NOTICE OF PRIVACY PRACTICES (AVISO DE PRACTICAS PRIVADAS)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Who will follow this notice
This notice describes Cook Children's Health Care System's (CCHCS) practices and those of:

• Any health care professional authorized to enter information into your medical record
• Any member of a volunteer group we allow to help you while you are in our care
• All CCHCS employees, staff and other personnel

The following entities within Cook Children's Health Care System will follow these practices:

• W. I. Cook Foundation dba Cook Children's Health Foundation
• Cook Children's Medical Center
• Cook Children's Health Care System
• Cook Children's Physician Network
• Cook Children's Home Health

These entities, sites and locations follow the terms of this notice and may share medical information with each other for treatment, payment or operational purposes described in this notice.

Our pledge regarding medical information
We understand that information about you and your health is personal. We are committed to protecting your information. We create a record of the care and services you receive at CCHCS in order to provide quality care and to comply with certain legal requirements. This notice applies to all of your health care records created by CCHCS. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic.

This notice will tell you about the ways in which we may use and disclose medical information about you and describes your rights and our obligations.

We are required by law to

• Make sure that medical information that identifies you is kept private
• Give you this notice of our legal duties and privacy practices with respect to medical information about you
• Follow the terms of the notice that is currently in effect

Email communications with Cook Children's Physician Network doctors and other health care providers - If you communicate with a Cook Children's health care provider by email for any reason those communications become part of your CCHCS medical record and are covered by this notice.

How we may use and disclose medical information about you
The following categories describe different ways that we use and disclose medical information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For treatment - We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students or other personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different units or practice locations may share medical information about you in order to coordinate your care such as prescriptions, lab work and X-rays. We also may disclose medical information about you to people outside Cook Children's who may be involved in your medical care such as family members, clergy or others we use to provide services that are part of your care.

For payment - We may use and disclose medical information about you so that the treatment and service you receive may be billed and payment collected. For example, we may need to give your health plan information about surgery you received so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. You may choose to restrict protected information from being provided to a health plan if (a) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise prohibited by law; and (b) the protected health information pertains solely to a health care item or service for which you or a person on your behalf has paid Cook Children's in full.

For health care operations - We may use and disclose medical information about you for operational purposes. These uses and disclosures are necessary to run the organization and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff that is caring for you. We may also combine medical information about many patients to decide what additional services we should offer, what services are not needed and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other health care providers to assess how we are doing and see where improvements can be made in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning specific patients' identities.

Appointment reminders - We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.

Treatment alternatives - We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest.

Health-related benefits and services - We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Fundraising activities - We may use certain information such as your name, address and phone number, to contact you in the future to raise money for Cook Children's Health Foundation. The money raised will be used to expand and improve the services and programs we provide to the community. If you do not want to be contacted for fundraising efforts, please notify us by calling our toll-free number 877-686-7722 or by sending an email to unsubcchf@cookchildrens.org.

Medical center directory - We may include certain limited information about you in the medical center directory while you are a patient at the medical center. This information may include your name, location in the medical center, your general condition (e.g., fair, serious, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. If you do not want to be listed in the directory, please contact Patient Registration at 682-885-4225.

Individuals involved in your care or payment for your care - We may disclose to a family member, other relative, a close personal friend of yours, or any other person identified by you, the health information directly relevant to such person's involvement with your care or payment related to your health care. We may also tell your family or friends your condition and that you are receiving treatment. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Medical research - Medical research is vital to the advancement of medical science. Federal regulations permit the use of protected health information in medical research, with either your authorization or when the research study
at Cook Children's Health Care System is reviewed and approved by an Institutional Review Board before any medical research study begins. In some situations, limited information may be used before approval of the research study to allow a researcher to determine whether enough patients exist to make a study scientifically valid.

As required by law - We will disclose medical information about you when required to do so by federal, state or local law.

To avert a serious threat to health or safety - We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to someone able to help prevent the threat.

SPECIAL SITUATIONS

Organ and tissue donation - We may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Workers' compensation - We may release medical information about you for workers' compensation or similar programs.

Public health risks - We may disclose medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability
• To report births and deaths
• To report child abuse or neglect
• To report reactions to medications or problems with products
• To notify people of product recalls
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence

Health oversight activities - We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and disputes - If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to
a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

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

• In response to a court order, subpoena, warrant, summons or similar process
• To identify or locate a suspect, fugitive, material witness or missing person
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement
• About a death we believe may be the result of criminal conduct
• About criminal conduct at any of Cook Children's sites
• In emergency circumstances to report a crime, the location of the crime or victims or the identity, description or location of the person who committed the crime.

Coroners, medical examiners and funeral directors - We may release medical information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors when necessary to carry out their duties.

National security and intelligence activities - We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Protective services for the president and others - We may disclose medical information about you to authorized federal officials so they may provide protection to the president, other authorized persons or foreign heads of state or conduct special investigations.

Inmates - If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be
necessary (1) for the institution to provide you with health care (2) to protect your health and safety needs or the health and safety of others (3) for the safety and security of the correctional institution.

Your rights regarding medical information about you
You have the following rights regarding the medical information we keep about you:

Right to inspect and copy - You have the right to inspect and request copies of medical information that may be used to make decisions about your care. Usually, this information includes medical and billing records, but does not include psychotherapy notes. To inspect and request copies of medical information that may be used to make decisions about you, you must submit your request in writing to the Director/Manager of Medical Records. If you request a copy of the information, Cook Children's may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy records in certain limited circumstances. If you are denied access to medical information, you may request the denial be reviewed. Another licensed health care professional chosen by the organization will review your request and the denial. The person conducting the review will not be the person who denied your request. We will notify you of the outcome of this review and will comply with the decision.

Right to amend - If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the organization. To request an amendment, your request must be made in writing and submitted to the Director/Manager of Medical Records, Cook Children's Medical Center, 801 Seventh Avenue, Fort Worth, TX 76104. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
• Is not part of the medical information kept by or for Cook Children's
• Is not part of the information which would be permitted to be inspected and copied
• Is accurate and complete
• For other reasons provided by state law

If we deny your request for amendment, we will notify you and provide reasons for the denial.

Right to an accounting of disclosures - You have the right to request a list of disclosures (also called an accounting of disclosures) we have made of your medical information.

To request this list or accounting of disclosures, you must submit your request in writing to the Director/Manager of Medical Records. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate how you want to receive the list (paper copy or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to request restrictions - You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to the Director/Manager of Medical Records. In your request, you must tell us (1) what information you want to limit (2) whether you want to limit our use, disclosure or both 3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to request confidential communications - You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.

To request confidential communications, you must make your request in writing to the Director/Manager of Medical Records. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a paper copy of this notice - You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a
paper copy. You may obtain a copy of this notice at www.cookchildrens.org or contact the Director/Manager of Medical Records.

Changes to this notice
We reserve the right to change this notice. We reserve the right to make the revised notice effective for medical information we already have about you, as well as any information we receive in the future. We will post a copy of the current notice in appropriate areas and on our Web site. In addition, each time you register or are admitted for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with Cook Children's by contacting the Patient Representative at 682-885-3926 or the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

Other uses of medical information
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

CCHCS Privacy Officer Contact:
682-885-1358

Effective Date:
January 1, 2011
Cook Children's Medical Center
Director/Manager of Medical Records
801 Seventh Avenue
Fort Worth, TX 76104
682-885-4351 (Written information)
682-885-1012 (Verbal release of information)