1) Do you have any allergies? ❑ Yes ❑ No known allergies Do you have a latex allergy? ❑ Yes ❑ No If yes, please list and briefly describe allergic reaction such as nausea or rash. (Include allergies to: medication, food, tape, latex, and topical solutions such as Betadine or Neosporin.)

____________________________________________________________________________________________

____________________________________________________________________________________________

Have you ever had an anaphylactic (severe life threatening) allergic reaction? ❑ Yes ❑ No Have you ever had a problem with topically applied or injected local anesthetics (Lidocaine, Novocain, etc.)? ❑ Yes ❑ No

2) Do you smoke? ❑ Daily ❑ Occasionally ❑ Never If daily, _____ packs a day for _____ years Are you a former smoker? ❑ Yes ❑ No If so, how many years ago did you quit?__________ Do you use smokeless tobacco? ❑ Yes ❑ No Nicotine patches or gum? ❑ Yes ❑ No

3) Do you drink alcohol? ❑ Daily ❑ Occasionally ❑ Never

4) Have you had a recent mammogram? ❑ Yes When? __________________________________ ❑ No Are you currently pregnant? ❑ Yes ❑ No Are you nursing? ❑ Yes ❑ No Are you actively trying to become pregnant? ❑ Yes ❑ No

5) Have you ever had surgery or been hospitalized? ❑ Yes ❑ No If yes, please describe what type of surgery, procedure, or condition, year, and name of physician. (Include childbirth, C-sections, injuries or accidents, cardiac caths, breast mass biopsy, broken bones, etc.)

____________________________________________________________________________________________

____________________________________________________________________________________________

Do you take blood thinning medications (Asprin, Plavix, Coumadin, etc.)? ❑ No ❑ Yes (Please list) ____________________________________________________________________________________________

6) Have you ever had general anesthesia before? ❑ Yes ❑ No If yes, did you experience any problems related to anesthesia? (i.e., nausea) ❑ Yes ❑ No If yes, please describe ____________________________________________________________________________________________

____________________________________________________________________________________________

7) What is your height? _____________ weight? ______________ _________ Over the last six months, has your weight: ❑ Increased ❑ Decreased ❑ Remained stable

8) Please describe any recent life changes or stressful events? (such as a new job, new baby, recent move, graduation, marriage, divorce, etc.)

____________________________________________________________________________________________

9) List any family history of illness _________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

10) Do you have a religious or other objection to receiving blood transfusions if your doctor deems it medically necessary? ❑ Yes ❑ No

Have you ever had any of the following?

Anemia .......................................... ❑ Yes ❑ No

Bone / Joint problems .................... ❑ Yes ❑ No

Breast mass / Lump ....................... ❑ Yes ❑ No

Cancer .......................................... ❑ Yes ❑ No

Drug dependency .......................... ❑ Yes ❑ No

Exposure to chemotherapy ............ ❑ Yes ❑ No

Exposure to radiation ..................... ❑ Yes ❑ No

Gold injections for arthritis ............. ❑ Yes ❑ No

Hearing problems .......................... ❑ Yes ❑ No

High blood pressure ...................... ❑ Yes ❑ No

HIV ................................................❑ Yes ❑ No

Keloids or abnormal scars ............. ❑ Yes ❑ No

Migraine headaches ...................... ❑ Yes ❑ No

Mitral valve prolapse ...................... ❑ Yes ❑ No

Nasal airflow obstruction ................ ❑ Yes ❑ No

Peripheral vascular disease ........... ❑ Yes ❑ No

Pneumonia .................................... ❑ Yes ❑ No

Mental health conditions ................ ❑ Yes ❑ No

Reproductive system problems ...... ❑ Yes ❑ No

Sickle cell anemia .......................... ❑ Yes ❑ No

Speech problems .......................... ❑ Yes ❑ No

Swallowing difficulty ....................... ❑ Yes ❑ No

TB ................................................. ❑ Yes ❑ No

Heart problems .............................. ❑ Yes ❑ No

Diabetes ........................................ ❑ Yes ❑ No

Lung problems............................... ❑ Yes ❑ No

Bleeding/clotting disorders ............. ❑ Yes ❑ No

Sleep apnea .................................. ❑ Yes ❑ No

Thyroid problems ........................... ❑ Yes ❑ No

Hepatitis ........................................ ❑ Yes ❑ No

Liver problems ............................... ❑ Yes ❑ No

Stroke............................................ ❑ Yes ❑ No

Seizures ........................................ ❑ Yes ❑ No

Auto immune disease .................... ❑ Yes ❑ No

Cold sores/fever blisters ................ ❑ Yes ❑ No

Other medical problems - please describe:

__________________________________

__________________________________

__________________________________

❑ No known medical problems

Name__________________________________________________________________________

DOB:__________________ MRN:_____________________ Date:_ ________________________

99659 - Plastic Surgery Health History Questionnaire 1/16 - page 1 of 2

Health History Questionnaire

❑ Sonia Alvarez, M.D.❑ Ben Gbulie, M.D. ❑ Petros Konofaos, M.D.❑ Roberto D. Lachica, M.D.

❑ Edward Luce, M.D.❑ Alex Senchenkov, M.D.❑ Robert D. Wallace, M.D.

Patient MRN: ______________________________

Name: ____________________________________

DOB: ______________________________________Patient Stamp or Label Above

1068 Cresthaven Road, Suite 500Memphis, Tennessee 38119-0846P 901.866.8525 F 901.302.2525

University Plastic Surgeons Health History Questionnaire - page 2

Name___________________________________________________________

DOB:_________________________ MRN:____________________________

Date: __________________________________________________________

What are your areas of concern? _____________________________________________________________________________

_____________________________________________________________________________________________________

It is important that your medical record stays up-to-date. Please keep us informed of any changes at future visits. Thank you.

❑ I have reviewed and confirmed the above history with the patient:

Ancillary staff / Date (if applicable): ____________________________________________________________________________________

Physician signature / Date: __________________________________________________________________________________________

Medications (Write name of medication and its dosage — include over-the-counter and supplements) (Be sure to include vitamins, birth control pills, diet pills, aspirin, ginseng, over the counter medication, etc.)

Name of medication and dosage Name of medication and dosage Name of medication and dosage

❑ None – No prescription medications ❑ None – no over-the-counter medications ❑ Medication List Reviewed by: _________________________________

Patient MRN: ______________________________

Name: ____________________________________

DOB: ______________________________________Patient Stamp or Label Above

Instructions: Please fill out this form completely in ink (please print). All information is strictly confidential! This information will not be released to anyone except when you have authorized us to do so. Please notify the receptionist at subsequent visits whenever any of the information below changes. We want to keep your records as accurate and up-to-date as possible. If you have any questions or need assistance, please ask us — we are happy to help.

Name: ___________________________________________________________________________Date: _________________________________ First Middle Last

Marital status: ❑ single ❑ married ❑ divorced ❑ separated ❑ widowed

Address: _______________________________________________________________________________________________________________ Street Apt# City State Zip

Home phone: __________________________________________ Work phone: _____________________________________________________

Cell phone: ____________________________________________ E-mail address: ___________________________________________________

May we call you at work? ❑ Yes ❑ No May we leave a message on your answering machine? ❑ Yes ❑ No

Preferred method of contact? ❑ home phone ❑ work phone ❑ cell phone ❑ email

Would you like to receive email newsletters about our practice? ❑ Yes ❑ No

Birthdate: _____________________________ Age: _________ Sex: __________ SSN: _________________________________________________

Employer: _________________________________________ Type of work/occupation: _______________________________________________

Name of person to contact in case of emergency: _____________________________________________________________________________

Relationship to patient: ___________________________________________________________________________________________________

Home phone: _______________________________________ Work phone: ________________________________________________________

Who are the doctors and therapists that participate in your care?

Speciality Name Phone #

Primary care physician ________________________________________________ __________________________

________________________________ ________________________________________________ __________________________

________________________________ ________________________________________________ __________________________

Have you had a recent checkup? ❑ Yes - if so, when?____________________________________ ❑ No

Pharmacy:_______________________________________________________Pharmacy phone: ________________________________________

How did you hear about our office? _________________________________________________________________________________________

What brings you to see the doctor today? What issues would you like to discuss? _______________________________________________________

_______________________________________________________________________________________________________________________

I request and authorize the direct payment of any benefits (including Medicare) directly to U T Medical Group, Inc. I authorize the re -lease of any information necessary to process all claims for services provided. I permit a copy of this authorization to serve as the original. I understand that I am financially responsible for any unpaid balance and for the entire bill if a claim is not covered by insurance.

Signature: ________________________________________________________________________ Date:_________________________________

99631 - 1/16

Patient Information❑ Sonia Alvarez, M.D.❑ Uzoma Gbulie, M.D. ❑ Petros Konofaos, M.D.❑ Roberto D. Lachica, M.D.

❑ Edward Luce, M.D.❑ Alex Senchenkov, M.D.❑ Robert D. Wallace, M.D.

1068 Cresthaven Road, Suite 500Memphis, Tennessee 38119-0846P 901.866.8525 F 901.302.2525

*If Personal Representative, the patient is unable to sign because (check one):

❑ Minor ❑ Incompetent ❑ Other (explain): _____________________________________________________________________

Date received ____________________ ❑ All complete ❑ Proof of I.D. ❑ Signed copy to patient

Received by (employee name): ______________________________________ Title: _______________________________________

For Office Use Only

Signature of Patient or Personal Representative*

Date

Printed Name of Patient or Personal Representative*

*Relationship to Patient (if Personal Representative)

Authorization To Photograph And Publish

090024 - 1/16 White copy - Medical Record Yellow copy - Patient

Please PRINT or TYPE and return completed form to the above address.

Patient Name: _______________________________________________________________________________________________

Address: _____________________________________________________City:____________________ State: ___ ZIP: _________

Date of Birth: ________ / ________ / _______________ Phone Number: ________________________________________________

1. I authorize University Clinical Health (“UCH”), including their physicians and support personnel, to obtain, use, and disclose photographs of me or my family member(s). I authorize the use of my pictures for the following purpose(s).

6 Medical Care Only (required) ❑ Educational Purposes ❑ Publicity ❑ Research ❑ Before and After Photo Album ❑ Media

2. I agree that the photographs may be published or used for purposes which my physician or UCH deems proper. These uses or disclosures may be made in connection with educational lectures, presentations, publications, journals, textbooks, and other media, including forms of electronic publications or distribution and to those persons attending such events or receiving such items. I also understand that in some cases my facial features may be visible and/or recognizable (facial surgeries only).

3. I understand that I will not be identified by name, date of birth, or social security number. In addition, I understand that photographs shall remain the property of UCH, and I relinquish any rights I may have to the photographs.

4. I may revoke this authorization any time by sending a written request to: UCH Health Information Services Depart-ment at 1407 Union Avenue, Suite 700, Memphis, TN 38104; (901) 866-8636. I understand that the revocation will not apply to information that has already been obtained, used and/or disclosed under this authorization. Such written revocation will be effective only after receipt and processing by UCH. If I revoke this authorization, the information described above may no longer be used or disclosed for the purposes described in this authorization. In the event UCH ceases to engage in the activities identified above, this Authorization shall expire.

5. I understand that a disclosure of information under this authorization carries with it the potential for re-disclosure by the recipient and that the information may no longer be protected by federal confidentiality rules. If I have questions about the uses and disclosures of my health information at UCH, I can contact: UCH Privacy Officer at 1407 Union Avenue, Suite 700, Memphis, TN 38104; (901) 866-8105.

6. I understand that I can refuse to sign this authorization. I need not sign this authorization in order to obtain treat-ment, payment, or health plan enrollment or eligibility.

1068 Cresthaven Road, Suite 500Memphis, Tennessee 38119-0846P 901.866.8525 F 901.302.2525

MRN

Name

DOB

Patient stamp or label above Consent and Agreement

Part I. Medical Treatment Consent: I (the undersigned, and/or the parent or legal guardian) consent to the administration of reasonable and necessary services in connection with treatment of the above-mentioned patient at University Clinical Health (UCH). This consent includes, but is not limited to, labora-tory procedures, medication administration, infusions, procedures, and/or services rendered to a patient by members of the medical staff, their representatives, and/or associates, and employees under the instruction of the physician. I acknowledge that no guarantees have been made to me as to the results of treatments or examination in the clinic.

Part II. Release of Information, Assignment of Insurance Benefits, and Financial Agreement: Release of Information: I hereby authorize UCH and any physician who has rendered services to release any and all information pertaining to my (or the patient’s) treatment to enable the collection of benefits for the services rendered. The authorization includes release of information to insurance companies or healthcare providers, in whole or in part, for payment in exchange for services rendered, whether such payment is in exchange for services rendered by UCH or by the physicians. Release of Information is also authorized to any providers for follow-up medical care. A copy of UCH’s Request for Restrictions Form must be submitted in writing to terminate this agreement.

Assignment of Benefits: I hereby authorize and assign payment directly to UCH for benefits, including secondary benefits, due to me for medical services. I understand that I am financially responsible for charges not covered by any insurance or medical benefit payor. I further acknowledge that any benefits, when received by and paid to UCH will be credited to my account in accordance with this assignment.

Financial Agreement: I understand and agree that I am financially responsible to UCH, and/or physician for any charges not covered by the authorization below or charges not covered by insurance.

I agree that in order to collect any amounts I may owe for services provided by UCH, UCH or its designee may contact me via telephone at any telephone number associated with my account, including wireless telephone numbers, which could result in cellular charges. We may also contact you by sending text messages or e-mails, using any e-mail address you provided to us. Methods to contact may include using pre-recorded/artificial voice messages and or use of an automatic dialing device, as applicable.

I/We have read this disclosure and agree that UCH and/or its designee for collecting any amounts I may owe UCH may contact me as described above.

In addition, with respect to future treatments at UCH, this document is ongoing in nature and will remain in effect until revoked by me in writing.

080314 - 12/15 - Scan to Consent White copy - Clinic, Yellow copy - Patient

*If Personal Representative, the patient is unable to sign because (check one): ❑ Minor ❑ Incompetent ❑ Other (explain): ___________________________________________________________________________________________

I hereby give permission to receive services and treatment by my physician (and/or associates) at UCH I authorize the release of in-formation including protected health information as needed to file for payment for services incurred. I fully understand my Financial Responsibility for services rendered at UCH.

Signature of Patient or Personal Representative*

Date

Printed Name of Patient or Personal Representative*

*Relationship to Patient (if Personal Representative)

For Office Use Only: Date received ____________________ Received by: _________________________ Check if applicable: ❑ Patient refused to sign Consent and Agreement (explain):__________________________

Dear Patient,

Thank you for choosing University Clinical Health (UCH). Each time you visit one of our health care providers, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. The doctors and staff of UCH use and maintain this and other health information related to the care you receive from us.

The attached version of our full Notice of Privacy Practices contains information to help you understand what is in your medical record and how your health information is used. This lets you better understand who, what, when, where, and why others may have access to your health information. It also helps you ensure the correctness of such information.

Please keep the full Notice and take it home with you. You may read it now or later. In either case, let us know if you have any questions after reviewing it. If you did not receive the full Notice, please ask the front desk staff person for a copy.

Please sign below to show that you received UCH’s full Notice:

Signature of Patient or Personal Representative* Printed Name of Patient or Personal Representative*

Date *Relationship to Patient (if Personal Representative)

*If Personal Representative, the patient is unable to sign because (check one):

❑ Minor ❑ Incompetent ❑ Other (explain): ___________________________________________________

Date received: _____________________________ Patient MRN: ____________________________

Received by (employee name): __________________________________________________________

❑ (Check if applicable) Patient refused to sign acknowledging receipt of the full Notice (explain):

____________________________________________________________________________________

____________________________________________________________________________________

For Office Use Only

Health Information Management - Medical Records1407 Union Avenue, Suite 700Memphis, Tennessee 38104-3600901-866-8400 • Fax: 901-302-2400

Summary ofNotice of Privacy Practices

030188 - 2/16 White - Medical Record | Yellow - Patient

UNDERSTANDING YOUR MEDICAL RECORD/HEALTH INFORMATION

Each time you visit University Clincal Health (UCH) a record of your visit is made. It usually includes information about your symptoms, examination, test results, diagnoses, treatment, and a plan for future care and treatment. This information is often called your “medical record.” This information and other information relating to your care are referred to in this Notice as “Health Information.”

The Health Information contained in your medical record is useful for many reasons. For example, this information: • Servesasabasisforplanningyourcareandtreatment • Provides a means of communication among the many health care professionals who are part of your care • Describesthecareyoureceive • Allowsyou,yourinsurancecompanyorotherthird-partypayertomakesurethattheservicesbilledwereprovidedtoyou • Allowshealthcareprofessionalsandorganizationsinvolvedinyourcaretoconducttreatment,payment,andhealthcare

operations • Containsinformationwewillneedtocontactyouaboutappointmentreminders,treatment

alternatives,orotherhealth-relatedbenefitsUnderstanding what is in your record and how your Health Information is used helps you to understand who, what, when,

where, and why others may access your Health Information and to make sure that it is correct. This, in turn, allows you to make better decisions about its use and disclosure.

YOUR HEALTH INFORMATION

EventhoughyourHealthInformationatourofficesbelongstoUCH,youhavecertainrightsrelatingtothisinformation.Asapatient, you generally have the right to: • RequestacopyorsummaryofyourHealthInformationortoinspectit • RequestanamendmenttoyourHealthInformationifyoufeelthereisanerror • RequestarestrictiononusesanddisclosuresofyourHealthInformationfortreatment,paymentorhealthcareoperations.Youalso

havetherighttorequestalimitontheHealthInformationwediscloseaboutyoutosomeoneinvolvedinyourcareorthepaymentforyourcare,likeafamilymemberorafriend.Wewillinformyouofourdecisiononyourrequest.RequestsshouldbesubmittedinwritingtoourPrivacyOfficerwhoseaddressislistedattheendofthisnotice.Unlessotherwiserequiredbylaw,wemustcomplywitharequestfromyounottodiscloseyourHealthInformationtoahealthplan,ifthepurposeforthedisclosureisnotrelatedtotreatment,andthehealthcareitemsorservicestowhichtheinformationapplies(suchasagenetictest)havebeenpaidforout-of-pocketandinfull;otherwise,wearenotrequiredtoagreetoyourrequest.Ifwedoagree,wewillcomplywithyourrequestunlessthe information is needed to provide you emergency treatment. Except for restrictions that we must comply with relating to health plans, we may terminate our agreement to a restriction at any time by notifying you in writing, but our termination will only apply to information created or received after we sent you the notice of termination, unless you agree to make the termination retroactive.

• Obtainanaccountingofwhenandwithwhomwehave sharedordisclosedyourHealth Information for some typesofdisclosures(afeewillbechargedtofulfillrepeatedrequestsforsuchaccountings)

• RequestthatwecommunicatewithyouaboutyourHealthInformationinaparticularwayoratacertainlocation • ObtainapapercopyofourNoticeofPrivacyPractices • RevokeapreviousauthorizationtocertainusesanddisclosuresofyourHealthInformationbyus,exceptwhereactionshave

alreadybeentakenbyusrelatingtothatauthorizationorwheretheauthorizationwasobtainedasaconditionofobtaininginsurance coverage, and other law provides the insurer with the right to contest a claim under the policy or the policy itself.

• FileacomplaintifyoubelievethatyourprivacyrightshavebeenviolatedAnyrequestsorquestionsabouttherightslistedaboveshouldbedirectedto:PrivacyOfficer,

University Clinical Health, at1407UnionAvenue,Suite700,Memphis,TN38104-3673, (901)866-8105,Fax:(901)302-2105.Youmayalsocallourconfidentialcompliancehotlineat901-866-8992.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

Notice of Privacy PracticesHealth Information Management - Medical Records1407 Union Avenue, Suite 700Memphis, Tennessee 38104-3600901-866-8400 • Fax: 901-302-2400

OUR RESPONSIBILITIES

UCHisrequiredto: • ProtecttheprivacyofyourHealthInformation • ProvideyouwithacopyofthisNoticedescribingourprivacypoliciesandlegalduties • AbidebythetermsofourcurrentNotice • Notifyyouifweareunabletoagreeto,ortocomplywith,yourrequestfor:accessorchangestoyourHealthInformation,

anaccountingofdisclosuresofyourHealthInformation,restrictionsondisclosuresofyourHealthInformation,confidentialcommunicationswithyouaboutyourHealthInformation,oryourrevocationofyourauthorization

• AccommodatereasonablerequeststocommunicatewithyouaboutyourHealthInformationinaparticularwayoratacertainlocation • NotifyyoufollowingabreachofyourunsecuredHealthInformation • ObtainwrittenauthorizationfromyouforanytypesofusesanddisclosuresnotmentionedinthisNotice.Youmayrevokeany

authorizationyouhavegivenusatanytimebysendingaletterto:UCHPrivacyOfficerat1407UnionAvenue,Suite700,Memphis,TN38104-3673.RevocationswillnotbeeffectivetotheextentweusedanddisclosedyourHealthInformationinrelianceontheauthorizationpriortoreceivingyourrevocationorwheretheauthorizationwasobtainedasaconditionofobtaininginsurancecoverage, and other law provides the insurer with the right to contest a claim under the policy or the policy itself.WereservetherighttochangeourNoticeandourprivacypracticesandtomakethenewprovisionseffectiveforallHealth

Information we keep. Should our privacy practices change, we will post our revised Notice at all of our clinics and on our website at www.univerityclinicalhealth.com.AnupdatedversionmayalsobeprovidedatyourrequestduringareturnvisittoUCHorfromourPrivacyOfficer.

WewillnotuseordiscloseyourHealthInformationwithoutobtainingyourauthorization,exceptasdescribedinthisNoticeorasotherwiserequiredorpermittedbylaw(forexample,inemergencytreatmentsituations).

Althoughotherhealthcareprovidersmayprovidetreatmenttoyou(forexample,hospitalsorotherphysiciangroups),wearenotjointly managed with or owned by such providers. They will have their own policies and procedures for handling your Health Information.

WAYS WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

UnderTennesseelaw,wemaynotdivulgeyourname,address,orotheridentifyinginformationexceptfor(a)statutorilyrequiredreportingtohealthorgovernmentauthorities,(b)respondingtoasubpoenaorcourtorder,(c)respondingtoarequestforinformationauthorizedbystateorfederallaw;and(d)allowingaccessbyinsurancecompaniesorotherpayersforutilizationreview,casemanagement, peer review or other administrative functions. Within these parameters, the following categories describe some of the ways in which we may use and disclose your Health Information:

1. Treatment. We will use your Health Information to treat you. For example, information obtained by a nurse, physician, or other member of your UCH health care team will be recorded in your record and used to determine your course of treatment.

Some of our clinics may keep your Health Information in an electronic medical record (EMR), and this Health Information may be sharedacrossourclinicsfortreatment.EMRsmaybeequippedwithpatientportals,whichallowsomepatientsorthosepersonstheyauthorizetoaccesscertainportionsoftheirrecord,paystatementsonline,andviewopenaccounts.Patientportalswillbegoverned by separate documents and may be deactivated by UCH in its discretion.

ExceptwhererestrictedbyapplicablelaworwhereUCHhasapprovedyourwrittenrequesttothecontrary,UCHmayalsoprovidecopies of your Health Information to other health care providers who care for you.

WemayshareyourHealthInformationwiththeMidSoutheHealthAllianceinacommunity-widehealthinformationsysteminwhichsomehealthcareprovidersmayaccessyourHealthInformationwhentreatingyou.Asapatient,youhavetherighttonotshareyourHealthInformationintheAlliance.Thisiscalled“OptingOut.”However,ifyouchoosetooptout,healthcareprovidersmay not have access to Health Information that may be important and useful in making choices about your medical care.

AnyquestionsaboutEMRs,thepatientportals,ortheAllianceshouldbedirectedtoourPrivacyOfficerat(901)866-8105.

2.Payment. We will use and disclose your Health Information to bill and collect payment for the services you receive from us. For example,wemaycontactyourhealthinsurertocertifythatyouareeligibleforbenefits,includingtherangeofbenefits.Wemayalso provide your insurer with details regarding your treatment or to obtain payment from third parties that may be responsible forsuchcosts,suchasfamilymembers.Also,wemayuseyourHealthInformationtobillyoudirectly.

3. Health Care Operations. We will use your Health Information in our business operations. For example, we may use your Health Informationtoevaluatethequalityofcareyoureceivefromus,totrainresidents,studentsorotherhealthcareprofessionals,andto make business plans for our practice. However, we will limit the use and disclosure of your medical records, images, videos orpicturesintendedtobeusedforappropriatemedicaleducationalpurposes,evenifyourinformationhasbeende-identified.

4. Vendors. Some of our services are provided by outside vendors. For example, we might use a copy service to make copies of patient records for us. We may disclose Health Information to our vendors so that they can perform the job we have asked them to do. To protect your Health Information, werequirethesevendorstoagreeinwritingtokeepyourHealthInformationsafeusingmanyofthesamestandardsthatwearerequiredtoobserve.

5.Organized Health Care Arrangements. We may participate in arrangements with other health care entities to conduct joint health care-relatedactivities(forexample,qualityassurance,utilizationreview).Inthesearrangements,yourHealthInformationmaybe shared between the participants for treatment, payment, and certain operations purposes. Participants in these arrangements remain separate entities from each other and will have their own policies and procedures for handling your Health Information.

6. Appointment Reminders & Treatment Alternatives. We will use your Health Information to remind you of an appointment ortotellyouabouttreatmentalternativesandotherhealth-relatedbenefitsorservices.

7. Communication with Family and Others/Notification. We may disclose to a family member or other relative, close personal friend, or other person you identify, Health Information that is relevant to that person’s involvement in your care or payment for your care. We mayalsodiscloseyourHealthInformationtodisasterreliefauthoritiessothatyourfamilycanbenotifiedofyourlocationandcondition.Ifyouwouldliketorequestarestrictiononsuchdisclosures,pleasecontactourPrivacyOfficerat(901)866-8105.

8.Persons under the Age of 18. Goodmedicalpractice,paymentrequirements,orstatelawmaymakeitnecessarytotellyourparents or guardian about your visit or provide them with all or part of your Health Information. This does not apply if you are or have been married or have by court order or otherwise been freed from the care, custody and control of your parents.

9. Limited Data Sets and De-identified Information. In some instances where we use or disclose information for purposes of research, public health, health care operations, or other activities, certain information (names, social security numbers, etc.) will be removed to help protect your identity.

10. Research. We may use or disclose your Health Information for research purposes in certain circumstances. For example, whenyouhaveprovidedawrittenauthorization,foractivitiespreparatorytoresearch,and/orwhenaresearchprotocolhasbeendesigned and approved by an Institutional Review Board (IRB) or privacy committee (for example, the IRB for The University of Tennessee Health Science Center or an IRB at Methodist Healthcare Foundation).

11. Deceased Patients. We may release Health Information to coroners, medical examiners or funeral directors to permit them to carryouttheirduties,orotherwisewiththeapprovalofanauthorizedrepresentativeforthedeceasedpatient.

12. Organ or Tissue Donation. WemaydiscloseyourHealthInformationtoorganizationsthathandleorgan,eyeortissueprocurementor transplantation, including organ donation banks, as necessary to facilitate organ, eye or tissue donation and transplantation. 13. News Gathering Activities.Amemberofyourhealthcareteammaycontactyouoroneofyourfamilymemberstodiscusswhether or not you want to participate in a media or news story. For example, a reporter working on a story about a new therapy may ask whether any of our patients undergoing that therapy would be willing to be interviewed. In such a case, we might contact youtoaskwhetheryouwouldbewillingtobeinterviewedandaskforyourauthorizationinwritingbeforegivingthereporteryour name.

14. Fundraising. Someone from The University of Tennessee Health Science Center or another business associate of UCH may wish to contactyouaspartofafund-raisingeffortonourbehalf.Wemayuse,ordisclosetoabusinessassociateorTheUniversityofTennesseeHealth Science Center, the following information to contact you for our fundraising activities: your name, address, other contact information, age, gender and date of birth, the department(s) where you received services, your treating physician, your outcome information, your healthinsurancestatus,andthedatesyoureceivedservices.Youhavetherighttooptoutofreceivingourfundraisingcommunications.Ifyouoptoutofreceivingfundraisingcommunications,youcanalwayschoosetooptbackinwithrespecttospecificcampaignsorasktobecontactedforourfundraisingeffortsbycallingusat(901)866-8105. We do not condition treating you on your choice of whether to receive fundraising communications.

15.Food and Drug Administration (FDA). We may disclose your Health Information to a person subject to the jurisdiction of theFDA,forpublichealthpurposesrelatedtothequality,safety,andeffectivenessofFDA-regulatedproductsandactivities(forexample,relatingtoadverseeventswithrespecttofoodorsupplements,productsandproductdefectsorpost-marketingsurveillanceinformation to enable product recall, repair or replacement of regulated items).

16. Workers Compensation. We may disclose your Health Information to comply with laws relating to workers compensation or other similar programs established by law.

17. Public Health. WemaydiscloseyourHealthInformation,asprovidedbylaw,topublichealthofficialsorlegalauthoritieschargedwith improving health or preventing or controlling disease, injury, or disability.

18.Military Service. WemayuseordiscloseyourHealthInformationifyouareintheArmedForcesforactivitiesdeemednecessaryto assure proper execution of military missions, provided certain conditions are met. If you are a member of a foreign military force, we may use your Health Information or disclose it to your appropriate foreign military authority for activities deemed necessary to assure proper execution of military missions, provided certain conditions are met.

19. National Security and Intelligence Activities.WemaydiscloseyourHealthInformationtoauthorizedfederalofficialsfortheconductoflawfulintelligence,counter-intelligence,andothernationalsecurityactivitiesauthorizedbytheNationalSecurityActandimplementingauthority.WemayalsodiscloseyourHealthInformationtoauthorizedfederalofficialsfortheprotectionofthePresidentorotherpersons,or for certain federal investigations.

20.Correctional Institutions/Law Enforcement Custodians. Should you be an inmate of a correctional institution or be in the lawfulcustodyofalawenforcementofficial,wemaydiscloseyourHealthInformationtotheinstitutionortheofficialifnecessaryfor your health, the health and safety of other inmates or law enforcement, and the safety of the institution at which you reside.

21.Required by Law.WemayuseordiscloseyourHealthInformationtotheextentthattheuseordisclosureisrequiredbylaw.Theuseordisclosurewillbemadeincompliancewiththelawandwillbelimitedtotherelevantrequirementsofthelaw.Ifrequiredbylaw,youwillbenotifiedofanysuchusesordisclosures.

22.Child Abuse and Neglect. We may disclose your Health Information for public health activities and purposes to a public healthauthorityorothergovernmentalauthoritythatisauthorizedbylawtoreceivereportsofchildabuseorneglect.

23.Other Abuse and Neglect. We may disclose your Health Information if we believe that you have been a victim of abuse, neglectordomesticviolencetothegovernmentalentityoragencyauthorizedtoreceivesuchinformation.Inthiscase,ifyoudonotagreetothedisclosure,thedisclosurewillbemadeconsistentwiththerequirementsofapplicablefederalandstatelaws,andonlyifrequiredorauthorizedbylaw.

24.Communicable diseases. We may disclose your Health Information for public health activities and purposes to a person who may beatriskofcontractingorspreadingadisease,ifsuchdisclosureisauthorizedbylaw.

25. Workplace Health Surveillance. We may disclose your Health Information for public health activities and purposes to your employer, for the purposes of conducting an evaluation of medical surveillance of the workplace or for the purposes of evaluating whetheryourhaveawork-relatedillnessorinjury.

26. Health Oversight Activities. WemaydiscloseyourHealthInformationtoahealthoversightagencyforactivitiesauthorizedbylaw,such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee thehealthcaresystem,governmentbenefitprograms,othergovernmentregulatoryprogramsandentitiessubjecttothecivilrightslaws.

27. Judicial and Administrative Proceedings. We may use or disclose your Health Information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal, or in certain conditions in response to a subpoena,discoveryrequestorotherlawfulprocessnotaccompaniedbyanorderofacourtoradministrativetribunal,subjectto any applicable privileges.

28. Law Enforcement. WemaydiscloseyourHealthInformationforalawenforcementpurposetoalawenforcementofficialifcertain conditions are met.

29. Averting a Threat. We may, consistent with applicable law and standards of ethical conduct, use or disclose your Health Information if we believe that the use or disclosure is necessary to prevent or lessen a serious threat to the health or safety of a person or the public; provided that, if a disclosure is made, it must be to a person(s) reasonably able to prevent or lessen the threat. We may also use or disclose your Health Information if we believe that the use or disclosure is necessary for law enforcement authorities to identify or apprehend an individual who: (i) admits to participation in a violent crime that we reasonably believe caused serious physical harm to the victim, or (ii) appears to have escaped from a correctional institution or lawful custody.

30. Certain Uses and Disclosures for which an Authorization is Required. Certain uses and disclosures by us of your medical informationrequirethatweobtainyourpriorwrittenauthorization.Theseinclude: a.PsychotherapyNotes.IfPsychotherapyNotesarecreatedforyourtreatment,wemustobtainyourpriorwrittenauthorizationbeforeusingordisclosingthem,except(1)ifthecreatorofthosenotesneedstouseordisclosethemfortreatment,(2)foruseordisclosureinourownsupervisedtrainingprogramsinmentalhealth,or(3)foruseordisclosureinconnectionwithourdefenseofaproceedingbroughtby you. “Psychotherapy Notes” means notes recorded (in any medium) by a health care provider who is a mental health professional documentingoranalyzingthecontentsofconversationduringaprivatecounselingsessionoragroup,joint,orfamilycounselingsessionand that are separated from the rest of the individual’s medical record. “Psychotherapy Notes” excludes medication prescription and monitoring,counselingsessionstartandstoptimes,themodalitiesandfrequenciesoftreatmentfurnished,resultsofclinicaltests,andany summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. b.Marketing.IfweuseordiscloseyourHealthInformationformarketingpurposes,wemustfirstobtainyourwrittenauthorizationtodoso,exceptifthecommunicationisface-to-facebyustoyou,orisapromotionalgiftofnominalvalue. c. Sale of your medical information. If a disclosure of your Health Information would constitute a sale of it, we must firstobtainyourwrittenauthorizationtodoso.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

Ifyouhavequestionsorwouldlikeadditionalinformation,youmaycontactourPrivacyOfficerat(901)866-8105. Communications may also be sent by mail addressed to: UCHPrivacyOfficer,1407UnionAvenue,Suite700,Memphis,TN38104-3673. Youmayalsocallourconfidentialcompliancehotlineat901-866-8992.Ifyoubelieveyourprivacyrightshavebeenviolated,pleasefileacomplaintwiththePrivacyOfficer,aslistedabove,orwiththeSecretaryoftheU.S.DepartmentofHealthandHumanServices.Therewillbenoretaliationforfilingacomplaint.

THE POLICIES IN THIS NOTICE BECAME EFFECTIVE ON: September 23, 2013Earlier versions: April 14, 2003