U.S. ANESTHESIA PARTNERS, INC. NOTICE OF PRIVACY PRACTICES

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.

To appropriately treat you and receive payment for the services we provide, we need to obtain information from you including your full name and address, insurance company, family medical history, current medical history, and current medical condition. We will use and disclose this information and other information we collect in the ways described below. To help you understand how we will use and disclose your information we have put the different uses and disclosures into categories and give examples of each. All of the ways we use or disclose your information will fit into one of the categories listed below, but we cannot list all of the uses and discloses in each category.

We may use and disclose your health information, without your consent or authorization, for treatment, payment, and health care operations, and for the following other reasons.

Treatment. We may use and disclose your information to provide you with medical treatment and services. Your information may be disclosed to individuals and facilities providing care to you. These individuals and facilities need your information to provide care, and to coordinate and provide services (such as prescriptions, lab tests, meals, and x-rays).

Payment. We may use and disclose your information to receive payment for the services and treatment provided to you. We use your information to create a bill and disclose your information when we send the bill to your insurance company, you, or a third party. The individual or entity paying the bill may request more information to determine whether the bill is covered by your insurance. We may tell your health plan about a treatment you are going to receive to get approval for payment or to determine whether your health plan will cover the treatment.

Health Care Operations. We may use and disclose your information for health care operation purposes. Health care operations includes review of the care you receive for quality assessment, educational, business planning, and compliance plan purposes.

Business Associates. From time to time, we enter into agreements with Business Associates who perform services on our behalf. These Business Associates are required to keep your information confidential according to the terms of the agreement and the requirements of the Health Insurance Portability and Accountability Act (HIPAA) privacy rules. In general, Business Associates are required to keep your information confidential to the same extent as we are.

Appointment Reminders. We may provide appointment reminders to you. You may request in writing that we send reminders to a confidential or alternative address.

Treatment Alternatives. We may provide you with information about treatment alternatives and other health related benefits and services.

We may also disclose your health information to outside entities, without your consent or authorization, in the following circumstances:

Required by Law. We disclose information as required by law. For example, we are required to report gunshot wounds to the police.

Public Health Purposes. We disclose information to health agencies as required by law for preventing or controlling disease. Examples are reporting of sexually transmitted, communicable, and infectious diseases.

To Prevent a Serious Threat to Health or Safety. We may disclose information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.

Research. Your information may be used by or disclosed to researchers for research approved by a privacy board or an institutional review board.

Health Oversight Activities. Your health information may be disclosed to governmental agencies and boards for investigations, audits, licensing, and compliance purposes.

Judicial and Administrative Proceedings. We may be required to disclose your health information to a court or for an administrative proceeding.

Law Enforcement Activities. We may be required to disclose your information as required by law, pursuant to a court order, warrant, subpoena, or summons.

In Emergency Circumstances.

Deceased Individual. We may disclose information for the identification of the body or to determine the cause of death.

Military and Veterans. If you are a member of the armed forces we may release information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official. This release must 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 or security of the correctional institution.

Protective Services for the President and Others.

Organ and Tissue Donation. If you are an organ donor, we may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ bank, as necessary to facilitate organ or tissue donation.

Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs.

National Security and Intelligence Activities. We may release information about you to authorized Federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

We will give you the opportunity to object to the following uses and disclosure of your information:

Notification. We may tell your friends, relatives and other caretakers information which is relevant to their involvement in your care.

Disaster Relief. We may disclose information about you to public or private agencies for disaster relief purposes.

Except as provided above, we will obtain your written authorization prior to disclosure of your information for any other purpose. Specifically, written authorization is required prior to the disclosure of your information:

Psychotherapy Notes. We will not use or disclose your psychotherapy notes without a written authorization except as specifically permitted by law.

Marketing. We will not use or disclose your information for marketing purposes, other than face-to-face communications with you or promotional gifts of nominal value, without your written authorization.

Sale of Information. We will not sell your PHI without your written authorization, including notification of the payment we will receive.

Where a disclosure is made under your written authorization, you have the right to revoke the authorization at any time. Revocation of an authorization must be in writing. The revocation is effective as of the date you provide it to USAP and does not affect any prior disclosures made under the authorization.

If a state or federal law provides additional restrictions or protections to your information, we will comply with the most stringent requirement.

Your Rights

You, or a person with legal authority to act on your behalf, have the right to:

Request a restriction on how information about you is used and disclosed. If you want to request a restriction of a use or disclosure of your information, contact our Privacy Officer at the number or e-mail listed at the end of this form. We are required to agree to a request for a restriction related to disclosure of information to your health plan for payment or healthcare operations where you pay for the service in full. We are not otherwise required to agree to any restriction on the use or disclosure of your information.

Request communications with you be made at an alternative address or phone number. We will honor any reasonable request. To request that communication be made at a different address or phone number contact our Privacy Officer at the number or e-mail listed at the end of this form to obtain the form to make your request.

Inspect and copy your PHI maintained in the USAP designated record set. To inspect and copy your record a request must be made in writing on the form provided by USAP. There are limited situations in which USAP may deny this request. To obtain a form contact our Privacy Officer at the number or e-mail listed at the end of this form.

Request that we amend your medical record if you believe the information we have about you is incorrect or incomplete. Your request must be made in writing on the form provided by USAP. To request a form contact our Privacy Officer at the number or e- mail listed at the end of this form.

You have the right to receive an accounting of disclosures, a list of individuals and entities that received your health information for reasons other than treatment, payment, or healthcare operations and other certain disclosures. You may receive one (1) free accounting during a twelve (12) month period. If you request more than one (1) accounting in a twelve (12) month period, you will be charged a fee. An accounting is not provided for disclosures prior to April 14, 2003.

You have the right to request a paper copy of this Notice.

Our Duties

We are required by law to maintain the privacy of PHI and to provide individuals with this Notice of our legal duties and privacy practice regarding health information.

We are required to notify you if there is a breach of your unsecured PHI.

We are required to follow the terms of the current Notice.

We may change the terms of this Notice and the revised Notice will apply to all health information in our possession. If we revise this Notice, a copy of the revised Notice will be posted and a copy may be requested from our Privacy Officer at the number or e- mail listed at the end of this form.

Organized Health Care Arrangement

If you are an inpatient or outpatient of a hospital or other health care facility where our health care professionals perform services, our practice is part of an organized health care arrangement (OCHA) with the hospital or other health care facility and the Notice of Privacy Practices of the hospital or other health care facility controls the use and disclosure of your information. The participants in the OCHA will share your information as necessary to carry out treatment, payment, and healthcare operations, and as permitted by law.

Use of Electronic Records

We may use an electronic health record. Your records may be disclosed in electronic form for treatment, payment, and healthcare operations, and as permitted by law.

Questions

If you have questions about this notice or want more information, please contact the USAP Privacy Officer at 972-663-8531 or compliance@usap.com.

Complaints

If you believe your privacy rights have been violated or you disagree with a decision made by USAP about your health information, you may contact the USAP Privacy Officer at 972-663- 8531 or compliance@usap.com or you may contact the U.S. Department of Health and Human Services Office for Civil Rights.

Under no circumstances will we ever ask you to waive your rights under this notice or retaliate against you in any manner for filing a complaint.

Effective Date

The effective date of this notice is June 5, 2015.