Welcome to American Health Network. Please plan to arrive at least 30 minutes early and bring your paperwork along with your current insurance card(s).

You will also be asked to show your picture ID (driver’s license, student ID card, Indiana ID card.) Anyone under the age of 18 yrs old must have a parent (or guardian) present. Also if you are under 18 yrs old without a picture ID your parent (or guardian) must present their picture ID at the visit.

Please be prepared to present your insurance card(s) and pay any co-pay at each visit.Co-pays may be paid by cash, check, or credit card. We accept most credit cards and alsoaccept Health Savings Account (HSA) cards. If you do not have insurance, we require aminimum payment of $100.00 at the time of service for each office visit. If you do not haveinsurance and pay in full for all charges at the time of service, you will receive a 15% discount.

If you have questions regarding payment please contact our office in advance. Please check with your insurance provider to be sure they have your doctor listed.

If you are unable to make your scheduled appointment time please contact our office at least 24 hrs in advance to reschedule or cancel. We will have to charge a fee for missedappointments due to the provider not being able to see another patient in your timeslot. There will be a fee of $50 for missed new patient appointments, and a fee of $25 formissed office visits.

Please note additional fees that may be billed are (1) Returned checks $25,(2) Completion of Forms (e.g. Disability or Family Medical Leave) $40 (3) copyingof Medical Records (fees are set by Indiana statute; amount varies based on numberof pages).

Thank You.

foot & ankle

Thank you for choosing American Health Network

Fees and charges may vary based on contracts with insurance companies and other payers.

Date Time AM PM

Your appointment is scheduled for ...

w w w . a h n i . c o m / f o o t a n d a n k l e

foot & ankle

Christopher Winters, DPM – Locations

5250 East U.S. 36, Suite 610Avon, IN 46123

P 317.208.3890F 317.575.6909

12188-B North Meridian Street, Suite 330Carmel, IN 46032

P 317.208.3890F 317.575.6909

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Patient Last Name First Name, MI Date of Birth SSN#

Home Address(include apt #)Street City, St, Zip

Sex:

M F

Marital Status

S M W D Sep

Phone Numbers

Home ( ) Work ( ) Cell ( )

Patient Employment Status: Full Time Part-Time F/T Student P/T Student Retired

Patient Employer Name and Address (if Student, Name of School)

Primary Care Physician (PCP) PCP Phone # City & State

Legal Guardian (if patient is under 18 years of age) Relationship Referring Physician (if different than PCP) City State

Emergency Contact (outside of home):

Name Relationship Phone #’s

Alternate Contact (Name, Phone#(s) or email(Inititals of Patient/Legal(guardian/Parent if minor)

PATIENT INFORMATION

PRIMARY INSURANCE INFORMATION*Primary Insurance Company Member/Policy # Group # Effective Date

*Subscriber Name (of “Self”) *Subscriber DOB (If other than self) *Subscriber SSN (if other than self)

*Relationship to Patient (if other than self) *Subscriber Employer (if other than self) *Subscriber Employer Phone #

Claims Address (if insurancecard was not provided)

SECONDARY INSURANCE INFORMATION

I UNDERSTAND THAT AMERICAN HEALTH NETWORK WILL USE MY HOME ADDRESS/PHONE # TO LEAVE MESSAGES REGARDING: TEST RESULTS, APPOINTMENTS, ETC., UNLESS I REQUEST THAT THE FOLLOWING ALTERNATIVE CONTACT BE USED: (I.E. CELL # OF FAMILY MEMBER/FAMILY) ________________________________________________________________________________________

I REQUEST/AUTHORIZE AMERICAN HEALTH NETWORK TO FURNISH THE MEDICAL CARE THAT IS NECESSARY FOR MY CONDI-TION, BUT I ACKNOWLEDGE THAT NO GUARANTEES AS TO THE RESULTS HAVE BEEN MADE TO ME. I WAS PROVIDED A COPY OF THE PRIVACY NOTICE AND PATIENT FINANCIAL POLICIES, (INCLUDING THE MEDICARE AGREEMENT IF APPLICABLE). I HAVE READ, UNDERSTOOD AND HAD THE OPPORTUNITY TO ASK QUESTIONS AND I AGREE TO ABIDE BY THESE TERMS.

Signature of Patient/Guardian Date

PATIENT INFORMATION Chart #

*Secondary Insurance Company Member/Policy # Group # Effective Date

*Subscriber Name (of “Self”) *Subscriber DOB (If other than self) *Subscriber SSN (if other than self)

*Relationship to Patient (if other than self) *Subscriber Employer (if other than self) *Subscriber Employer Phone #

Claims Address (if insurancecard was not provided)

Printed Name

AHN Notes

foot & ankle

Name

Date of Birth Age

Height Weight Shoe Size

Marital Status: ❏ single ❏ married ❏ divorced ❏ partnered ❏ separated ❏ widowed

Phone E-Mail

Primary Care Physician

Location

Referring Provider (or how did you hear about us?)

Location

foot & anklePATIENT HISTORY

Past Medical History/System Review (check positives)

Details of any of the above:

❏ headaches❏ neck problems❏ glaucoma❏ dentures❏ sinus problems❏ heart disease❏ pacemaker/defibrillator❏ high blood pressure❏ rheumatic fever❏ stroke❏ poor circulation❏ asthma❏ sleep apnea❏ COPD/emphysema❏ heartburn/GERD❏ ulceration

❏ constipation/diarrhea❏ hepatitis A B C❏ liver/gall bladder problems❏ kidney disease❏ bladder disease❏ arthritis--degenerative❏ arthritis--rheumatoid❏ arthritis--psoriatic❏ osteoporosis❏ gout❏ epilepsy/seizures❏ neurologic condition❏ bleeding disorder❏ blood clots❏ anemia❏ transfusions

❏ HIV/AIDS❏ Diabetes # years ❏ diet control ❏ oral med ❏ insulin❏ thyroid disease❏ psychiatric disorder:❏ chemical dependancy❏ alcoholism❏ skin condition❏ keloid/hypertrophic scar❏ pregnancy❏ births❏ last tetanus❏ problems with anesthesia❏ cancer - type

Please describe the problem you are experiencing:

When did this problem begin/how long have you had it?

Did this problem develop as a result of a specific injury? ❏ yes ❏ no

Did this problem result from a work injury? ❏ yes ❏ no

Have you seen other physicians for this problem? ❏ yes ❏ no Who?

What tests or treatments have you had for this problem?

If you have had previous procedures related to this problem, when?

If cardiac history, please provide your cardiologists contact information:

Details regarding any significant health related events during the past 6 months:

Date

Past Surgeries/Hospitalizations

Date Procedure/Reason Complications

Family History (include foot and ankle problems, anesthesia reactions, medical conditions)

Grandparents:

Father:

Mother:

Siblings:

Occupation:

Shoe type:

Regular exercise? ❏ yes ❏ no Type:

Date of Last Physical Exam?

Performed by?

Smoking? ❏ yes ❏ no ❏ quit

packs per day? How long?

If quit, when?

Alcohol? ❏ yes ❏ no ❏ quit

Number drinks per week?

If quit, when?

Recreational drugs? ❏ yes ❏ no

Narcotic drug abuse? ❏ yes ❏ no

Social History

Medication Dosage Frequency

Allergies

Allergen/Medication Reaction

Current Medicines

Medication Dosage Frequency

*Please use the back of this form if you need to add more medications.

215 Common Latest Board Approval: 07/25/2012

215 - Patient/Guardian Authorization to Disclose Protected Health Information to Others Patient Name: ______________________ DOB: _____________Today’s Date: ___________ To the patient: American Health Network will attempt to follow your instructions to the extent the healthcare provider believes such disclosure will not interfere with your treatment. Please note that American Health Network does not need specific authorization to disclose information for treatment, operations or payment purposes consistent with its Notice of Privacy Practices. Authorization by: Patient Legal Guardian: American Health Network may disclose all of my Protected Health Information* (including that about alcohol/substance abuse, human immunodeficiency virus (HIV) and/or AIDS, or information related to psychiatric treatment or counseling, and related to communicable disease, unless I limit below) to:

Spouse (name) ________________

Child(ren): All ___ or by name _________________________________________ __________________________________________________________

Others (name(s)):

* Limitation - The following Protected Health Information may NOT be disclosed: Expiration: I understand this Authorization will stay in effect during my treatment at American Health Network unless it is revoked/revised by me in writing. I understand that American Health Network is not responsible for information that might be re-disclosed by those persons who I have authorized to receive information. Patient/Guardian Signature: Date: ____________________ [Form information to be entered into electronic medical record when appropriate. Patient may have a copy if desired]

9-23-2013 The patient (or representative) agrees to these terms as evidenced by signature on the Patient Data Sheet.

Financial Policies, Terms, and Conditions

Payment Guarantee: For services rendered by American Health Network (“AHN”), you guarantee payment of your account at the time services are provided for any and all costs that will not are not paid by an insurance carrier, govern-ment payer (including Medicaid), and other third party payer (together, referred to as “PAYER”), including in the event that if at a later date after initial approval your Payer denies your claim. You further understand that any out-of-network charges may be your responsibility as determined by your PAYER. You acknowledge that if your dependent is provided services you will be responsible for payment under these same policies, terms, and conditions. The “Responsible Party” listed on the Patient Data Sheet will be sent the Statement and shall be responsible for paying it. If the Responsible Party is not you and that person does not pay the bill, YOU are responsible for satisfying the Statement. Assignment of Benefits: To the extent there is third party coverage for payment of services, you agree that all medical and related benefits PAID by PAYER will be irrevocably assigned to AHN on your behalf. Billing Information: It is essential that you provide us with complete and accurate information so that we may properly submit billing information to your insurance company (i.e. home address, phone numbers). We will make every effort to submit claims to your insurance company and promptly provide you with our statements. However, if for any reason the statement is returned to our office because of a problem with an address you provided, you may be dismissed in accor-dance with these policies, terms, and conditions and referred to a collection agency. To avoid this, please ensure that all of your information is accurate, current, and up-to-date. Please be sure to bring your government-issued photo identi-fication and your insurance cards to every visit so that we may properly bill your insurance company. If you do not have your insurance card with you, you may be required to make payment in full that day. Medicare Agreement: If you have Medicare coverage, you acknowledge that payment of benefits will be made to you or on your behalf for any services furnished to you by AHN (or the party who accepts assignment), including your physician services. You authorize any holder of medical or other information about you to release to Medicare and its agents, any information needed to determine these benefits or any benefits for related services. Payment terms: We require payment at the time of your office visit. If you fail to make payment at the time of service we may charge an extra processing fee in recognition of the expenses of preparing and sending out a Statement. Depending on your insurance policy benefits, this payment could be for a co-payment, co-insurance, deductible, or for the entire services rendered at that visit.

Insurance Billing: As your healthcare provider we will file your claims with your insurance company as a courtesy after services are provided, however, if you notify us not to file it with your Payer we will honor your request. It is your respon-sibility to understand what services are covered under your medical insurance policy. If you have any questions whether a service will be covered we urge you to contact your insurance company before the service is provided. The codes that are listed for the services that are provided to you are based on the guidelines of the American Medical Association. There are several factors involved when making the decision for the type of services to be billed. Among those deciding factors are whether you are a new patient, the reason for the visit, the amount of time the service takes, and the complexity of the medical problem.

Insurance companies make their payment decisions about specific medical services by looking at what your insurance policy provides. Example: If the reason for your visit is a sports physical and your insurance company does not cover that service we cannot go back and change the reason for your visit. It is your responsibility to find this out ahead of time. Routine services such as office visits, laboratory services, mammograms, screenings, and annual physicals may be covered under your insurance policies. If they are not covered you will be fully responsible for them. We suggest that you contact your insurance company to find out what benefits you have under your policy before services are rendered. The customer service number is usually found on your insurance card.

Your insurance company may require a pre-certification, prior authorization, or referral for some services, such as: radiology, surgery, or specialist visits. Receiving prior authorization does not guarantee that your insurance company will pay for it. Patients have the responsibility to ensure that prior authorization is obtained prior to services rendered. You should normally receive a response from your insurance company within 30 days. This is in the form of an "Explanation of Benefits" (or "EOB"). If you do not receive it, we would appreciate you contacting your insurance company to check the status of your claim in order to expedite payment. Please call our Billing Department if you encounter any difficulty with your insurance company and we will try to assist you. You are responsible for payment until the account is paid in full by your insurance company. Once we have received an EOB from your insurance company indicating the amount you will

9-23-2013 The patient (or representative) agrees to these terms as evidenced by signature on the Patient Data Sheet.

be responsible for, a Statement for the balance will be sent to you and payment is expected by the due date contained on our Statements. Interest and Attorney's Fees: In the event that amounts due on account of services provided to you are not satisfied when due, AHN shall be entitled to charge interest at the rate of 1.5% per month (18% per annum) and you shall be responsible for all costs and expenses incurred in efforts to collect any unpaid amounts due from you, including any interest charges due, court costs, and all reasonable attorney's fees. Further, in the event that a check is returned for insufficient funds, all charges incurred by AHN shall be your responsibility. Note to divorced parents of dependents: The Statement for your dependent will be sent to you and you are expected to pay it promptly. Even if you do not believe you are the “responsible party” we expect you to make payment, and then you can take action on your own to recoup from the party you believe responsible. Workers Compensation Injury: If you believe you are being seen for an injury/illness as a result of your job, we must have written authorization from your employer to confirm this, and directions from your employer regarding who we should bill for this service. If we do not have this information at the time services are provided, we will bill you and/or your insurance company. Self Pay Services: Are services that are not covered by an insurance policy or third party payer. Self Pay Services will receive a 15% discount across the board for professional services rendered, when payment is made in full at the time services are rendered (and where no claim form is prepared or billing statement has to be mailed). Payment is YOUR responsibility: Our relationship is with you, to provide quality healthcare to you and/or your dependent. Consequently, all charges incurred are your responsibility. The obligation to ensure payment in a timely manner lies with you. Unfortunately, we cannot always depend on your insurance company to make timely payment on your behalf. We are not responsible for delays, misplaced claims, or the need for additional information from you by your insurance company. Payment Options: If you are unable to meet your financial obligation, payment arrangements can be made. Financing options may be available. Contact our Billing Department to discuss payment options, before your account becomes over due. In cases of financial hardship you might be considered under our hardship policy and you may ask us about it. Making Payments: Patients may pay by cash, money order, check or personal credit card, which can include credit cards to pay from your "flexible spending account" and/or “health savings account,” if you have these. One, or all, of these cards may be used to pay your bill, and may be kept on file by us to facilitate billing. If you have a credit balance after paying for a service, AHN can apply it to any outstanding balances on your account. Fees Assessed by AHN: You may be charged fees for the following: (1) Returned Checks (2) Completion of Forms (e.g. Disability or Family Medical Leave) (3) Copying of Medical Records (4) Failure to Cancel Appointment ("No Show") - if you do not advise us of your inability to keep your appointment prior to 24 hours before your appointment. The Fee for a No Show appointment may be assessed up to the amount in our current Fee Schedule. Termination of Services: If you fail to keep your account current (do not respond to 3 notices to the address we have on file), you agree that AHN may terminate your relationship with all of its offices immediately. In such event you agree that you are no longer a patient and AHN will not offer you a future appointment. You will be considered an active patient as long as your account in good standing and we provide you services within a 3 year period. You will have deemed yourself as terminating our relationship if you have no contact with us for this period of time. Acceptance back into the practice as a new patient is at the discretion of the individual provider/location. Authorization to Release of Medical Information: You authorize the release of information by AHN to third party payers, health care institutions, physicians and other providers involved in your medical care. You agree that as neces-sary for your care, AHN may share information with family members and friends as minimally necessary to make deci-sions about your care. You agree that AHN may provide your medical records to third-party payers, insurance companies, review agencies, employers, welfare departments, and to third-party data service providers, including Health Information Exchanges, like the Indiana Health Information Exchange (IHIE). This may include records about infectious diseases and drug and alcohol abuse treatment. Accidents and Motor Vehicle Injuries: Each individual location can decide whether or not to work with you through a third party payer to cover services rendered. In all cases you bear the responsibility for these costs and must pay them promptly at any time that location decides to bill you directly.

Continuing Agreement: I have read this information carefully and agree that everything in this Agreement applies to current and future health care services provided by AHN. I acknowledge that AHN may change these terms without notice to me.

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000c Last Board Approval: 04/24/2013 Common

000c American Health Network Privacy Policy

NOTICE OF PRIVACY PRACTICES

Effective Date: 09/23/2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION MAY BE USED AND DISCLOSED BY AMERICAN HEALTH NETWORK and HOW YOU CAN GET ACCESS TO YOUR MEDICAL INFORMATION

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this Notice, please contact the Privacy Officer at 317-580-6306.

OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION We create a record of the care and services you receive at American Health Network. We understand that this health information about you is personal and protected by law (it is called protected health information or “PHI”). We are committed to protecting PHI. This Notice will tell you about the ways in which we may use and disclose your PHI. We also describe your rights and certain obligations we have regarding the use and disclosure of PHI.

We are required by law to: • Make sure that PHI that identifies you is protected; • Give you this Notice of our legal duties and privacy practices with respect to your PHI; and • Follow the terms of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE PHI ABOUT YOU

The following categories describe different ways that we use and disclose PHI. We will give some examples. Not every use or disclosure in a category will be listed.

For Treatment. We may use your PHI to provide you with treatment or services, including sharing PHI with doctors, nurses, medical students, or other personnel who are involved in taking care of you. Example: A doctor treating you for a cardiac problem may need to know if you have diabetes because diabetes may affect the condition being treated. Different departments may share PHI about you in order to coordinate the different services you need. We also may disclose PHI about you to people outside American Health Network who may be involved in your medical care.

For Payment.

We may use and disclose your PHI to bill and collect payment for treatment and services provided to you. However, if you have insurance but decide to pay for a service yourself out-of-pocket in full on the day of service and do not wish us to provide the information to your insurance company, you can tell us in writing to “restrict” disclosure consistent with the section below entitled Right to Request Restrictions on Uses and Disclosures of PHI. Example: We may give your health information to your insurance company about treatment you received so they will pay us or reimburse you. In some cases we may also tell your insurance about a proposed treatment you may receive in order to obtain prior approval.

For Health Care Operations.

We may use and disclose PHI about you for our business operations. These uses and disclosures are necessary to run American Health Network and make sure our patients receive quality care. Examples: • We may use PHI to review our treatment and services and to evaluate our performance. • We may disclose PHI to doctors, nurses, technicians, medical students, and other personnel for review and/or

learning purposes. • We may remove information that identifies you so others may use it to study health care and health care delivery

without learning the identities of the specific patients.

Business Associates. We contract with outside organizations, called business associates, to perform some of our operational tasks on our behalf. Examples would include billing agencies or a copy service we use when making copies of your medical record. When these services are performed, we disclose the necessary health information to these companies so that they can perform the tasks we have asked them to do. To protect your PHI, however, we require the business associate to appropriately safeguard your information.

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000c Last Board Approval: 04/24/2013 Common

Appointment Reminders. We may use and disclose your PHI to remind you of things like appointments, annual exams, and/or prescription refills.

Treatment Alternatives. We may use and disclose PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you. For example, this may include specific brand name or over-the-counter pharmaceuticals.

Health-Related Benefits and Services. We may use and disclose PHI to tell you about health-related benefits or services. For example, this could include a new heart care program that we might offer.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your PHI that directly relates to that person’s involvement in your health care or payment related to your care. If you are unable to agree or to object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals directly involved in your health care.

Research. Under certain circumstances, we may use and disclose PHI about you for research purposes. All research projects, however, are subject to a special approval process. Before we use or disclose PHI for research, the project will have been approved through a research approval process. Examples: A research project may involve comparing the health and recovery of patients who received one medication to those who received another, for the same condition. We may disclose PHI about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs.

THE FOLLOWING USES AND DISCLOSURES ARE REQUIRED BY LAW

To Avert a Serious Threat to Health or Safety. We may use and disclose PHI 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, however, would only be to someone able to help prevent the threat.

Military and Veterans. If you are a member of the armed forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.

Public Health Risks. We may disclose PHI about you for public health activities. We will make these disclosures when required or authorized by law. Examples of these activities generally include the following:

• To prevent or control disease, injury or disability; • To report births and deaths; • 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 or neglect. .

Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone involved in the dispute.

Law Enforcement. We may release PHI 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; • 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 PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release PHI about patients to funeral directors as necessary to carry out their duties.

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000c Last Board Approval: 04/24/2013 Common

National Security and Intelligence Activities. We may release PHI 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 PHI about you to authorized federal officials so they may provide protection to the President, or to other authorized persons.

Inmates. The rights listed in this Notice will not apply to inmates of a correctional institution.

In Any Other Situation Required By Law. We will disclose PHI about you when required to do so by federal, state or local law.

OTHER USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Other uses and disclosures of PHI not covered by this Notice or law will be made only with your written permission. Examples of such uses and disclosures, include, but are not limited to the following:

Psychotherapy Notes. Except in certain limited circumstances permitted by law, AHN must obtain an authorization from you for any use or disclosure of psychotherapy notes.

Marketing. AHN must obtain an authorization from you for any use or disclosure of PHI for marketing unless the communication is in the form of: (i) a face-to-face communication made by AHN to you; or (ii) a promotional gift of nominal value provided by AHN. If AHN receives any payment for the marketing from a third party, the authorization must state that payment is involved.

Sale of PHI. AHN must obtain an authorization from you for any disclosure of PHI that it intends to sell to a third party in exchange for payment.

If you provide us permission to use or disclose PHI, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose PHI about you for the reasons covered by your written authorization. American Health Network is unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we provided to you.

YOUR RIGHTS REGARDING YOUR PHI

Right to Inspect and Obtain a Copy. You have the right to inspect and have a copy of PHI that may be used to make decisions about your care. This includes medical and billing records, but does not include psychotherapy notes (if applicable). This right does not apply to information that may be used in a civil, criminal or administrative action or proceeding and information that is not part of the records maintained by or on behalf of AHN about you. In some cases copies may be made available in electronic format in addition to paper.

To inspect and have a copy of PHI that may be used to make decisions about you, you must submit your request in writing to the location’s medical records supervisor If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We have a reasonable time-period to make a response to your request.

We may deny your request to inspect and have a copy in some limited circumstances. If you are denied access to your PHI, you may request that the denial be reviewed. Another licensed health care professional chosen by AHN will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Request an Amendment. If you feel that PHI we have about you is incorrect you have the right to request an amendment (a change to your record).

To request an amendment, your request must be made in writing and submitted to the Privacy Officer. 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:

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000c Last Board Approval: 04/24/2013 Common

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment to those records not created by us;

• Is not part of the PHI kept by American Health Network; • Is not part of the information which you would be permitted to inspect and copy; or • AHN believes the current record is accurate and complete.

Right to Receive Notice of a Breach. You have the right to receive written notice in the event we learn of any unauthorized acquisition, use or disclosure of your PHI that has not otherwise been properly secured as required by HIPAA (a “breach”). In that event, we would notify you as soon as reasonably possible but no later than sixty (60) days after the breach has been discovered Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of people who saw your records who you did not specifically authorize. For example, if we responded to a legal request for your records.

To request this list or accounting of disclosures, you must submit your request in writing to the ORS. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. 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 cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions on Uses and Disclosures of PHI. You have the right to request a restriction or limitation on how we use your PHI. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure that you had performed in our office. Although we will consider your request carefully, 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 emergency treatment. Additionally, if you pay for a particular service in full, out-of-pocket, on the date of service, you may ask us not to disclose any related PHI to your health plan if you have completed your request no later than the time of the service. For all Requests for Restrictions use the American Health Network form: “PATIENT REQUEST FOR RESTRICTION ON USES AND DISCLOSURES OF 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; and (3) to whom you want the limits to apply, for example, disclosures to your spouse, insurance company, etc. Keep in mind we cannot fulfill your request to the extent that action might have already taken place.

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. For example, you can ask that we only contact you at your work phone number or by mail. To request confidential communications, you must make your request in writing to your AHN doctor’s office. 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. This request should be made on the American Health Network form #215 “PATIENT AUTHORIZES AHN TO DISCLOSE PHI TO OTHERS.”

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 from your provider’s office or the Privacy Officer. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of it.

CURRENT NOTICE, CHANGES TO THIS NOTICE

American Health Network is required to and will abide by the terms of this Notice. We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for PHI 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 all American Health Network patient facilities. The Notice will contain the effective date. In addition, each time you register or are seen for treatment or health care services at an AHN facility a copy of the current Notice will be available to you.

COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with American Health Network or with the Secretary of the Department of Health and Human Services. To file a complaint, contact the AHN Privacy Officer at American Health Network, 10689 N. Pennsylvania Street, Suite 200, Indianapolis, IN 46280, Attn: Privacy Officer. All complaints must be submitted in writing and must be filed within 180 days of the time you became aware or should have been aware of the violation.

YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT

P. 844.424.3668 (844.424.foot) www.ahni.com/footandankle

NOTE FOR MEDICAID PATIENTS As your foot and ankle specialty provider I wanted to make you aware of some important facts about your Medicaid coverage that may affect your treatment.

• Many physicians do not accept Medicaid. This can limit care for all Medicaid beneficiaries.

• Certain conditions require the expertise of a foot and ankle specialty

provider/podiatrist. Issues that are not treated appropriately may result in hospitalizations and more expensive care.

• Medicaid will only pay for one office visit per year per condition (when the provider is

a foot and ankle specialist/podiatrist) Thank you. American Health Network − Foot and Ankle