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Privacy Policy

This Notice of Privacy Practices applies to Fort Wayne Psychiatry, PC

Effective November 1, 2019

Privacy Officer Prevesh K Rustagi, MD 3400 East Coliseum Blvd. #340 Fort Wayne IN 46805. Tel 260-484-1312 Fax 260-471-0996

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. You have a right to:

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we have shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1

• You can file a complaint with the U.S. Department of Health and HumanServices Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visitingwww.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you • We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization • We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Bill for your services • We can use and share your health information to bill and get payment from health plans or other entities.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues : We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Do research • We can use or share your information for health research.

Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests • We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director • We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions • We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of
your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice: We can change the terms of this notice, and the changes will apply to all the information we have about you. The new notice will be available upon request, in our office, and on our website.

Terms and Conditions

Fort Wayne Psychiatry Web Portal : Terms and Conditions of Use

FOR ALL MEDICAL EMERGENCIES, IMMEDIATELY DIAL 911. DO NOT USE THIS CONVENIENCE TOOL TO COMMUNICATE MEDICAL EMERGENCIES.

"Individual" means the patient, patient applicant, patient’s or patient applicant’s guardian or authorized representative who is communicating through Fort Wayne Psychiatry Webchart patient portal. The use of the words "we", "our" and "Fort Wayne Psychiatry" mean Fort Wayne Psychiatry PC and its owner Prevesh Rustagi, MD.

NO PHYSICIAN-PATIENT RELATIONSHIP WITH FORT WAYNE PSYCHIATRY IS ESTABLISHED OR IMPLIED UNTIL THE PATIENT APPLICANT HAS BEEN EVALUATED BY A FORT WAYNE PSYCHIATRY PHYSICIAN DURING A PROFESSIONAL VISIT.

1. Fort Wayne Psychiatry Webchart patient portal is designed as a secure Internet-based environment through which an Individual may send and receive certain confidential medical information. Individuals are responsible for remembering the Fort Wayne Psychiatry Webchart patient portal ID and password and for keeping this information confidential. Individual is responsible for safeguarding the Fort Wayne Psychiatry Webchart patient portal ID, password, and security question and answer. Individual is responsible for keeping this information in a safe place for future reference. It is Individual's responsibility to prevent disclosure of Individual's ID and password and to change Individual's password and security question and answer if Individual feels that Individual's security has been compromised. Fort Wayne Psychiatry shall not be liable for any damages that result from Individual's failure to keep such password secure.

2. The Fort Wayne Psychiatry Webchart patient portal program will be activated once Individual creates an account.

3. After Individual has activated a Fort Wayne Psychiatry Webchart patient portal account, Fort Wayne Psychiatry Webchart patient portal will become a vehicle through which Individual will receive important messages from Individual's physician and certain test results and other personal medical information. Individual may receive from time to time important email notices and messages from the Webchart patient portal team and/or Fort Wayne Psychiatry . Individual therefore MUST verify and update Individual's email address and mobile telephone number by contacting Fort Wayne Psychiatry. Fort Wayne Psychiatry is not responsible for any damage resulting from Individual's failure to verify and update Individual's email and account information.

4. For all urgent medical matters, go to an emergency room, and/or call 911. Never send any messages requiring urgent attention using Fort Wayne Psychiatry Webchart patient portal. Delays can occur based upon, but not limited to, volume and availability of staff, the complexity of Individual's condition, or technology occurrences outside of the

Fort Wayne Psychiatry 's control.

5. By accessing or using Fort Wayne Psychiatry Webchart patient portal Individual agrees to be bound by all the terms and conditions of this Agreement and the Privacy Policy outlined in website FortWaynePsychiatry.com. It is important to review the Agreement and Privacy Policy periodically as we may modify this Agreement and the Privacy Policy at any time, and Individual agrees that such modifications are effective and binding upon Individual immediately upon the posting of the modified version.

6. Individual agrees that Fort Wayne Psychiatry Webchart patient portal is a communication service offered only as a convenience tool to Fort Wayne Psychiatry patients and patient applicants. Individual understands that it provides Individual with online access to portions of Individual's Fort Wayne Psychiatry electronic medical record and that Individual is solely responsible for any sharing of Fort Wayne Psychiatry Webchart patient portal content that Individual intentionally or unintentionally communicates to others. Individual understands that Individual may receive messages, test results, and other communications delivered via Fort Wayne Psychiatry Webchart patient portal. Individuals may not be provided paper

versions of the information contained in Fort Wayne Psychiatry Webchart patient portal; however, Individual may request a copy of Individual's medical record from Fort Wayne Psychiatry.

7. INDIVIDUAL HEREBY ASSUMES THE SOLE LIABILITY FOR HIS/HER ACTIONS IN USING FORT WAYNE PSYCHIATRY WEBCHART PATIENT PORTAL AND SHALL HOLD FORT WAYNE PSYCHIATRY HARMLESS AND DEFEND IT AGAINST ALL DAMAGES RELATED TO SUCH USE OR DIRECTIONS TO FORT WAYNE PSYCHIATRY UPON WHICH FORT WAYNE PSYCHIATRY RELIES.

8. Individual understands that not all of their Fort Wayne Psychiatry medical record may appear on Fort Wayne Psychiatry Webchart patient portal. Posting of Individual's medical information to Fort Wayne Psychiatry Webchart patient portal, in whole and in part, is pursuant to Fort Wayne Psychiatry policy and at the discretion of Individual's physician.

9 . Individual can discontinue use of Fort Wayne Psychiatry Webchart patient portal at any time by contacting Fort Wayne Psychiatry.

10. Individual agrees that Individual will not post or send any harassing or offensive material on this site.

11. Fort Wayne Psychiatry reserves the right, at its sole discretion, to suspend or discontinue Individual's use of this service and to discontinue the general use of the service itself.

12. Messages Individual sends via Fort Wayne Psychiatry Webchart patient portal will be made part of Individual's medical record.

13. If Individual's physician is out of the office or unavailable to respond, messages sent via Fort Wayne Psychiatry Webchart patient portal may be routed to other covering physicians or personnel in order to facilitate a timely response to Individual's request.

14. All communications between Individual and Individual's Fort Wayne Psychiatry health care team using Fort Wayne Psychiatry Webchart patient portal are carried over a secure connection directly into the Fort Wayne Psychiatry electronic medical record.

15. Individual may have access to Fort Wayne Psychiatry Webchart patient portal features that allow Individual to download portions of Individual's health information and/or transmit this information to other health providers who may be unaffiliated with the Fort Wayne Psychiatry . Fort Wayne Psychiatry relies on Individual's representation and direction and Individual is responsible for the use of such features.

INDIVIDUAL AGREES AND INTENDS THAT FORT WAYNE PSYCHIATRY SHALL NOT BE RESPONSIBLE FOR, AND SHALL NOT BE LIABLE FOR, ANY DAMAGES THAT RESULT FROM, OR ANY ACTIONS FORT WAYNE PSYCHIATRY TAKES THAT RESULT FROM, THE SELECTION OF THE RECIPIENT OF THE INFORMATION OR THE SUBSEQUENT USE OR DISCLOSURE OF SUCH INFORMATION AFTER THE DOWNLOAD OR TRANSMISSION OCCURS, AS DIRECTED BY INDIVIDUAL. INDIVIDUAL AGREES TO HOLD FORT WAYNE PSYCHIATRY HARMLESS FROM ANY DAMAGES RESULTING FROM SUCH A RELEASE TAKEN ON BEHALF OF INDIVIDUAL AND AS DIRECTED BY INDIVIDUAL, AND FURTHER, WAIVES ALL LIABILITY OF FORT WAYNE PSYCHIATRY ASSOCIATED WITH SUCH A RELEASE AS DIRECTED BY INDIVIDUAL. INDIVIDUAL UNDERSTANDS AND AGREES THAT FORT WAYNE PSYCHIATRY CANNOT AND DOES NOT VERIFY RECEIPT OF INDIVIDUAL'S RECORD AT THE DESIGNATED RECIPIENT LOCATION.

16. All content included on Fort Wayne Psychiatry Web sites, including, but not limited to, text, photographs, graphics, button icons, images, artwork, names, logos, trademarks, service marks and data, in any form including the compilation thereof, are protected by U.S. and international copyright law and conventions. The content includes both content owned or controlled by Fort Wayne Psychiatry and content owned or controlled by third parties and licensed to Fort Wayne Psychiatry. Except as set forth below, direct or indirect reproduction of the content, in whole or in part, by any means, is prohibited without the express written consent of Fort Wayne Psychiatry .

17. Fort Wayne Psychiatry grants a limited, revocable license to Individual to make personal use only of the Web site and the associated services in accordance with these terms and conditions of use. This license expressly excludes, without limitation, any reproduction, duplication, sale, resale or other commercial use of the Web site and the associated services, making any derivative of the Web site or the associated services, the collection and use of user email addresses or other user information, including, without limitation, health information or any data extraction or data mining Through this license, Individual may be able to upload third party data into Fort Wayne Psychiatry Webchart patient portal or download limited medical information from Fort Wayne Psychiatry Webchart patient portal to select third party sites.

18. Once information enters this Web site it is protected with industry standard software. While we use reasonable security, no system can perfectly guard against risks of intentional intrusion or inadvertent disclosure of information. When using Fort Wayne Psychiatry Webchart patient portal, information will be transmitted over a medium that is beyond the control of Fort Wayne Psychiatry and its contractors.

INDIVIDUAL HEREBY EXPRESSLY ASSUMES THE SOLE RISK OF ANY UNAUTHORIZED ACCESS AND/OR DISCLOSURE OR INTENTIONAL INTRUSION, OR OF ANY DELAY, FAILURE, INTERRUPTION, OR CORRUPTION OF DATA OR OTHER INFORMATION TRANSMITTED IN CONNECTION WITH THE USE OF THIS SERVICE AND AGREES THAT FORT WAYNE PSYCHIATRY WEBCHART PATIENT PORTAL IS NOT ERROR-FREE. Once the information is received by Fort Wayne Psychiatry, Individual's medical information will be treated as confidential and given the same protection that all other Fort Wayne Psychiatry medical records are given.

19. This Web site contains links to Web sites operated by other parties. The links are provided for Individual's convenience only. Fort Wayne Psychiatry does not control such Web sites and Fort Wayne Psychiatry is not responsible for the content and performance of these sites. The inclusion of links to other Web sites does not imply any endorsement of the material on the Web sites or any association with their operators. Fort Wayne Psychiatry does not operate, control, or endorse any information, products, or services provided by third parties through the Internet. Use of other sites is strictly at Individual's own risk, including, but not limited to, any risks associated with destructive viruses. Individual is responsible for viewing and abiding by the terms and conditions of use and the privacy statements of the other Web sites.

20. This site and all other sites hosted by Fort Wayne Psychiatry and are provided by Fort Wayne Psychiatry on an "As Is" basis. Fort Wayne Psychiatry makes no representations or warranties of any kind, express or implied, as to the operation of its sites, or the content, products and/or services included therein. To the fullest extent permissible by applicable law, Fort Wayne Psychiatry disclaims all warranties, express, or implied, including, but not limited to, implied warranties of merchantability, fitness for a particular purpose, title, and/or infringement.

21. Some of the material on the Fort Wayne Psychiatry site is provided by third parties and Fort Wayne Psychiatry shall not be held responsible for any such third-party material. Fort Wayne Psychiatry disclaims any responsibility for or liability related to such third-party material and Individual uses of such third-party material. Any questions complaints or claims related to any product should be directed to the appropriate third party.

22. Patient agrees that Indiana law shall be applicable to any claim or dispute relating to the Fort Wayne Psychiatry website or Patient's reliance on this website and all activity and any dispute that might arise between Individual and Fort Wayne Psychiatry , its doctors, staff or other affiliates hereunder, regardless of where the Individual resides.

23. Webchart patient portal is a communication service offered as a convenience to Fort Wayne Psychiatry patients. We reserve the right, at our sole discretion, to discontinue the service at any time.

RUSTAGI WebChart