BERKELEY MIDDLE SCHOOLS

Transcription

1 BERKELEY MIDDLE SCHOOLS H1N1 (Swine Flu) Vaccination Clinics December 2009 Dear Parents: The City of Berkeley Public Health Division, in partnership with the Berkeley Unified School District, will be offering free H1N1 vaccines at your child s school. Based on availability, vaccinations will be administered sometime after December 7, This is voluntary, not mandatory. The H1N1 vaccine comes in two forms: a shot and a nasal spray. Information about both forms is enclosed. No child will be vaccinated without the consent of a parent or guardian. If you would like your child to receive a free H1N1 flu vaccine at school then you MUST fill out the consent form completely. Please return the completed Immunization Consent and Release to your child s teacher by Friday, December 4, You will receive notification of the exact day and time of the vaccination clinic at your child s school once the schedule has been finalized. You do not need to return the consent form if you do not wish your child to be vaccinated at school. 1) Fill in this section using your student s name and information 2) The answers to these screening questions will be reviewed by a nurse to determine what type (shot or nasal spray) of H1N1 flu vaccine your student should get. Please review vaccine information sheet for more information and answer all questions 3) This box MUST be checked in order for your student to receive H1N1 flu vaccine 4) Don t forget to sign and date! If you have any questions or concerns after reading this material, please call (510) for more information. Remember, getting your child vaccinated is the best way to protect your child from getting and spreading the flu! Sincerely, Janet Berreman, MD, MPH City of Berkeley Health Officer William Huyett BUSD Superintendent

2 IMMUNIZATION CONSENT AND RELEASE Care Dynamix Inc dba Flu Busters CPT HCPCS G9141 First Name MI Last Name Number & Street Address City State Zip Code Phone Number - - Birth Date / / Age Name of School (where receiving vaccination) - Male Female H1N1 VACCINE The H1N1 flu vaccine does not protect against all strains of the influenza virus. The ability of flu vaccine to protect a person depends on the age and health status of the person receiving the vaccine, and the similarity or "match" between the virus strains in the vaccine and those in circulation. If you question whether you should receive the flu vaccine, please contact your personal physician. A small percentage of those vaccinated may experience minor side effects, such as soreness around the vaccination site for up to two days, headache or low-grade fever. Immediate, presumably allergic, reactions such as hives, angiodema, allergic asthma or anaphylaxis occur rarely after influenza vaccination. These reactions probably result from hypersensitivity to some vaccine component - the majority of reactions are most likely related to residual egg protein. Individuals with anaphylactic hypersensitivity to eggs should not be given an influenza vaccine. Guillain-Barre Syndrome (GBS) was noted to be a rare sequel of influenza vaccination during the 1976 "swine" influenza immunization program. Please contact your personal physician in the event of a reaction. Because of the potential for allergic reaction, your child will be asked to remain in the immediate area for observation purposes for the next 20 minutes after receiving the vaccine. PLEASE ANSWER ALL QUESTIONS. Please check "YES" or "NO" 1. Is your child allergic to eggs? 2. Has your child ever had a serious allergic reaction to the influenza (flu) vaccine or to any other type of vaccine? 3. Has your child ever had Guillain-Barre syndrome (a paralyzing illness)? 4. Has your child received a MMR and/or Varicella (chickenpox) and/or nasal flu vaccine in the past month? 5. Could your child be pregnant? 6. Does your child have any long term medical condition or a weakened immune system? a. If yes, please write the medical condition(s): 7. Does your child have asthma? 8. Does your child take aspirin every day? 9. Does your child have close contact with a person who needs to be in a protected medical environment (for example, someone who has recently had a bone marrow transplant)? By signing this form below, I understand that, depending on the answers to the questions above, my child will receive either the injectable or the nasal flu vaccine(s) at his/her school. I give my permission for my child whose name is listed above to receive the H1N1 influenza (flu) vaccines. WAIVER AND RELEASE I hereby release and forever discharge and hold harmless the City of Berkeley and Flu Busters and its directors, officers, employees, agents and assigns, any retail site, grocery store, pharmacy, corporation, physician and/or medical director and their respective directors, officer, employees, agents and assigns (hereinafter, collectively referred to as "Releasees") from any and all liability, claims, demands, and causes of action of whatever kind of nature, either in law or equity, which may hereafter arise from my child's receipt of the flu vaccine. I understand and acknowledge that this Consent and Release discharges Releasees from any liability or claim that may arise as a result of my child's receipt of the flu vaccine, with respect to any bodily injury or other injury, including any mental injury, illness, death, or property damage that may result. I understand that Releasees do not assume any responsibility or obligation to provide financial assistance or other assistance, including, but not limited to medical, health, or disability insurance, in the event of injury, illness, death or property damage, unless otherwise expressly governed by and interpreted in accordance with the laws of the State of California. I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not affect the remaining provisions of this Consent and Release. I HAVE RECEIVED, READ AND UNDERSTAND THE NOVEL H1N1 VACCINE INFORMATION STATEMENT. I HAVE HAD THE CHANCE TO ASK QUESTIONS AND DISCUSS MY CONCERNS WITH A HEALTHCARE PROFESSIONAL (please check box if "yes" and MUST be checked to receive vaccine). NURSE INFO ONLY Injectable Vaccine Nurse Initials Mfr. Lot # check one: Right Deltoid Left Deltoid Nasal Spray Nurse Initials Mfr. Lot # INFORMED CONSENT AND HIPAA PRIVACY INFORMATION I have read the above Consent and Release and understand its provisions and applicability. I understand the benefits and risks of the flu vaccine as described and request that the vaccine be given to me or the person named above for whom I am the legal guardian. My medical record may be shared with my physician and/or insurer. I understand that the City of Berkeley and Flu Busters will use and disclose my personal health information to treat me, to receive payment for the care it provides me, and for other health care operations, which generally include activities to improve the quality of care. I acknowledge that I have received a copy of Flu Busters' NOTICE OF PRIVACY AND CONFIDENTIAL PRACTICES. I hereby freely and voluntarily, without duress, execute this Consent and Release under the above written terms. Signature (or Legal Guardian) Date Print Name Nurse's Signature

3 2009 H1N1 INFLUENZA INACTIVATED (the flu shot ) VACCINE W H A T Y O U N E E D T O K N O W Many Vaccine Information Statements are available in Spanish and other languages. See 1 What is 2009 H1N1 influenza? 2009 H1N1 influenza (also called Swine Flu) is caused by a new strain of influenza virus. It has spread to many countries. Like other flu viruses, 2009 H1N1 spreads from person to person through coughing, sneezing, and sometimes through touching objects contaminated with the virus. Signs of 2009 H1N1 can include: Fatigue Fever Sore Throat Muscle Aches Chills Coughing Sneezing Some people also have diarrhea and vomiting. Most people feel better within a week. But some people get pneumonia or other serious illnesses. Some people have to be hospitalized and some die. 2 How is 2009 H1N1 different from regular (seasonal) flu? Seasonal flu viruses change from year to year, but they are closely related to each other. People who have had flu infections in the past usually have some immunity to seasonal flu viruses (their bodies have built up some ability to fight off the viruses). The 2009 H1N1 flu is a new flu virus. It is very different from seasonal flu viruses. Most people have little or no immunity to 2009 H1N1 flu (their bodies are not prepared to fight off the virus) H1N1 influenza vaccine Vaccines are available to protect against 2009 H1N1 influenza. These vaccines are made just like seasonal flu vaccines. They are expected to be as safe and effective as seasonal flu vaccines. They will not prevent influenza-like illnesses caused by other viruses. They will not prevent seasonal flu. You should also get seasonal influenza vaccine, if you want to be protected against seasonal flu. Inactivated vaccine (vaccine that has killed virus in it) is injected into the muscle, like the annual flu shot. This sheet describes the inactivated vaccine. A live, intranasal vaccine (the nasal spray vaccine) is also available. It is described in a separate sheet. Some inactivated 2009 H1N1 vaccine contains a preservative called thimerosal to keep it free from germs. Some people have suggested that thimerosal might be related to autism. In 2004 a group of experts at the Institute of Medicine reviewed many studies looking into this theory, and found no association between thimerosal and autism. Additional studies since then reached the same conclusion. 4 Who should get 2009 H1N1 influenza vaccine and when? WHO Groups recommended to receive 2009 H1N1 vaccine first are: Pregnant women People who live with or care for infants younger than 6 months of age Health care and emergency medical personnel Anyone from 6 months through 24 years of age Anyone from 25 through 64 years of age with certain chronic medical conditions or a weakened immune system As more vaccine becomes available, these groups should also be vaccinated: Healthy 25 through 64 year olds Adults 65 years and older The Federal government is providing this vaccine for receipt on a voluntary basis. However, state law or employers may require vaccination for certain persons. WHEN Get vaccinated as soon as the vaccine is available. Children through 9 years of age should get two doses of vaccine, about a month apart. Older children and adults need only one dose.

4 5 Some people should not get the vaccine or should wait You should not get 2009 H1N1 flu vaccine if you have a severe (life-threatening) allergy to eggs, or to any other substance in the vaccine. Tell the person giving you the vaccine if you have any severe allergies. Also tell them if you have ever had: a life-threatening allergic reaction after a dose of seasonal flu vaccine, Guillain Barré Syndrome (a severe paralytic illness also called GBS). These may not be reasons to avoid the vaccine, but the medical staff can help you decide. If you are moderately or severely ill, you might be advised to wait until you recover before getting the vaccine. If you have a mild cold or other illness, there is usually no need to wait. Pregnant or breastfeeding women can get inactivated 2009 H1N1 flu vaccine. Inactivated 2009 H1N1 vaccine may be given at the same time as other vaccines, including seasonal influenza vaccine. 6 What are the risks from 2009 H1N1 influenza vaccine? A vaccine, like any medicine, could cause a serious problem, such as a severe allergic reaction. But the risk of any vaccine causing serious harm, or death, is extremely small. The virus in inactivated 2009 H1N1 vaccine has been killed, so you cannot get influenza from the vaccine. The risks from inactivated 2009 H1N1 vaccine are similar to those from seasonal inactivated flu vaccine: Mild problems: soreness, redness, tenderness, or swelling where the shot was given fainting (mainly adolescents) headache, muscle aches fever nausea If these problems occur, they usually begin soon after the shot and last 1-2 days. Severe problems: Life-threatening allergic reactions to vaccines are very rare. If they do occur, it is usually within a few minutes to a few hours after the shot. In 1976, an earlier type of swine flu vaccine was associated with cases of Guillain-Barré Syndrome (GBS). Since then, flu vaccines have not been clearly linked to GBS. 7 What if there is a severe reaction? What should I look for? Any unusual condition, such as a high fever or behavior changes. Signs of a severe allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness. What should I do? Call a doctor, or get the person to a doctor right away. Tell the doctor what happened, the date and time it happened, and when the vaccination was given. Ask your provider to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you can file this report through the VAERS website at or by calling VAERS does not provide medical advice. 8 Vaccine injury compensation If you or your child has a reaction to the vaccine, your ability to sue is limited by law. However, a federal program has been created to help pay for the medical care and other specific expenses of certain persons who have a serious reaction to this vaccine. For more information about this program, call or visit the program s website at: 9 How can I learn more? Ask your provider. They can give you the vaccine package insert or suggest other sources of information. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): - Call (1-800-CDC-INFO) or - Visit CDC s website at or Visit the web at DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention Vaccine Information Statement 2009 H1N1 Inactivated Influenza Vaccine 10/2/09

5 VACCINE LIVE, ATTENUATED (the nasal spray vaccine) W H A T Y O U N E E D T O K N O W 2009 H1N1 INFLUENZA Many Vaccine Information Statements are available in Spanish and other languages. See 1 What is 2009 H1N1 influenza? 2009 H1N1 influenza (sometimes called Swine Flu) is caused by a new strain of influenza virus. It has spread to many countries. Like other flu viruses, 2009 H1N1 spreads from person to person through coughing, sneezing, and sometimes through touching objects contaminated with the virus. Signs of 2009 H1N1 can include: Fatigue Fever Sore Throat Muscle Aches Chills Coughing Sneezing Some people also have diarrhea and vomiting. Most people feel better within a week. But some people get pneumonia or other serious illnesses. Some people have to be hospitalized and some die. 2 How is 2009 H1N1 different from regular (seasonal) flu? Seasonal flu viruses change from year to year, but they are closely related to each other. People who have had flu infections in the past usually have some immunity to seasonal flu viruses (their bodies have built up some ability to fight off the viruses). The 2009 H1N1 flu virus is a new virus strain. It is very different from seasonal flu viruses. Most people have little or no immunity to 2009 H1N1 flu (their bodies are not prepared to fight off the virus) H1N1 influenza vaccine Vaccines are available to protect against 2009 H1N1 influenza. These vaccines are made just like seasonal flu vaccines. They are expected to be as safe and effective as seasonal flu vaccines. They will not prevent influenza-like illnesses caused by other viruses. They will not prevent seasonal flu. You should also get seasonal influenza vaccine, if you want protection from seasonal flu. Live, attenuated intranasal vaccine (or LAIV) is sprayed into the nose. This sheet describes the live, attenuated intranasal vaccine. An inactivated vaccine is also available, which is given as a shot. It is described in a separate sheet. The 2009 H1N1 LAIV does not contain thimerosal or other preservatives. It is licensed for people from 2 through 49 years of age. The vaccine virus is attenuated (weakened) so it will not cause illness. 4 Who should get 2009 H1N1 influenza vaccine and when? WHO LAIV is approved for people from 2 through 49 years of age who are not pregnant and do not have certain health conditions (see number 5 below). Groups recommended to receive 2009 H1N1 LAIV first are healthy people who: are from 2 through 24 years of age, are from 25 through 49 years of age and - live with or care for infants younger than 6 months of age, or - are health care or emergency medical personnel. As more vaccine becomes available, other healthy 25 through 49 year olds should also be vaccinated. Note: While certain groups should not get LAIV for example pregnant women, people with long-term health problems, and children from 6 months to 2 years of age it is important that they be vaccinated. They should get the flu shot. The Federal government is providing this vaccine for receipt on a voluntary basis. However, state law or employers may require vaccination for certain persons. WHEN Get vaccinated as soon as the vaccine is available.

6 Children through 9 years of age should get two doses of vaccine, about a month apart. Older children and adults need only one dose. 5 Some people should not get the vaccine or should wait You should not get 2009 H1N1 LAIV if you have a severe (life-threatening) allergy to eggs, or to any other substance in the vaccine. Tell the person giving you the vaccine if you have any severe allergies H1N1 LAIV should not be given to the following groups. children younger than 2 and adults 50 years and older pregnant women, anyone with a weakened immune system, anyone with a long-term health problem such as - heart disease - kidney or liver disease - lung disease - metabolic disease such as diabetes - asthma - anemia and other blood disorders children younger than 5 years with asthma or one or more episodes of wheezing during the past year, anyone with certain muscle or nerve disorders (such as cerebral palsy) that can lead to breathing or swallowing problems, anyone in close contact with a person with a severely weakened immune system (requiring care in a protected environment, such as a bone marrow transplant unit), children or adolescents on long-term aspirin treatment. If you are moderately or severely ill, you might be advised to wait until you recover before getting the vaccine. If you have a mild cold or other illness, there is usually no need to wait. Tell your doctor if you ever had: a life-threatening allergic reaction after a dose of seasonal flu vaccine, Guillain-Barré syndrome (a severe paralytic illness also called GBS). These may not be reasons to avoid the vaccine, but the medical staff can help you decide H1N1 LAIV may be given at the same time as most other vaccines. Tell your doctor if you got any other vaccines within the past month or plan to get any within the next month. H1N1 LAIV and seasonal LAIV should not be given together. 6 What are the risks from 2009 H1N1 LAIV? A vaccine, like any medicine, could cause a serious problem, such as a severe allergic reaction. But the risk of any vaccine causing serious harm, or death, is extremely small. The risks from 2009 H1N1 LAIV are expected to be similar to those from seasonal LAIV: Mild problems: Some children and adolescents 2-17 years of age have reported mild reactions, including: runny nose, nasal congestion or cough fever headache and muscle aches wheezing abdominal pain or occasional vomiting or diarrhea Some adults years of age have reported: runny nose or nasal congestion sore throat cough, chills, tiredness/weakness headache Severe problems: Life-threatening allergic reactions to vaccines are very rare. If they do occur, it is usually within a few minutes to a few hours after the vaccination. In 1976, an earlier type of inactivated swine flu vaccine was associated with cases of Guillain-Barré Syndrome (GBS). LAIV has not been linked to GBS. 7 What if there is a severe reaction? What should I look for? Any unusual condition, such as a high fever or behavior changes. Signs of a severe allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness. What should I do? Call a doctor, or get the person to a doctor right away. Tell the doctor what happened, the date and time it happened, and when the vaccination was given. Ask your provider to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you can file this report through the VAERS website at or by calling VAERS does not provide medical advice. 8 Vaccine injury compensation If you or your child has a reaction to the vaccine, your ability to sue is limited by law. However, a federal program has been created to help pay for the medical care and other specific expenses of certain persons who have a serious reaction to this vaccine. For more information about this program, call or visit the program s website at: 9 How can I learn more? Ask your provider. They can give you the vaccine package insert or suggest other sources of information. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): - Call (1-800-CDC-INFO) or - Visit CDC s website at or - Visit the web at DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention Vaccine Information Statement 2009 H1N1 LAIV 10/2/09

7 Immunization Registry Notice to Patients and Parents Immunizations or shots prevent serious diseases. Keeping track of shots you have received can be hard. It s especially hard if more than one doctor gave them. Today, doctors use a secure computer system called an immunization registry to keep track of shots. If you change doctors, your new doctor can use the registry to see the shot record. It s your right to choose if you want shot records shared in the California Immunization Registry. How Does a Registry Help You? Keeps track of all shots, so you don t miss any or get too many Sends reminders when you or your child need shots Gives you a copy of the shot record from the doctor Can show proof about shots needed to start child care, school, or a new job How Does a Registry Help Your Health Care Team? Doctors, nurses, health plans, and public health agencies use the registry to: See which shots are needed Prevent disease in your community Remind you about shots needed Help with record-keeping Can Schools or Other Programs See the Registry? Yes, but this is limited. Schools, child care, and other agencies allowed under California law may: See which shots children in their programs need Make sure children have all shots needed to start child care or school What Information Can Be Shared in a Registry? patient s name, sex, and birth place parents or guardians names limited information to identify patients details about a patient s shots What s entered in the registry is treated like other private medical information. Misuse of the registry can be punished by law. Under California law, only your doctor s office, health plan, or public health department may see your address and phone number. Patient and Parent Rights It s your legal right to ask: not to share your (or your child s) registry shot records with others besides your doctor not to get shot appointment reminders from your doctor s office to look at a copy of your or your child s shot records who has seen the records or to have the doctor change any mistakes If you DO want your or your child s records in the registry, do nothing. You re all done. If you DO NOT want your child s immunization shared in the registry, please call * By law, public health officials can also look at the registry in the case of a public health emergency.

8 Care Dynamix dba Flu Busters NOTICE OF PRIVACY PRACTICES As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS COMPANY) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY A. OUR COMMITMENT TO YOUR PRIVACY Our Company is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our Company concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time. We realize that these laws are complicated, but we must provide you with the following important information: How we may use and disclose your IIHI Your privacy rights in your IIHI Our obligations concerning the use and disclosure of your IIHI The terms of this notice apply to all records containing your IIHI that are created or retained by our Company. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our Company has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our Company will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time. In addition, a copy of the Notice is maintained on our website at B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Natascha Corbett, Privacy Officer, 235 Hembree Park Drive, Suite 300, Roswell, GA or (770) C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS The following categories describe the different ways in which we may use and disclose your IIHI. 1. Treatment. Our Company may use your IIHI to treat you. For example, we may use your IIHI to determine your eligibility to receive the flu vaccine. Many of the people who work for our Company including, but not limited to, our doctors and nurses may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your IIHI to other health care providers for purposes related to your treatment. 2. Payment. Our Company may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your IIHI to bill you directly for services and items. We may disclose your IIHI to other health care providers and entities to assist in their billing and collection efforts. 3. Health Care Operations. Our Company may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our Company may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our Company. 4. Treatment Options. Our Company may use and disclose your IIHI to inform you of potential treatment options or alternatives. 5. Health-Related Benefits and Services. Our Company may use and disclose your IIHI to inform you of health-related benefits or services that may be of interest to you. 6. Disclosures Required By Law. Our Company will use and disclose your IIHI when we are required to do so by federal, state or local law. D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES The following categories describe unique scenarios in which we may use or disclose your identifiable health information: 1. Public Health Risks. Our Company may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of including, but not limited to the following: maintaining vital records preventing or controlling disease, injury or disability notifying a person regarding potential exposure to a communicable disease notifying a person regarding a potential risk for spreading or contracting a disease or condition reporting reactions to drugs or problems with products or devices notifying individuals if a product or device they may be using has been recalled notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance. 2. Health Oversight Activities. Our Company may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general. 3. Lawsuits and Similar Proceedings. Our Company may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested in accordance with state and federal law and regulations.

9 4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official. 5. Deceased Patients. Our Company may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. 6. Serious Threats to Health or Safety. Our Company may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. 7. Military. Our Company may disclose your IIHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 8. National Security. Our Company may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. 9. Inmates. Our Company may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals. 10. Workers Compensation. Our Company may release your IIHI for workers compensation and similar programs. E. YOUR RIGHTS REGARDING YOUR IIHI You have the following rights regarding the IIHI that we maintain about you: 1. Confidential Communications. You have the right to request that our Company communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Natascha Corbett, Privacy Officer, 235 Hembree Park Drive, Suite 300, Roswell, Georgia 30076, (770) specifying the requested method of contact, or the location where you wish to be contacted. Our Company will accommodate reasonable requests. You do not need to give a reason for your request. 2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your IIHI, you must make your request in writing to Natascha Corbett, Privacy Officer, 235 Hembree Park Drive, Suite 300, Roswell, Georgia 30076, (770) Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our Company s use, disclosure or both; and (c) to whom you want the limits to apply. 3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records. You must submit your request in writing to Natascha Corbett, Privacy Officer, 235 Hembree Park Drive, Suite 300, Roswell, Georgia 30076, (770) in order to inspect and/or obtain a copy of your IIHI. Our Company may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our Company may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews. 4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our Company. To request an amendment, your request must be made in writing and submitted to Natascha Corbett, Privacy Officer, 235 Hembree Park Drive, Suite 300, Roswell, Georgia 30076, (770) You must provide us with a reason that supports your request for amendment. Our Company will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the Company; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our Company, unless the individual or entity that created the information is not available to amend the information. 5. Accounting of Disclosures. All of our patients have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain non-routine disclosures our Company has made of your IIHI for non-treatment, non-payment or non-operations purposes. Use of your IIHI as part of the routine patient care in our Company is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Natascha Corbett, Privacy Officer, 235 Hembree Park Drive, Suite 300, Roswell, Georgia 30076, (770) All requests for an accounting of disclosures must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, The first list you request within a 12-month period is free of charge, but our Company may charge you for additional lists within the same 12-month period. Our Company will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. 6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time, or you may obtain a copy of this notice from our website at To obtain a paper copy of this notice, contact Natascha Corbett, Privacy Officer, 235 Hembree Park Drive, Suite 300, Roswell, Georgia 30076, (770) Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our Company or with the Secretary of the Department of Health and Human Services. To file a complaint with the Secretary of the Department of Health and Human Services at the Office of Civil Rights at (800) or in writing to Region IV, Office of Civil Rights, U.S. Department of Health and Human Services, Atlanta, Federal Center, Suite 3B70, 61 Forsyth Street SW, Atlanta, Georgia To file a complaint with our Company, contact Natascha Corbett, Privacy Officer, 235 Hembree Park Drive, Suite 300, Roswell, Georgia 30076, (770) All complaints to the Company must be submitted in writing. You will not be penalized for filing a complaint. 8. Right to Provide an Authorization for Other Uses and Disclosures. Our Company will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records of your care. Again, if you have any questions regarding this notice or our health information privacy policies, please contact Natascha Corbett, Privacy Officer, 235 Hembree Park Drive, Suite 300, Roswell, Georgia or (770)