Notice of Privacy Practices Summary

Maintaining privacy of your health information is very important to us. Our website (www.kansassurgical.com) and our reception staff will provide you with our Notice of Privacy Practices. The following is a brief summary of the content of the policy. We encourage you to read the entire Notice and ask any questions you may have regarding its contents.

Uses and Disclosures of Your Health Information That May Be Made Without Your Authorization. This section describes the different ways we may use or disclose your health information without first obtaining a specific authorization from you. These types of uses and disclosures are specifically permitted by law because it is assumed you would want us to use or disclose your information for these purposes, or because such use or disclosure is recognized as critical to the functioning of our health care system.

Your Health Information Rights. This section describes the following rights you have with respect to your health information and tells you how you may exercise these rights.

• Right to access
• Right to request amendment
• Right to and accounting disclosures
• Right to request restrictions on certain uses and disclosures
• Right to request alternative means of communication
• Right to be notified of a breach of your protected health information
• Right to receive a paper copy of our Notice of Privacy Practices

How to File Complaints Concerning Our Privacy Practices. This section tells you what you can do if you believe any of your rights have been violated. You will not be penalized for filing a complaint.

I acknowledge that the Notice of Privacy Practices of Kansas Surgical Consultants with the effective date of September 23, 2013 has been given or offered to me and are available upon request at any time.