We participate in most healthcare plans and gladly accept medicare and worker's compensation cases. Please contact our office to confirm our participation in and acceptance of your particular plan. Brookfield Office (203) 775-3000; New Milford Office (860) 355-8000; Newtown Office (203) 426-6600; Sharon Office (860) 364-0134.

Payment Terms:

• For patients with participating insurance plans, your copayment is due at the time of your visit.

• For patients with indemnity plans ("traditional insurance"), we submit claims directly to the carrier as a courtesy. After 30 days, any unpaid balance is your responsibility.

• For patients without insurance, we request a cash payment prior to treatment. A payment plan must then be arranged with the billing department. For your convenience, we accept: cash, check, Visa, Mastercard, Discover and American Express.

Use and Disclosure of Protected Health Information:

**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**

New Milford Orthopedic Associates is required by law to maintain the privacy of protected health information and to provide you with notice of its legal duties and privacy practices. New Milford Orthopedic Associates myst abide by the terms of the notice currently in effect, but New Milford Orthopedic Associates reserves the right to change the terms. If there is a change, New Milford Orthopedic Associates will provide you with a written, revised notice as soon as practicable by mail or hand delivery.

As a patient of New Milford Orthopedic Associates, information about you must be used and disclosed to other parties for purposes of treatment, payment, and health care operations. These uses and disclosures require your consent, and include, but are not limited to, a release of information contained in financial records and/or medical records, including information concerning communicable diseases such as Human Immune Deficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), drug/alcohol abuse, psychiatric diagnosis and treatment records and/or laboratory test results, medical history, treatment progress and/or any other related information, to:

1. Your insurance company, self-funded or third-party health plan, Medicare, Medicaid, or any other person or entity that may be responsible for paying or processing for payment any portion of your bill for services;

2. Any person or entity affiliated with or representing for purposes of administration, billing, and quality and risk management;

3. Any hospital, nursing home, or other health care facility to which you may be admitted;

4. Any assisted living or personal care facility of which you are a resident;

5. Any physician providing you care;

6. Family members and other caregivers who are part of your home care plan for service;

7. Licensing and accrediting bodies, including the information contained in the OASIS Data Set to the state agency acting as a representative of the Medicare/Medicaid program;

8. Contact you to provide appointment reminders or information about other health activities we provide;

New Milford Orthopedic Associates is permitted to use or disclose information about you without consent or authorization in the following circumstances;

1. In emergency treatment situations, if New Milford Orthopedic Associates attempts to obtain consent as soon as practicable after treatment;

2. Where substantial barriers to communicating with you exist and New Milford Orthopedic Associates determines that the consent is clearly inferred form the circumstances;

3. Where New Milford Orthopedic Associates is required by law to provide treatment and we are unable to obtain consent;

4. Where the use or disclosure is required by law;

5. For certain public health activities;

6. Where New Milford Orthopedic Associates reasonably believes you are a victim of abuse, neglect, or domestic violence to a government authority authorized to receive abuse, neglect or domestic violence;

7. Health care oversight activities;

8. Certain judicial administrative proceedings;

9. Certain law enforcement purposes;

10. To coroners, medical examiners and funeral directors, in certain circumstances;

11. For cadaveric organ, eye or tissue donation purposes;

12. For certain research purposes;

13. To avert a serious threat to health and safety;

14. For specialized government functions, including military and veterans' activities, national security and intelligence activities, protective services for the President and others, medial suitability determinations, correctional institution and custodial situations;

15. For Workers' Compensation purposes;

New Milford Orthopedic Associates is permitted to use or disclose information about you without consent or authorization provided you are informed in advance and given the opportunity to agree to or prohibit or restrict the disclosure in the following circumstances:

1. The use of a directory of individuals served by New Milford Orthopedic Associates;

2. To a family member, relative, friend, or other identified person, the information relevant to such persons involvement in your care or payment for care.

Other uses and disclosures will be made only with your written authorization. That authorizations may be revoked, in writing, at any time, except in limited situations.

Your Rights:

You have the right, subject to certain conditions, to:

1. Request restrictions on certain uses and disclosures of information about you. However, New Milford Orthopedic Associates is not required to agree to the requested restriction;

2. Receive confidential communication of protected health information;

3. Inspect and copy protected health information;

4. Amend protected health information;

5. Receive an accounting of disclosures;

6. Obtain a paper copy of this notice, if you had agreed to receive this notice electronically.

Complaints:

You may complain to New Milford Orthopedic Associates and the Secretary of the U.S. Department of Health and Human Services if you believe that your privacy rights have been violated. There will be no retaliation against you for filing a complaint. The complaint should be filed in writing with New Milford Orthopedic Associates and should state the specific incident(s) in terms of subject, date, and other relevant matters. A complaint to the Secretary must comply with the standards set out in 45 CFR �§ 160.306.

For further information regarding filing a complaint with New Milford Orthopedic Associates, contact: Patty Allen, Medical Records, phone number 860-355-8000, ext 108.

I have read or have had explained this Notice to me. I understand this notice and have had the opportunity to ask questions regarding any matters of concern.