REFERENCE PATHOLOGY AND GENETIC TESTING
When a mass is found, a second round of lab testing may be performed where additional stains, immunochemistry and genetic testing are completed to help determine a treatment plan. This additional testing is not part of the colonoscopy and is not covered in our flat rate even if the specimen tested was collected during the colonoscopy.

EMERGENCY & FOLLOW UP TREATMENT POLICY

There is always a risk of complication during any medical procedure. Your payment to ColonoscopyAssist is only for the services scheduled and there is no implied warranty that the procedure will be successfully completed and that there will be no complications.

ColonoscopyAssist will not cover the cost of any urgent or non urgent follow up treatment even if it is due to a complication arising from the procedure. This includes costs such as ambulance costs, ER visits, labs, surgery and any other such costs. Additionally ColonoscopyAssist will not refund the cost of the procedure.

This policy is no different than if you were self-pay or were covered by an insurance plan. Complications are a part of life and follow up treatment due to complications must be paid for separately.

As always when such things occur, ColonoscopyAssist will be an advocate for you and assist you with negotiating down any bills that you may receive as a courtesy if possible.

Additionally, it should be understood that ColonoscopyAssist only facilitates scheduling and billing of a medical procedure.
The ColonoscopyAssist program is not liable in any way for any medical complications that may arise, as they are not the provider of any medical treatment or procedures.

INTERRUPTED COLONOSCOPY POLICY

Although rare, at times a Colonoscopy procedure can not be completed and needs to be interrupted. Reasons why a Colonoscopy may not be completed include :

1. Poor Bowel Prep
2. Problems with sufficiently sedating patient
3. A blockage in the colon

In the event that a procedure is interrupted, ColonoscopyAssist will refund 20% of the cost of the interrupted procedure.
If a physician asks for the procedure to be repeated. The patient will be responsible for cost of the repeat procedure.
In many cases, a repeat colonoscopy might not be necessary. A barium enema Xray or a CT Virtual Colonoscopy might be sufficient.

HEALTH INSURANCE CLAIMS POLICY

The ColonoscopyAssist Program is an out-of-pocket program unless your insurance plan has a direct written agreement with ColonoscopyAssist. Our program, our facilities and our physician offices are not authorized to and will not file an insurance claim for you. However, you may choose to submit a claim to your insurance provider for reimbursement on your own.

1. I understand that I am scheduling a procedure through the ColonoscopyAssist program. ColonoscopyAssist, or its healthcare providers will not file insurance claims on behalf of patients scheduled through this program.
2. I understand that I must consult with my insurance provider to see if they will accept a statement from the ColonoscopyAssist program provided by you.
3. I will not ask the ColonoscopyAssist program or any healthcare provider (facility, physician, pathology or anesthesia office) to file an insurance claim on my behalf. I will also not provide any insurance information to the providers on the day of the procedure or any time before or after. If insurance information is provided and a claim is filed by the provider in error, no reimbursements will be refunded to the patient and no refunds will be made by ColonoscopyAssist. ColonoscopyAssist nor the provider will be able to assist in resolving the matter.

INFORMED CONSENT

COLONOSCOPY

Please read this information carefully and if you have additional questions, feel free to discuss them with a member of our team prior to the procedure.

What is the purpose of a colonoscopy?
Colonoscopy is used to examine the lining of the large intestine (colon) and, if necessary, to take biopsy specimens (tiny bits of tissue) or remove polyps (abnormal growths that can become a cancer). Since colon cancer starts as a polyp, removal of those polyps prevents colon cancer. Cancer of the colon is the second leading cause of cancer related death for men and women in United States.

How is a colonoscopy done?
Colonoscopy is a test using a video camera on a long flexible tube designed to pass through your large bowel looking for abnormalities. The image from the camera is projected on a video monitor and the doctor steers the scope around your bowel. During the procedure the tube needs to pass around some bends in your bowel, and requires that air be introduced into your bowel, to help with visualization. Sedation is provided to minimize any discomfort you may have as a result of these maneuvers. Up to 30% of the time polyps are found. Most can be removed through the colonoscope at the time of the procedure. Polyps can be snared (lassoed with a wire loop) and removed. A small piece of tissue (biopsy) may also be removed to send for analysis to determine if the abnormality was benign (noncancerous) or malignant (cancerous). Biopsies and polypectomies do not cause any discomfort.

What can I expect during the colonoscopy?
Colonoscopy is usually well tolerated and rarely causes much pain. An intravenous will be started, so that the doctor may give you medication to make you feel relaxed and sleepy. While you are lying on your side, the tube is inserted into the rectum and gradually advanced through the colon. The doctor will examine the lining of the bowel, perform any necessary biopsies or polyp removal, then the tube is slowly withdrawn. You may feel uncomfortable during the test from time to time because air is used to inflate the bowel.

What are possible complications? (IMPORTANT)
While all the physicians that participate in the program are experienced and use the utmost caution, there is a well-documented risk associated with the procedure. However the risk of not getting screened is far more significant (1 in 20 lifetime risk for colon cancer).

• Bowel Preparation: There is a risk of dehydration with the bowel preparation. Drinking lots of fluids with electrolytes (like sports drinks) helps to increase the quality of the bowel preparation and also decreases the risks of dehydration and the associated risks.
• Drug reaction: It is possible, although extremely unlikely, that you will develop a reaction to one of the medications. The reaction is usually mild and in the form of rashes, hives, or itching at the site of the IV catheter.
• Perforation: Puncture of the wall of the colon is very rare (1:1000 chance). If it occurs surgery might be necessary to repair the perforation and you will be hospitalized.
• Bleeding: There is a small risk of significant bleeding (1:100 chance) if a polyp is removed. Bleeding can occur up to 10 days later. This usually settles without further treatment and rarely blood transfusions or surgery may be required. Contact your physician or go to the emergency department if you have rectal bleeding of more than one half cup.
• Missed abnormalities: Some polyps or abnormalities might be missed. The risks are significantly higher if your bowel is not cleaned properly.

What can I expect after the colonoscopy?
Your pulse, respiration and blood pressure will be checked while you are in the recovery room. You may feel bloated or have some cramping. Due to the sedation given, your judgment and reflexes may be impaired for the rest of the day. Someone must accompany you home. You cannot drive or operate machinery for 12 hours post sedation. Unless your doctor tells you otherwise, you may resume your regular diet after leaving the facility. The doctor will explain the results of the examination to you and provide you with a written summary. These findings will also be communicated to your referring doctor.

UPPER GI ENDOSCOPY / EGD

Please read this information carefully and if you have additional questions, feel free to discuss them with a member of our team prior to the procedure.

What is the purpose of an upper GI endoscopy / EGD?
You are considering a procedure called upper endoscopy, which is the examination of your esophagus (food pipe), stomach, and duodenum (first part of the small intestine) with a flexible, lighted scope.This procedure is most often done for:

• upper abdominal pain or discomfort
• gastroesophageal reflux disease (acid reflux or heartburn)
• difficulty swallowing
• persistent nausea and vomiting
• bleeding from the upper gastrointestinal tract
• unexplained anemia or weight loss
• follow up of previous abnormal findings, such as Barrett’s esophagus (a precancerous condition), ulcers or polyps
• further investigation of abnormalities found on X-ray studies, such as an upper GI or CT scan.

How is an Upper GI Endoscopy Performed?
Patients may receive a local, liquid anesthetic that is gargled or sprayed on the back of the throat. The anesthetic numbs the throat and calms the gag reflex. An intravenous (IV) needle is placed in a vein in the arm if a sedative will be given. Sedatives help patients stay relaxed and comfortable. While patients are sedated, the doctor and medical staff monitor vital signs. During the procedure, patients lie on their back or side on an examination table. An endoscope is carefully fed down the esophagus and into the stomach and duodenum. A small camera mounted on the endoscope transmits a video image to a video monitor, allowing close examination of the intestinal lining. Air is pumped through the endoscope to inflate the stomach and duodenum, making them easier to see. Special tools that slide through the endoscope allow the doctor to perform biopsies, stop bleeding, and remove abnormal growths. During the upper endoscopy, various procedures to aid in diagnosis or treatment may be performed:

• A biopsy, which is a small tissue sample about the size of a match head, may be taken.
• If a polyp is noted, the Physician may choose to remove it using a small instrument that is passed through the scope.
• Abnormal bleeding may be treated with cauterization, injection of constricting medicines, metal clips or rubber bands.
• Strictures (narrowed areas) may be dilated (stretched) with balloons or tapered tubes.
• A pH probe can be placed to determine amount of acid reflux and correlate symptoms with acid reflux.
• Ingested foreign objects may be removed with a variety of small instruments passed through the scope.
• Feeding tubes can be placed for long term nutritional support.

What are possible complications? (IMPORTANT)
Upper endoscopy performed by a trained physician is generally a very safe procedure, but, like any medical procedure, does carry some possible risks:

• Major complications such as bleeding or perforation (making a hole or tear in the upper gastrointestinal tract) occur in less than 3 out of 10,000 upper endoscopy procedures and may require surgery.Bleeding and perforation are more likely when large polyps are removed, dilation is performed (less than 4 out of 1000 dilations), foreign objects are removed, or feeding tubes are placed.
• Bleeding may be more likely to occur if you take certain medications that thin the blood: Coumadin (warfarin), Eliquis (apixaban), Pradaxa (dabigatran), Xarelto (rivaroxaban), Lovenox (enoxaparin), Arixtra (fondaparinux), heparin, Plavix (clopidogrel), Brilinta (ticagrelor), Effient (prasugrel) aspirin products, or arthritis medications. Be sure to discuss with the physician or his staff what to do if you take any of these medications.
• Uncommonly, aspiration (inhaling food or liquids into the lungs) can occur, possibly causing pneumonia or difficulty breathing.The risk of aspiration can be minimized by not eating or drinking before the procedure.(See separate instructions)
• Reactions to the sedative medications given during the procedure may occur, although this is uncommon.Please notify the physician or his staff if you have any medication allergies or previous unusual reactions to sedatives.Also, you can undergo the procedure without sedation.Be sure to notify The Physician if you prefer no sedation.
• Very rarely, there can be unforeseen complications that include breathing or heart problems, infection, damage to teeth or dental work, injury to other internal abdominal organs, or even death.
• Sometimes it is not possible to examine the entire upper gastrointestinal tract and additional testing may be required.It is also possible to miss cancer, although this is rare.

Depending on the reason for your upper endoscopy, you should also know that there may be potential risks to not doing the procedure, such as delayed diagnosis of cancer or missed diagnosis of disease.

There are alternatives to upper endoscopy:

The upper gastrointestinal tract can be examined with a barium upper GI X-ray examination.If abnormalities are found, an upper endoscopy may be required for further investigation.

Polyps, bleeding and strictures can be treated with surgery.Foreign objects may be removed and feeding tubes may be placed surgically.

Sometimes bleeding can be treated and feeding tubes can be placed with a radiologic procedure.

What am I consenting to?
You acknowledge that you have :

1. read and fully understand what is involved in a colonoscopy and an upper endoscopy procedure; including the benefits and risks
2. that you understand that there is a risk of complication
3. that you would like to proceed to schedule for either one or both procedures.

If you have any questions about the information contained in this document please contact the program at (855) 542 6566. We would be happy to assist you or provide clarification. You will have an opportunity before the procedure to discuss your concerns with a physician or nurse at your request.

Your signature acknowledges that you have read the informed consents for both procedures and grants your consent to the procedure(s).

RELEASE OF MEDICAL RECORDS

TERMS & CONDITIONS

1. YOUR RIGHTS AND THE ROLE OF COLONOSCOPYASSIST
   1. I understand that the ColonoscopyAssist program is not providing me with any medical treatment or advice. The ColonoscopyAssist program is an optional referral service referring me to health care providers that it does not own, employ or have any direct supervision over.
   2. I understand that I have a choice in selecting my healthcare providers. I am responsible for conducting my own independent research about the physician and healthcare provider where my appointment is scheduled beforehand.
   3. I understand that I have the right to deny any medical treatment from a provider that I do not see fit for any reason. I have the choice to not use the program and am voluntarily doing so. There is no incentive from the ColonoscopyAssist program for me to go through with any medical treatment against my will.
   4. I understand that the ColonoscopyAssist program is not liable in any way for any medical complications that may arise, as they are not the provider of any medical treatment or procedures. The provider of medical treatment is liable for any liability producing acts or omissions.
   5. I understand that the ColonoscopyAssist program is not involved in any medical matters pertaining to me after the Colonoscopy procedure. Any follow up medical consultation or treatment has no involvement with the ColonoscopyAssist program.
2. COMMUNICATION VIA EMAIL
   1. RISK OF USING E-MAIL
      RadiologyAssist offers patients the opportunity to communicate by e-mail. Transmitting patient information by e-mail, however, has a number of risks that patients should consider before using e-mail.These include, but are not limited to, the following risks:

       

      1. E-mail can be circulated, forwarded, and stored in numerous paper an electronic files.
      2. E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients.
      3. E-mail senders can easily misaddress an email.
      4. E-mail is easier to falsify than handwritten or signed
      5. Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
      6. Employers and on-line services have a right to archive and inspect e-mails transmitted through their systems.
      7. E-mail can be intercepted, altered, forwarded, or used
         without authorization or detection.
      8. E-mail can be used to introduce viruses into computer
      9. E-mail can be used as evidence in court.
   2. CONDITIONS FOR THE USE OF E-MAIL
      Because of the risks outlined above, ColonoscopyAssist / RadiologyAssist (‘COMPANY’) cannot guarantee the security and confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information. Thus, the patients must consent to the use of e-mail for patient information. Consent to the use of e-mail includes agreement with the following conditions:

       

      1. All e-mails to or from the patient concerning diagnosis or treatment can be printed out and made part of the patient’s medical record. Because they are part of the medical record, other individuals authorized to access the medical record, such as staff and billing personnel, will have access to those e-mails.
      2. COMPANY may forward e-mails internally within the organization and externally to your Provider’s staff or  agent necessary for diagnosis, treatment, reimbursement, and other handling. COMPANY will not, however, forward emails to independent third parties without the patient’s prior written consent, except as authorized or required by law.
      3. Although COMPANY will endeavor to read and respond promptly to an e-mail from the patient, COMPANY cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Thus, the patient shall not use e-mail for medical emergencies or other time sensitive matters.
      4. If the patient’s e-mail requires or invites a response from COMPANY, and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the e-mail and when the recipient will respond.
      5. The patient should not use e-mail for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.
      6. The patient is responsible for informing COMPANY of any types of information the patient does not want to be sent by e-mail, in addition to those set out in 2(e) above.
      7. The patient is responsible for protecting his/her password or other means of access to e-mail. Provider is not liable for breaches of confidentiality caused by the patient or any third party.
      8. It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.
   3. INSTRUCTIONS
      To communicate by e-mail, the patient shall:

       

      1. Limit or avoid use of his/her employer’s computer.
      2. Inform COMPANY of changes in his/her email address.
      3. Put the patient’s name in the body of the e-mail.
      4. Include the category of the communication in the e-mail’s subject line, for routing purposes (e.g., billing question).
      5. Review the e-mail to make sure it is clear and that all
         relevant information if provided before sending to COMPANY .
      6. All emails sent by COMPANY to patient are considered received and read. COMPANY will not wait for acknowledgement from patient.
      7. Take precautions to preserve the confidentiality of e-mail, such as using screen savers and safeguarding his/her computer password.
      8. Withdraw consent only by e-mail or written communication to Provider.
   4. PATIENT ACKNOWLEDGEMENT AND AGREEMENT
      I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail between COMPANY and me, and consent to the conditions herein. In addition, I agree to the instructions outlined herein, as well as any other instructions that Provider may impose to communicate with patients by e-mail. Any questions I may have had were answered.
3. Liability for our Services
   WHEN PERMITTED BY LAW, COLONOSCOPY ASSIST LIMITED and its subsidiaries, providers, affiliates, officers, agents, employees, partners and licencors WILL NOT BE RESPONSIBLE FOR DAMAGES, LOST PROFITS, REVENUES, OR DATA, FINANCIAL LOSSES OR INDIRECT, SPECIAL, CONSEQUENTIAL, EXEMPLARY, OR PUNITIVE DAMAGES.TO THE EXTENT PERMITTED BY LAW, THE TOTAL LIABILITY OF COLONOSCOPY ASSIST LIMITED and its subsidiaries, providers, affiliates, officers, agents, employees, partners and licencors, FOR ANY CLAIMS UNDER THESE TERMS, INCLUDING FOR ANY IMPLIED WARRANTIES, IS LIMITED TO THE AMOUNT YOU PAID US TO USE THE SERVICES (OR, IF WE CHOOSE, TO SUPPLYING YOU THE SERVICES AGAIN).IN ALL CASES, COLONOSCOPY ASSIST LIMITED and its subsidiaries, providers, affiliates, officers, agents, employees, partners and licencors, WILL NOT BE LIABLE FOR ANY LOSS OR DAMAGE.
4. Indemnity
   You agree to indemnify and hold COLONOSCOPY ASSIST LIMITED and its subsidiaries, providers, affiliates, officers, agents, employees, partners and licencors harmless from any claim or demand, including reasonable attorneys’ fees, made by you or any third party due to your use of COLONOSCOPY ASSIST LIMITEDs services, your violation of the TOS, or your violation of any rights of another.
5. About these Terms
   We may modify these terms or any additional terms that apply to a service offered by ColonoscopyAssist, for example, reflect changes to the law or changes to our services. You should look at the terms regularly. We’ll post notice of modifications to these terms on our website. Changes will not apply retroactively and will become effective no sooner than seven days after they are posted. However, changes addressing new functions for a service or changes made for legal reasons will be effective immediately. If you do not agree to the modified terms for a Service, you should discontinue your use of that Service and inform Colonoscopy Assist via a written letter immediately. Please follow up with us to ensure that we have received the letter.If there is a conflict between these terms and the additional terms, the additional terms will control for that conflict.These terms control the relationship between ColonsocoscopyAssist Limited and you. They do not create any third party beneficiary rights.If you do not comply with these terms, and we don’t take action right away, this doesn’t mean that we are giving up any rights that we may have (such as taking action in the future).

    

   If it turns out that a particular term is not enforceable, this will not affect any other terms.

6. PRIVACY POLICYTHIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
   1. Who We Are
      This Notice describes the privacy practices of ColonoscopyAssist.We will share your health information among ourselves to facilitate your treatment, payment, and health care operations.
   2. Our Privacy Obligations
      The law requires us to maintain the privacy of certain health information called “Protected Health Information” (“PHI”). Protected Health Information is the information that you provide us or that we create or receive about your health care. The law also requires us to provide you with this Notice of our legal duties and privacy practices. When we use or disclose (share) your Protected Health Information, we are required to follow the terms of this Notice or other notice in effect at the time we use or share the PHI. Finally, the law provides you with certain rights described in this Notice.
   3. Ways We Can Use and Share Your PHI Without Your Written Permission (Authorization)
      In many situations, we can use and share your PHI for activities that are common in many hospitals and clinics. In certain other situations, which we will describe in Section IV below, we must have your written permission (authorization) to use and/or share your PHI. We do not need any type of permission from you for the following uses and disclosures:

       

      1. Uses and Disclosures for Treatment, Payment and Health Care Operations. We may use and share your PHI to provide “Treatment,” obtain “Payment” for your Treatment, and perform our “Health Care Operations.” These three terms are defined as:We use and share your PHI to provide care and other services to you—for example, to diagnose and treat your illness. In addition, we may contact you to provide appointment reminders or information about treatment options. We may tell you about other health-related benefits and services that might interest you. We may also share PHI with other doctors, nurses, and others involved in your care.
         Payment. We may use and share your PHI to receive payment for services that we provide to you. For example, we may share your PHI to request payment and receive payment from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of some or all of your health care (“Your Payor”) and to confirm that Your Payor will pay for health care. As another example, we may share your PHI with the person who you told us is primarily responsible for paying for your Treatment, such as your spouse or parent.
         Health Care Operations. We may use and share your PHI for our health care operations, which include management, planning, and activities that improve the quality and lower the cost of the care that we deliver. For example, we may use PHI to review the quality and skill of our physicians, nurses, and other health care providers. As another example, we may share PHI with a Patient Relations Coordinator to resolve any complaints you may have and make sure that you have a comfortable experience with us.
         In addition, we may share PHI with certain others who help us with our activities, including those we hire to perform services.
      2. Your Other Health Care Providers. We may also share PHI with your doctor and other health care providers when they need it to provide Treatment to you, to obtain Payment for the care they give to you, to perform certain Health Care Operations, such as reviewing the quality and skill of health care professionals, or to review their actions in following the law.
      3. Judicial and Administrative Proceedings. We may share your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
      4. Law Enforcement Purposes. We may share your PHI with the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a subpoena.
      5. We may share PHI with a coroner or medical examiner as authorized by law.
      6. As required by law. We may use and share your PHI when required to do so by any other law not already referred to above.
   4. Uses and Disclosures Requiring Your Written Permission (Authorization)
      1. Use or Disclosure with Your Permission (Authorization). For any purpose other than the ones described above in Section III, we may only use or share your PHI when you grant us your written permission (authorization).
      2. We must also obtain your written permission (authorization) prior to using your PHI to send you any marketing materials. However, we may communicate with you about products or services related to your Treatment, case management, or care coordination, or alternative treatments, therapies, health care providers, or care settings without your permission.
      3. Uses and Disclosures of Your Highly Confidential Information. Federal and state law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including any portion of your PHI that is: (1) kept in
         psychotherapy notes; (2) about mental health and developmental disabilities services; (3) about alcohol and drug abuse prevention, Treatment and referral; (4) about HIV/AIDS testing, diagnosis or Treatment; (5) about venereal disease(s); (6) about genetic testing; (7) about child abuse and neglect; (8) about domestic abuse of an adult with a disability; (9) about sexual assault; or (10) Invitro Fertilization (IVF). Before we share your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written permission.
   5. Your Rights Regarding Your Protected Health Information
      1. For Further Information; Complaints. If you want more information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact our office. You may also file written complaints with the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services. When you ask, we will provide you with the correct address for the OCR. We will not and can not take any action against you if you file a complaint with us or with the OCR.
      2. Right to Receive Confidential Communications. You may ask us to send papers that contain your PHI to a different location than the address that you gave us, or in a special way. You will need to ask us in writing. We will try to grant your request if we feel it is reasonable. For example, you may ask us to send a copy of your medical records to a different address than your home address.
      3. Right to Revoke Your Written Permission (Authorization). You may change your mind about your authorization or any written permission regarding your Highly Confidential Information by giving or sending a written “revocation statement” to our office. The revocation will not apply to the extent that we have already taken action where we relied on your permission.
      4. Right to Inspect and Copy Your Health Information. You may request access to your medical record file, billing records, and other records used to make decisions about your Treatment and payment for your Treatment. You can review these records and/or ask for copies. Under limited circumstances, we may deny you access to a portion of your records.
      5. Right to Amend Your Records. You have the right to request that we amend PHI maintained in medical record files, billing records, and other records used to make decisions about your Treatment and payment for your Treatment.
   6. Effective Date and Duration of This Notice
      1. Effective Date. This Notice is effective as of June, 2018.
      2. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice date on this internet site page. You also may obtain any new notice by contacting us.

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Who We Are

This Notice describes the privacy practices of ColonoscopyAssist Limited.
We will share your health information among ourselves to facilitate your treatment, payment, and health care operations.

II. Our Privacy Obligations

The law requires us to maintain the privacy of certain health information called “Protected Health Information” (“PHI”). Protected Health Information is the information that you provide us or that we create or receive about your health care. The law also requires us to provide you with this Notice of our legal duties and privacy practices. When we use or disclose (share) your Protected Health Information, we are required to follow the terms of this Notice or other notice in effect at the time we use or share the PHI. Finally, the law provides you with certain rights described in this Notice.

III. Ways We Can Use and Share Your PHI Without Your Written Permission (Authorization)

In many situations, we can use and share your PHI for activities that are common in many hospitals and clinics. In certain other situations, which we will describe in Section IV below, we must have your written permission (authorization) to use and/or share your PHI. We do not need any type of permission from you for the following uses and disclosures:

A. Uses and Disclosures for Scheduling, Treatment, Payment and Health Care Operations. We may use and share your PHI to provide “Treatment,” obtain “Payment” for your Treatment, and perform our “Health Care Operations.” These three terms are defined as:

• Scheduling. We use and share your PHI with providers that participate in our program so that we may schedule appointments for you. We may also share PHI with other doctors, nurses, and others that would be involved in your care.
• Treatment. We use and share your PHI to provide care and other services to you—for example, to diagnose and treat your illness. In addition, we may contact you to provide appointment reminders or information about treatment options. We may tell you about other health-related benefits and services that might interest you. We may also share PHI with other doctors, nurses, and others involved in your care.
• Payment. We may use and share your PHI to receive payment for services that we provide to you. For example, we may share your PHI to request payment and receive payment from Medicare, Medicaid, your health insurer, HMO, or other company, payer or program that arranges or pays the cost of some or all of your health care (“Your Payor”) and to confirm that Your Payor will pay for health care. As another example, we may share your PHI with the person who you told us is primarily responsible for paying for your Treatment, such as your spouse or parent.
• Health Care Operations. We may use and share your PHI for our health care operations, which include management, planning, and activities that improve the quality and lower the cost of the care that we deliver. For example, we may use PHI to review the quality and skill of our physicians, nurses, and other health care providers. As another example, we may share PHI with a Patient Relations Coordinator to resolve any complaints you may have and make sure that you have a comfortable experience with us.
  In addition, we may share PHI with certain others who help us with our activities, including those we hire to perform services.

B. Your Other Health Care Providers. We may also share PHI with your doctor and other health care providers when they need it to provide Treatment to you, to obtain Payment for the care they give to you, to perform certain Health Care Operations, such as reviewing the quality and skill of health care professionals, or to review their actions in following the law.

C. Judicial and Administrative Proceedings. We may share your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

D. Law Enforcement Purposes. We may share your PHI with the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a subpoena.

E. Decedents. We may share PHI with a coroner or medical examiner as authorized by law.

F. As required by law. We may use and share your PHI when required to do so by any other law not already referred to above.

IV. Uses and Disclosures Requiring Your Written Permission (Authorization)

A. Use or Disclosure with Your Permission (Authorization). For any purpose other than the ones described above in Section III, we may only use or share your PHI when you grant us your written permission (authorization).

B. Marketing. We must also obtain your written permission (authorization) prior to using your PHI to send you any marketing materials. However, we may communicate with you about products or services related to your Treatment, case management, or care coordination, or alternative treatments, therapies, health care providers, or care settings without your permission. For example, we may remind you when you are due for a follow up visit without your permission.

C. Uses and Disclosures of Your Highly Confidential Information.Federal and state law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including any portion of your PHI that is: (1) kept in
psychotherapy notes; (2) about mental health and developmental disabilities services; (3) about alcohol and drug abuse prevention, Treatment and referral; (4) about HIV/AIDS testing, diagnosis or Treatment; (5) about venereal disease(s); (6) about genetic testing; (7) about child abuse and neglect; (8) about domestic abuse of an adult with a disability; (9) about sexual assault; or (10) Invitro Fertilization (IVF). Before we share your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written permission.

V. Your Rights Regarding Your Protected Health Information

A. For Further Information; Complaints. If you want more information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact our office. You may also file written complaints with the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services. When you ask, we will provide you with the correct address for the OCR. We will not and can not take any action against you if you file a complaint with us or with the OCR.

B. Right to Receive Confidential Communications. You may ask us to send papers that contain your PHI to a different location than the address that you gave us, or in a special way. You will need to ask us in writing. We will try to grant your request if we feel it is reasonable. For example, you may ask us to send a copy of your medical records to a different address than your home address.

C. Right to Revoke Your Written Permission (Authorization). You may change your mind about your authorization or any written permission regarding your Highly Confidential Information by giving or sending a written “revocation statement” to our office. The revocation will not apply to the extent that we have already taken action where we relied on your permission.

D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file, billing records, and other records used to make decisions about your Treatment and payment for your Treatment. You can review these records and/or ask for copies. Under limited circumstances, we may deny you access to a portion of your records.

E. Right to Amend Your Records. You have the right to request that we amend PHI maintained in medical record files, billing records, and other records used to make decisions about your Treatment and payment for your Treatment.

VI. Effective Date and Duration of This Notice

A. Effective Date. This Notice is effective as of September, 2010. An amendment was made in July 2019.

B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice on this internet site page. You also may obtain any new notice by contacting us.

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