso disciose iaforoticnto doctols, nrses,techicisnc mediesl $uded\ aad otherhospitalpersomel forreview and leamirypuposes We nryalso crmbine the meitical iaforEtio we have withmedical infudation &om other hospitals to coryarchow rile are doing aad see where we cat oakeirymveneos in the sare ald services ne oftr. Wemay remove iaicrmaticathFt iderfifies you Aom thisset of med.ical idonoatim so others may use it to sudyhealth care aud heslth carc delivery withort leardngv&o tbe specific patieft are.

.. . .{eooll@gnjReEinilers Wemav".eaodo.rsclose lDerucal llloElaEon 10 colrttact you 8s arcninlg1ttr4 ysu bave an appoi'rt-"'t for treDbrcd| 6.medical carc aa the hospiEl.

Tr.eatpe[t Alternetives \tre uay use anddisclose medical inforostion to teil you abo& oi.recommend possr'ble telheut options q! aiteridivestbu may be of icerecio you

Eealfh-.Related Benelits and Sen'ices. Wemay use and disciose medicsl idornatico to tell vouabod hesittr related benefits q services that may'be ofinterest to you

Fundraising Actirdties We may use meilicalfuformatim abort youto cutact you iu aa effort toraise noney forthe hospitai ad its orperatious. Weoay disclose uredical inforostico to a formdaticorelated to tbe hospibl so tbst the foundaticn maycontact you i! raising money for the hospiEl V/e calywouid relesse c@tact inforoztio4 such as you lamc,address and phcrne number and the dates you receivedteahed or sen'ices d tbe hospial If you do uot wadthe hospital to coffact you for fiEdraisilg effortr, ysu

HIPAA Form #2EHive Dder April 14, Z0O3

arrlrrroti$ Griffl liospital Developnen !,n(Grifi.nHospital 130 Dvisisa Street, Derby, Ci06418.

,. Foloitrl9ire.cton'. We nay hclurie certainiEuted uuonDElim aboE you in the hospihl directorvrfrf,e you are a pciem c the horyibl. Ihisinfomatim uay inoiude your!8ne, iocatim in thehospital your gcoeral oonriitim (e.g, goo4 fti!, ac.)aod your reiigious afEliatio- The direarvinfolmetioa except fr! your Eligious afrliatior, Esyalso be reieased to people vho ask for you b5r nrnr.

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Your rcligious afliatim nay be pvern to a nenrer s1the cier6l, such as a priest or nbbi, even ifthcy dcrn'task for you by 'ane. This is so yorr frnrly, fiendsand ciergr can visit you iuthe hospital and generaliykaow how you zre doiug:

Indiviiiuah hvolved in Your igl€ orPavment for Your Cerc- We may relcase medicalinforoatim aborr you to a friend u frFTly memt ervho is iuvolved iryornuedical crre. We may alsogive hformation to someonc ufio helps pay for yourcarc. We may also tell yorr ftoily or fiiends yorncoaditiotrEtrd rh'r you are in tle hospital In additio,ue ury disciose rnedical idornaticn bot youto inentity assi$ing ia 1 dis<ter Eliel[g6ert so that vourfrmily cau be uotif ed abort your coditirn, strrus audlocilltqL

Reseo.ch. Under certaia circuE$BDEEq vc Eavuse snd disciose Eedigsl inrofr4ioo lbout ysu fo.nsearch puposes lu exa4le, a reseamh gojeamay iuvolve cryaringthe healtt4ad rccovcry ofallpatiet< vho rcceived cae ncdicccim to tbose whoreceived another, forthc same coditio_ AIl rescarEh

._ Imjects, honicve4 rrE $bjaEl ta a-ryecial rpprornl

. pmcesa Ehisprocess evaluatesa prcposed researchploject 8Dd itsuse ofnedical fufmatio, lyiugObalance the research needs wift pati"nt<' med fuprivary ofttreir nedicai infmrtio_ Befun we use ordisciose meiiical infc(@tim fo rcsealr.b, the pojectwill have been aggoved tbmugh thfu nsearEh spprovslprocesg hd a,E nry, howiver, disslose nedicalinformation abori you to peopie prep8rilg to coldust aresearch project, fcn ex8!ele, to lelp lhern look fr

.patients with ryecific nedical aeedq so lmg as themedicEl idorrstio thry review does no! Iea.ve thehospital. We will almo* always ask firybu pecificpermissim ifthe researcher will hsvc acssss to yournrng, addrEs 91 otbgr informstio rt't Evesls vfroyou are, owill be iwolved in yorr carc r the horyial

.As Reouired Ev Law. We will disclosE

medicsi irfornatim abort you nrhen reguired to do so

b federal, $Ete or local lEw.

To .Avert a Serions Thrept to Eeslth orSar@!6 We rnay use and disciose medical inforostiotrabort you rrlen necessary to Feved a serious tlreat toyou heaith and vftty or the health aad safetSr oflhepublic or auotherpenon- Ary disclosure, howwer,would mly be to soneone able to help prevetthc&red.

SPECI,AL SITUAfiONS:Orgsn anal Tissne Donttio& If you are ao

orgzl dolor, we nay rclease medical iDforortim toorg3uiztiots rhlr hnndlg orgatr pro6lrrErneft or orEilreye or tissue tral*lautation cr! to & orgru donaticobat as necessary to frcilitate organ sr tissue donatiolard trarsplatrtEtin

Militarv eld Veterans If you an a memberofthe aroed forceq we may release medicalfuformatiol abort you os required by milinrycomoznd aElcrities. We may also release mEdicalinformation abort foreign nf,itary penonel to ttreappropriate foreign niiury auLority.

'Workerts Comoeusation, T{e may releasemedical idc$rtion aborf you for wo*cn'coryensatiou or similar pmgraus. These pmgrarasprovide beoefits for wo*-reiated injrries or :llaess

Pnblic Eerltt Risks We may disclosemedical infrnoatim abort you for public heaittactivitieE these activities generally include thcfo[o.wiug: to lIEvEd on cqtrol disease, injuy ordisability; to rryott hifts md deafhE to rErpoi-t shidabrse or legiecq to rEpolt tEacti@s to nedio*icns orproblelos with productq to noti$ pe4ie of recals ofpmduuts they uay be *i'g to nstiry a pcno rrhomay have been c4osed to a disease cnsy bs rt rirkfor co&ctiag cspadiDg s diseas c coditiq tonotifr the agprqriate gDveEmErt Eltthority if rvcbelieve a pried has becn lhc victin dabnrse, acgtector domestic violencc. We vrll oly mtce gi;disclosm ifyou agrce c cthc! requircd or arntsrizedby iaw.

.. 4F4th Oyersisht Activities. Wc nrv ,tiscloseDedrcar lItorlufi@ to E hEuith ovclsigb ageary fcactirrities arlhqized by law. ftesc wusigit astivitiesinciude, fcr ouqlq audiu,'iuve*igdi@t,inTection<, and iiccn$Ee. Ihcsc activitics altnecessary forte govelnlrrdto m@itmthe health careV{i+ got eEEerr programs, and coqliauce wilhcivil righsbur6.

Lgrtgui8 rrd Disntrtca Ifyou arc iwolved iaa lawsuit G a disprft, rre nzy disclose medicaliufonaado abort you in respcnse to a coint rrr.lh;nisttti.rre oder. We may also rfiebsa Dlgd.icslinforaatim abort you in r,epcose to a sbpoca4discwery reqwst, u chcrlavrfirl process Ly ,or.mcelse invoived ir thc diF {q brt mly if cmre Urcbeeu oade to tcll you aborrthc reqrtei, orto obtai! eorder protecting the idomadcn requeccrl

Law Euforcement We nay release nedicalfufoauatio ifaskcd to do so by r law eoftrcemrntgfficial h ES-o€ to r court qdcrrorbpocoq_ya*rt "*"T ot eim'trr Fmcesq to iderni$ cIocate a srryect, firghive, naterial wihesE orii*irePetsoa; abou the vicim of a ryine E urier cenain-linitert cirsmgm.ces" we:rc rmable to olnil thcprr8@'s agreemeq sbod a derith wc believ! tlry bcthe resdt of criEinrl cmdurt'abort ri-in"l sniuctd the hospiUt and in energiEc', cirEEsrqncestorepolt 8 criEe, the locsficn ofthe sriue ofvidimf qtle idertity, descriptio or loc*iou ofthc pcrs@ uihocomitted the crime.

Corons_rs. Medical E:amiuers and FuleralDirector.s. fit may reiease redi"dffiGETcorcner or medical BEEiter. This mly bc aecessary,for e:auple, to iderti$ a dcceased persm rdacriinette cause of deadt" We nay also rcl-ease medicatinforodim abort pdi"'*< oflle hosgital to fueraldireaors as aecessar5r to carry orn tdiir drties.

. IYitional Securitv ard InteUieenccActivities. We may rclease meaicat tfongtim abortyou to aUlorized federal offcials fcr iutelligrnce,colEleriutellige,ace, and other nrticnal secrdtyactivities adhorized by law.

^._ Pru.lFctive Sewices for the president eld

Others. We may disctose nraical inforosti;;E;you to aEhorjzed federal ofrci8.ls ro they ory prwideprotecticn to tle presideut, other artrhorizeii persos cforeign heads of $de of coDduEt special iwestigrcioas.

. trnmates Ifyousrc 8[ irnate ofa corrcstimatirurinrion or rmdcrthe custody of a law enfsr.enert_ofrcial, we may release medieal ilfrrostio! atort vouto the conestional itstifiti@ or l8w enforcemEttoftcial Ttis Eleasc vould be tecessary (l) brtheiutitrrico to pmvide you with health *i.rj fZl topro'tect you health sd s8ftty or the healtb aud safetvofottrerq or (3) forthe safety and security ofthes631scti mn I iustinrisn_

@rcal,AlFo.RlvIATIoN anOUI ybE: youEiltlerollowrag ngtls rcganiing nedicai idorogdo wcEaurEr!abouyoE

Rieht to Inspest ard CoEv. you have therEtr to Dspest rhd copy bedicsl infouatim +hrt mav

be used to !os&e desjsioEs aboE your care. UsuaIIy,this inciudes EEdical and billing records h[ does'r;inciude psychotr erapy notes.

J6 inTect aud copy medical inbrantiootbatnay be used to make decisims abot yoq you Eustsubmit your reguest h witilgto Medical fccordsDeprrtnd,.GritrnHoqpital lfyoureque$ a cory ofthe infcrordim, ue nay charge a fec foithe co*s ofcopying nqiling or oher srpplies associced with yourIEquest

. We may dely yorr request to irTect ald cqy i[

certain very limited circuostanccs Ifyou are aeaicaaeces to medical infomaticn, you Eay tequcst ihr, thederisl be reviewed Aaothcr licEfised heatti crnlmfessimal chosea by the hospial will reniew yourEqlest a19 the deaial lle persoa cmductiugthe

5:yre1y:I nc be the persa vfro denied yournque*.Wawill corylywiththe ortcme oftle revigw.

'Ripht to.Arnend. If you feel rhot med.i'cal

$rornalr@ we bave abou you is iucorect minc.'Tletq you rnay rsk Us to aueod the idorci@.Youhave the righto reque$ a[ srnendErat for gs iomas the infouuticn is kept by or fortbc hospital ToEque$ a! anendued, yourr€que$ rlust b€.msde irvriting aad submitted to Medical Reccrds Deparacc,GriffnHospita! 130 Divisicn Stsect,Derty, 6T05418. h additi@, you Eus poeide a reasrn tbrdsrpports your requesl We mzy deuy your request frau amendnet if it is not in writing or does nd ilcludca ressm to sryport tie requed. h adriitio, we maydeuy yourrequeS ifyou ask 'sto amcod iafomdiotlat rras notseded by rr, mlcssthe perso or etityih"t crested tLe idomatim is uo lmgcr nrailable to-rake the anend-F,,t is nm part ofrhe medicalidarEEfi$ keFt by c fch-tte hogital; is nd parr of _lths infouorrio vdich you would bc punitei toiDspest ad cop54 or is accurdc ald ir.dac.. S4Ug asequutins ofDisclosur* youIzrre lte nglt to rEgucst ro'accorming o[disclosues- lAis is a Ii$ of the di<clostrec rrre Erdeofnedical iuftnnatio abort yo[ To rcquesc rhii listu accorming of disclosres, you[|rS subEit yourregue$ i! Eitirgto Medical Records Oeparucc,GrifrrHopitg{9O Divisio Sregt, O.*y, Cf06418. Yorr reguest Eult stEte 1 rine prgriod. yfiichrosy rct be loagel rhm siy yss15 ssd may uot includedates before April 14, 2003. you rEquesr shouldiniiicaa in qrhat fqm you rad the Ii$ (for e:cqle, mpaper m eiectrouically). The first lieyourcqueswithir a 12 nonthperiod will be Aee, For additi@at

li"c lF utf cbarge you fu the co$ of prsviding fre1i$. We wiU Ddri$' you ofthe co* iwolved ad louuay choose to withdnw ormodiSyourreque$ ai rh.rtine lgfsre 8rry costs arE incuued"

. _ Rieht to R.equF4 Res{Tictious you have tlengttr to rEquest a re$ricti@ or liBitEticn ou themedical irforostiou we use or disclose abort you fute{tuel(t' psyEenJ or health care qenticrus you alsohave tle righr to request a limit cn the uedicalinfomation we disclose abort youto soaeorc who isiuyoived in your care orthe paymeut for yorr care, likes &m-ly EeErber or ftiad- For exaryIe, you couid a.skthlt we rrot ule or disclose infcnnricn aborf a surgeryyoutud Ve az not requhzdto agnE ro jort rtnud.Ifwe do agree, we will complywihyourrEque$ -uless the infonoation is needed to provide youeEergeroy teahe|d" To reques legigti@s, you EuShqke your request in writing to Medical Recsrds

P.qry:+ Griftr Hospial 13O Dvisicrn SteegDerty, CT 06418. in your reque$, you Eust tell us fi)v&st ilforodio! you wsut ro liEiq (2) whetherSrouwam to limit orr use, disclosue or bm[ aad (3)ioufiom you vrut the Iiaits to apply, tor ex"ryL,qrsdosures to your sporr€.

Rieht to Requ*t Cotr_fidentislCommuniqations, You bave fre rigirt to reqirest tbatve co@unicate with you abort medical natters in acedaia rny or at a certain locatios. lor example, you

2

cal ask ttat_we oiy coract you at n"nt or by nqil tsrequest cmfidential commrmicatio4 you nust :"rlcyour request in uiting to Medicai Recqds

Pq*g Gri6a Hospital 130 Divisioi Sucer,Defu, CT 064i8. We will not ark youthe reasm frnyou leguest We wili accsmrodde all reasoablcrequests Yourrcque* must specif how orrA.-re youwlsnIo 0e coftacte&

. F!4lto-e Papiro-s rlper Conv of This lfotice youIIrye rbe nBtt to a pEp.-r cwy of this lotice, you aav3sk

rs.1o eve You a copy oftbis uotice at ary dmc.Even if you hrve agecd to receivs &is mticeelectronically, you rre *itl editled to a paper copy ofthis astisg. You rD-Ey obtain a copy of this oCi.. ,t or1'website: www. grifrlhealthorg

To obtaia a paper copy ofrhis noticE cmtsctMcdical Records DepErbed, Griffit Hospital, i3ODivisiou Strest, Defty, CT 06418.

CEANGES TO TEIS NOTICE: We rcerpc rherigb to chaage this aotise. We rescrve the righ tomke the revised o cbanged aotice etrestivc fqmedical bfoungtio rve alrcarly havc aborf you as vetlas any informtim qre receive iE the firuc. We willpo$a copy oftle curnutnsticcinlhchospibt Tleuotice will cry*rin su thc firrt page, in the top rigitr.hmd comcq the efective dste. In adriitio, i"ch t*you rcgister a or 8rE r'rEited to the hopital furtEslDedt r health care sen'ices as a iupatied uolfpciem, we will o&ryou a copy of the crrrcdrotice iu eftct.

COWLAnffS: Ifyou believe yow pdvrcy righ- have becr violde( youmgy flg3 cdFFieid wil th!hosit l.by colzcting Gdffn Uopin! nnertiu.Privacy Ofrcer, e,03) 732-7506, nto ffE DirEstor,Medical Records DEpsrtEEd (203) ?32.f390, 130Dvisiu Sreet, Defty, gI, orfu cailingthD Glifr!Eoqpiul Aler&ine, 1-800-932-5328. AJI corytai*Eu$ br subtaited in writing rniess called in toAlertliac. You rray also filc a coqliu with tbcSecrEtsry of tha Depareed ofEealth and HrmraSen'iceC Offce of Civil Ri8iis, 200 hdepadeaccAve SW, Hrryhny Building; Mail Stop Room 505'F,Wr<h;rrgtm,9g 20201. You wiII not bCp"nqtb.d.lsyfiting I complaint

OTHER. USES OFMEDICALINFORMATION: Other uses aud disclosues ofmedical idormatica aot covercd by tlis aotice orthelasrtba apply to us will be made ouly witlyorrwriuen penaission Ifyou provide rs permissim to useor disclose medicsl inforostiotr abort yoq you to8yrevoke tb.rt pemisicm, il writing at auy time. If yourevoke yompermissico, we vdl no imgerlse udisclose medical inforasticn Bbotd you fsrlhe rcEsotscovered fui yorr wittea arr+.orizrtiou- you Ederstaudtlat wp ar= rrable to tske back auy disclosures we bavealready made wit! yourpermissio4 anf rhr+ vs arErequired to retaiu ourrecords ofthe care tb6 vreprovided to you