FMOLHS Patient Information/Facesheet ===================================================================================================

Referring Physician:

MRN (Epic) __________________ Primary Care Physician:

Name ________________________________________________ Social Security # ____________________ Sex: M F Unknown Last First Middle

Date of Birth ___________________ other known name(s) ________________________________________ ______ _____

Mailing Address ______________________________ _______ _____________________ ________________ ____________ City State Zip

Parish ______________________

Home phone _________________ __________ Work phone ________________ ______ Mobile phone __________ ___________

Email address _________________________________ Language English Spanish Other ___ ____________

Person outside of household to contact in case of emergency or in case we must reschedule an appointment for you.

Name ________________________________________________ Phone #’s ______________________________ Relationship ___________ _____

Marital Status: (circle one) Ethnicity: (circle one) Race: (circle one)

Married Divorced Hispanic or Latino American Indian or Alaska Native Legally Separated Single Not Hispanic or Latino Asian Widowed Significant Other Unknown Black or African American Unknown Other No Answer Native Hawaiian or Other Pacific Islander

White or Caucasian

========================================================================================================================

Responsible Party Information (If different from patient)

Name __________________________________________________ Social Security # __________________ Sex: M F Unknown Last First Middle

Date of Birth ________________________ other known name(s) ____________________________________________________

Mailing Address ________________________________________ _________________________ ________________ ________ City State Zip

Parish ________________________________ Relationship to patient ______________________________________

Home phone __________________________ Work phone ______________________ Mobile phone _________________________

========================================================================================================================

Employer (Responsible party if patient is a child) ____________________________________________________________________

Employer address ____________________________________ ______________________ __________________ ____________ City State Zip

Employer phone _________________________

Employment Status: (circle one disabled full-time part-time not employed on active military duty

Self-employed student full-time student part-time unknown retired

Policy Holder Information (if different from patient and responsible party)

Name __________________________________________________ Social Security # ____________________ Sex: M F Unknown Last First Middle Date of Birth ________________ other known name(s) _____________________________________________________________ Mailing Address _____________________________________________ _____________________ ________________ ________ City State Zip

Parish ______________________ Relationship to patient _____________________

Home phone __________________________ Work phone _____________________ Mobile phone ___________________________ Employer ____________________________________________________________________________________________________ Employer address ___________________________________ _________________________ __________________ ____________ City State Zip Employer phone _________________________

Employment Status: (circle one) disabled full time part time not employed on active military duty retired Self-employed student full-time student part-time unknown

================================================================================================== Insurance Information

(Primary Coverage) (Secondary/Supplemental Coverage)

Insurance Company ______________________________ Insurance Company _____________________________

Ins Address _____________________________________ Insurance Address ______________________________ City _______________________ State _______________ City ________________________ State _____________ Zip ____________ Phone __________________________ Zip ___________ Phone __________________________ Relationship to Patient ____________________________ Relationship to Patient ___________________________

Insurance ID # ___________________________________ Insurance ID# __________________________________ Effective Date ___________________________________ Effective Date __________________________________ Group # ________________________________________ Group # _______________________________________ Name on Card ___________________________________ Name on Card _________________________________

Cobra/continuation of benefits Cobra/continuation of benefits Other ____________________ Other ____________________

================================================================================================== By signing below, I agree to the following:

I agree to pay for all financial obligations and abide by the terms and provisions of the Financial, Patient Responsibilities and Clinic Polices of Lourdes Physician Group, LLC, which I acknowledge that I have read and fully understand, including the sections pertaining to Payment Guarantee and Insurance Authorization/Assignment of Insurance Benefits, Precertification, 24-Hour Cancellation policy, Termination of Physician-Patient Relationship policy, Other Physician Charges and Medical Records Copying Fees.

Print Name: _______________________________ Signature of Patient: _______________________ Date: ________________

Patient Medication List

Patient: _____________________________ DOB: ____________ Date: _______________

Medication: Dosage: Frequency:

PHARMACY: ______________________ PHONE: __________________ FAX: ________________

Revised 4/27/2017

Authorization for Individuals Involved in the Care of a Patient

I give Lourdes Physician Group permission to release medical information to the following

individuals:

Name:

1. _______________________________ Relationship to Patient__________________________

2. _______________________________ Relationship to Patient__________________________

3._____________________________ __ Relationship to Patient__________________________

Authorization to Leave a Detailed Message

I hereby authorize my provider or other representative of Lourdes Physician Group to leave a

detailed message concerning my lab results, insurance/billing information or questions,

appointments, surgery, prescriptions, or any other issues on the following devices:

Please check all that apply and write appropriate phone number in the blank:

______Answering machine at home: ____________________________________

______Voice mail at work: ____________________________________________

______Cell phone: ___________________________________________________

______MyChart:_____________________________________________________

______Other:________________________________________________________

THE ABOVE AUTHORIZATIONS ARE VALID UNTIL SUCH TIME AS I REVOKE THEM

IN WRITING.

_________________________________________ __________________________

Signature Date

_________________________________________ __________________________

Staff Signature Date

PAGE 4 General Consent for Treatment.doc07/01/13

FMOLHS Physician Office Consent to Treatment

I consent to and authorize the physician(s), physician assistant(s), nurse practitioner(s), resident

physician(s), health care student(s), clinical staff of Lourdes Physician Group (LPG, LLC) and/or certain

outpatient departments of Our Lady of Lourdes RMC (hereafter referred to as OLOL RMC) to provide

diagnostic procedures and medical treatment including, but not limited to minor procedures and routine

services deemed necessary at the time of the office visit, to me or the patient named on this form. I

understand that the practice of medicine is not considered exact science, and acknowledge that no

guarantees have been made to the patient named on this form.

The following sections may not apply to all clinics. If you have any questions, feel free to discuss with your provider.

Medical Education

I agree that care from LPG, LLC and/or OLOL RMC may be provided by student nurses, technicians,

therapists, interns, residents, fellows and other providers and observers, who are supervised by qualified

faculty and/or LPG, LLC and/or OLOL RMC staff, in accordance with the policies of the LPG, LLC.

Photography and Other Recordings

I consent to photographs, digital or other images that may be recorded to document my care. I understand

that these images will be stored in a secure manner and will be released when requested for non-treatment

reasons, only upon written authorization by me, or my legal representative.

_____________________________________________ __________________________

Signature Date

_____________________________________________ __________________________

Staff Signature Date

Patient Financial Policy

This is an agreement between Lourdes Physician Group,

(LPG), as creditor, and the Patient/Debtor named on this

form.

In this agreement the words “you”, “your”, and “yours”

mean the Patient/Debtor. The word “account” means the

account that has been established in your name to which

charges are made and payments credited. The words “we”,

“us”, and “our” refer to LPG.

By executing this agreement, you are agreeing to pay for all

services that are received.

PAYMENT IN FULL IS REQUIRED AT TIME OF

SERVICE

1. You may pay by cash, check, or credit card on the

day that services are rendered (credit card services

may not be available at some locations).

2. It is your responsibility to know your insurance

benefits before you arrive for your appointment

and to bring your insurance card to every visit.

3. Monthly payment plans are available with

approval. Please see front desk personnel for more

information.

4. Payments: Unless other arrangements are

approved by us in writing, the balance on your

statement is due and payable when the statement is

issued, and is past due if not paid within 30 days.

If you have a previous balance owed, this is due at

the time of service.

Required Payments: Any co-payment/ co-

insurance/deductibles required by an insurance company

must be paid at the time of service. Because co-pays are an

insurance requirement, we cannot bill you for these.

Services not covered by your plan become your

responsibility to file with your insurance company.

Returned checks: There is a fee (currently $25) for any

checks returned by the bank. If two or more checks are

returned, all patient responsible portions thereafter, must be

paid in cash.

Monthly Statement: You will receive a statement for any

balance due. This statement will indicate all charge,

payments, and credits posted to your account. If payment

has not been received after 3 statement mailing cycles, you

will be contacted regarding your balance responsibility.

Past due accounts: If your account becomes past due, we

will take necessary steps to collect this debt, including

collection agency involvement as well as possible discharge

from the practice.

Waiver of confidentiality: You understand if this account

is submitted to an attorney or collection agency, if we have

to litigate in court, or if past due status is reported to an

agency, the fact that you received treatment at our office

may become a matter of public record.

Divorce: In case of divorce or separation, the party

responsible for the account prior to the divorce or

separation remains responsible for the account. After a

divorce or separation, the parent authorizing treatment for a

child will be the parent responsible for those subsequent

charges. If the divorce decree requires the other parent to

pay all or part of the treatment costs, it is the authorizing

parent’s responsibility to collect from the other parent.

Transferring of Records: You will need to request in

writing to have copies of your records sent to another

doctor or organization. For current medical record copying

fees see (LA R.S. 40:1299.96 (A)(2)(b) Act NO. 740).

Personal Injury: We do not bill Attorneys or third party

payers for personal injuries due to motor vehicle accidents

or workers compensation. Patient will be responsible for

charges.

Effective Date: By signing this agreement, you are

agreeing to all of the terms and conditions contained herein

and the agreement will be in force and effect. Failure to

comply with terms and conditions may result in discharge

from the practice.

Revised 07/01/2013

Patient’s Signature :

Date:

Print Patient’s Name :

DOB:

Witness (LPG Team Member):

Revised 10/2017

Patient Responsibilities and Clinic Policies

Payment Guarantee & Insurance Authorization/ Assignment of Insurance Benefits

Patients are responsible for all past due balances. This may include amounts denied by insurance

companies, copays, co-insurance, deductibles or non-covered charges for diagnostic procedures

and medical treatment and understand that payment is due at the time of service. If I do not have

medical insurance, I understand that it is my responsibility to make financial arrangements prior to

receiving services. I understand that health insurance companies pay directly to Lourdes

Physician Group, LLC and/or certain outpatient departments of Our Lady of Lourdes RMC

(hereafter referred to as OLOL RMC) any insurance benefits due for services rendered. I agree to

notify Lourdes Physician Group, LLC and/or OLOL RMC of any changes in insurance, address

or other information included in patient registration. I understand I am responsible for all charges

not paid by my insurance company. If it becomes necessary to collect any sum due through an

attorney, then, I agree to pay all reasonable costs of collection including attorney’s fees, whether

suit is filed or not. Additionally, I agree to pay court costs associated with such collection efforts.

I understand that I am responsible for verifying that my provider participates with my insurance

plan and that I must present a copy of my card and picture ID at each office visit. New patient

appointments without a picture ID will be rescheduled.

I understand that if the patient is a minor, the adult accompanying the child for treatment will

ultimately be responsible for payment. Lourdes Physician Group, L.L.C. and/or OLOL RMC

does not become involved in third party liabilities, personal injury, or custody issues to determine

the responsible party for payment. We cannot accept an attorney’s letter of payment guarantee.

I understand that any account that has been placed in my responsibility that is over 120 days past

due will be sent to an independent collection service. This balance may be subject to reporting to

the credit bureau and possible termination of the doctor/patient relationship. If you are having

financial difficulties that prevent you from paying your balance, please refer to your patient service

representative for payment options.

Pre-certification – Pre-certification or prior approval may be required by your health plan before

certain procedures, tests, or surgeries are performed. We will assist you in the pre-certification

process by contacting your insurance company on your behalf. However, it is your responsibility

to confirm that you have been granted approval or certification before your appointment or you will

be responsible for any charges insurance has not granted prior approval.

Appointment/ Cancellation policy – Your appointment time is reserved for you and your provider.

When calling for an appointment please be very specific about the reason for your visit. We want

to ensure that adequate time is assigned with your doctor. In order for our providers to stay on

schedule and spend quality time with you, we ask that you arrive promptly. Although we do realize

that emergencies do occur, we expect you to keep all of your appointments. If you need to

reschedule an appointment we require a 24 hour notice. This is a courtesy not only to the providers

but to other patients who may need to schedule their medical care. In the instance of repeated non-

compliance with your scheduled visits, we reserve the right to discontinue care.

Revised 10/2017

Refills/Medications – Please bring all medications in their original bottles with you to each

appointment. It is very important for us to complete an accurate record of all prescriptions, over

the counter medications, herbal supplements and vitamins that you are currently taking. The

quickest way to get your medications refilled is to call your pharmacy and have them request

authorization electronically. Certain conditions may require a follow-up appointment and your

doctor may issue a refill.

Termination of Physician-Patient Relationship policy – Your physician at his/her discretion and

judgment, may discontinue treatment of a patient for rude, inappropriate or egregious behavior,

noncompliance with treatment recommendations, failure to obtain medically necessary referrals or

further testing, failure to follow medication regimens, failure to meet financial obligations, or

breakdown of the physician/patient relationship.

Other physician charges – Our practice is committed to providing the best treatment for our

patients which may necessitate the outsourcing of some services to other professionals. When this

occurs, you may receive a statement from the provider of ancillary services such as Pathology,

Laboratory, and/or Radiology interpretation services.

Forms / Letters / Copy of Medical Records – Fees for these administrative services will not be

filed to your insurance. This includes completion of all forms, letters and copying of medical

records. Depending on the circumstances, the costs associated with these services may be billed

directly to the patient.

Patient Printed Name:

Patient Signature:

Date:

Requester’s Name/Relationship to Patient:

Provider’s Name/Address:

This authorization shall expire on this expiration date______________________________ ** If I fail to specify an expiration date or event, this authorization will expire six (6) months from the date on which it was signed

Purpose of Disclosure� Medical Care � Legal � Insurance � Personal � Other

Description of Information to be used or disclosed. Is this request for psychotherapy notes? � Yes, then this is the only item you may request on this authorization. You must submit another authorization for other items below. � No, then you may check as many items below as you need Information to be disclosed: � Discharge Summary � History & Physical Exam � Operative Report � EKG � ER Record � Laboratory Report � Radiology Report � Itemized Bill � Pathology Report � Consultation � Other: ______________________________

Date of Service: ___________ to ___________ The information is to be released to: _____________________________________________________________________________________________ ___________________________________________________________________________________________________ (address) (city) (state) (zip)

I have read the above and authorize the disclosure of the protected health information as stated.

Signature of Patient or Legal Representative: Date:

Print Name of Patient or Legal Representative: Relationship to Patient or Legal Representative:

Authorization for Release of Protected Health Information (PHI)

OUR LADY OF LOURDES OUR LADY OF THE LAKE ST. ELIZABETH HOSPITAL ST. FRANCIS MEDICAL CENTER OUR LADY OF THE ANGELS HOSPITAL4801 Ambassador Caffery Pkwy 5000 Hennessy Blvd. 1125 West Hwy 30 309 Jackson Street 433 Plaza Street

Lafayette, LA 70508 Baton Rouge, LA 70808 Gonzales, LA Monroe, LA 71201 Bogalusa, LA 70427(337) 470-2136 (225) 765-8541 (225) 647-5088 (318) 966-4754 (985) 730-2240

107457

The following information will be released when included in the above unless you indicate otherwise:❑ Do not release and AIDS or HIV test results ❑ Do not release any records of psychiatric care❑ Do not release any records of alcohol/drug abuse ❑ Do not release records of genetic testing

1. I understand that this authorization is voluntary and that I may refuse to sign per the Health Insurance Portability andAccountability Act (HIPAA). Louisiana law requires a written authorization in order to release protected health information.

2. If I do not sign this form, my health care and the payment for my health care will not be affected unless stated otherwise.3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to

receiving the revocation. Further details may be found in the Notice of Privacy Practices.4. If the requester or receiver is not a health plan or health care provider, the released may no longer be protected by federal

regulations and may be redisclosed.5. I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask

for it.6. I may get a copy of this form after I sign it._______________________________________________

Our Lady of the Lake Regional Medical CenterOur Lady of Lourdes Regional Medical Center

St. Francis Regional Medical CenterSt. Elizabeth Hospital

Our Lady of the Angels Hospital

Patient’s Name/Address/Phone

Medical Record / Fin #: Birth Date: Last 4 Digits of Social Security Number

x

See Page 2: _Last Office Note

I understand this information may be disclosed to multiple providers. _____(Initials)

Lourdes Physician Group

Patient authorization to release specific medical records

Name of patient:_____________________ Date of birth:____________

Information to be released from:

1)______________________ Fax number:_______________

________________________ Phone number:_____________

________________________ ___ Most recent mammogram ___ Most recent PAP results

___ Last colonoscopy report ___ Most recent Diabetic eye exam

___ Last DEXA report ___ Most recent A1C

2)______________________ Fax number:_______________

________________________ Phone number:______________

________________________

___ Most recent mammogram ___ Most recent PAP results

___ Last colonoscopy report ___ Most recent Diabetic eye exam

___ Last DEXA report ___ Most recent A1C

3)______________________ Fax number:_______________

________________________ Phone number:______________

________________________ ___ Most recent mammogram ___ Most recent PAP results

___ Last colonoscopy report ___ Most recent Diabetic eye exam

___ Last DEXA report ___ Most recent A1C

Information to be released to:

Address:

FAX:

Phone:

I authorize the above provider to release the information marked to the recipient.

_____________________ _______________ _______ Signature of Patient Relationship to patient Date

____________________________Printed Patient Name

page 2 (note page 1 also reviewed and signed by patient) Medical release health maintenance.docx

How Do I Sign Up? In your Internet browser, go to https://mychart.fmolhs.org/MyChart/

1. Click on the GREEN Sign Up Now link near the middle of the page. 2. Enter your MyChart Access Code exactly as it appears on your After Visit Summary. You

will not need to use this code after you’ve completed the sign-up process. If you do not sign up before the expiration date, you must request a new code. MyChart Access Code: Can be found under the To-Do list section on the After Visit Summary Expiration date: Listed under the MyChart Access Code

3. Enter the last four of your SSN and Date of Birth (mm/dd/yyyy) as indicated and click

Submit. You will be taken to the next sign-up page. 4. Create a MyChart ID. This will be your MyChart login ID and cannot be changed, so

think of one that is secure and easy to remember. 5. Create a MyChart password. You can change your password at any time. 6. Enter your Password Reset Question and Answer. This can be used at a later time if you

forget your password. 7. Enter your e-mail address. You will receive e-mail notification when new information is

available in MyChart. 8. Click Sign Up. You can now view your medical record.

If you have any questions, you can call 337-470-2259. Remember, MyChart is NOT to be used for urgent needs. For medical emergencies, dial 911.

Revised 08/2016

NOTICE OF PRIVACY PRACTICES

In compliance with Federal Law, Effective: September 23, 2013

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices (the “Notice”) describes the legal obligations of Lourdes Physician Group, LLC

(sometimes collectively referred to hereinafter as “Organization” or “Organizations”) and your legal rights regarding

protected health information held by the Organization under the Health Insurance Portability and Accountability Act of

1996 (“HIPAA”). HIPAA protects only certain health information known as “protected health information.” Generally,

protected health information is individually identifiable health information, including demographic information, collected

from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on

behalf of a group health plan that relates to:

(1) Your past, present or future physical or mental health or condition;

(2) The provision of health care to you; or

(3) The past, present or future payment for the provision of health care to you.

If you have any questions about this Notice or about our privacy practices, please contact Our Lady of Lourdes,

Compliance Officer, at (337) 470-2825.

WHO WILL FOLLOW THIS NOTICE

This Notice describes the Organization’s practices and that of:

All employees, staff, volunteers, contractors and other personnel.

All departments and units of the Organization.

Any member of a volunteer group we allow to help you while you are in our care.

Any physician or allied health professional who is a member of the Medical Staff and involved in your

care.

All entities, sites and locations will follow the terms of this Notice. When this Notice refers to “we” or

“us”, it is referring to the following entities, sites and locations: Lourdes Physician Group, LLC. In

addition, these entities may share medical information with each other for treatment, payment or health

care operations purposes described in this Notice.

The Organization, the members of its Medical Staff, and other health care providers affiliated with the Organization

typically work together in a clinically integrated setting to provide you with health care. In such settings, HIPAA permits

the use of a single Notice to describe how the Organization, Medical Staff members, and other health care providers who

participate in “Organized health care arrangement” will use or disclose your health information. In addition, Organization

and other participating entities in the Capital Area Shared Services Organization (“CASSO Participants”) share a unified

electronic medical record system and certain other electronic systems for patient services, such as, scheduling and billing

systems to support the efficient care and services provided by each of the CASSO. Your patient information maintained

in these electronic systems and your medical record will be maintained in electronic form as a single unified record and

may be shared with among CASSO Participants for treatment, payment and healthcare operations purposes. Any request

for your medical record maintained in the CASSO system will encompass the entire unified record unless otherwise

specified by you in a written authorization.

OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that medical information about you and your health is personal. We are committed to protecting health

information about you. We create a record of the care and services you receive at our Organization. We need this

record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the

records of your care generated by our Organization, whether recorded in your medical record, invoices, payment forms,

videotapes or other ways, that include protected health information. Physicians and other care providers who are not

employed by the Organization may have different policies or notices regarding the use and disclosure of your protected

health information created in the physician’s office or clinic.

ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE

You will be asked to provide a signed acknowledgement of receipt of this Notice. Our intent is to make you aware of

the possible uses and disclosures of your protected health information and your privacy rights. The delivery of health

care services will in no way be conditioned upon your signed acknowledgement. If you decline to provide a signed

acknowledgement, we will continue to provide your treatment, and will use and disclose your protected health

information as provided in this notice, when necessary.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

In some circumstances we are permitted or required to use or disclose your protected health information without

obtaining your prior authorization and without offering you the opportunity to object. The following categories describe

these different circumstances. For each category of uses or disclosures we will explain what we mean and list an

example. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and

disclose information will fall within one of the categories.

For Treatment. We may use and disclose your protected health information to provide you with medical

treatment or services. We may disclose your protected health information to doctors, nurses, technicians,

medical students, or other health care providers who are involved in taking care of you. For example, a

doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the

healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can

arrange for appropriate meals. Different departments of the Organization also may share medical

information about you in order to coordinate the different things you need, such as medications, lab work

and x-rays and we may disclose your protected health information to third parties with whom we

coordinate and manage your care.

For Payment. We may use and disclose your protected health information so that the treatment and

services you receive at the Organization’s facilities may be billed to and payment may be collected from

you, an insurance company or a third party. For example, we may inform your health insurance company

of your diagnosis and treatment in order to assist the insurer in processing our claim for the health care

services provided to you or share information with a person who helps pay for your care.

For Health Care Operations. We may use and disclose your protected health information for our day-

to-day operations and functions. For example, we may we may compile your protected health

information, along with that of other patients, in order to allow a team of our health care professionals to

review that information and make suggestions concerning how to improve the quality of care provided at

our Organization. We may also disclose information to doctors, nurses, technicians, medical students,

members of our quality improvement team, and other participants in our organized health care

arrangements for review and learning purposes and to improve the quality and effectiveness of the

services you receive.

To Business Associates. We may contract with individuals or entities known as Business Associates to

perform various functions on our behalf or to provide certain types of services. In order to perform these

functions or to provide these services, Business Associates will receive, create, maintain and/or transmit

protected health information about you, but only after they agree in writing with us to implement

appropriate safeguards regarding your protected health information.

Health Information Exchange. We may share your information for treatment, payment, and healthcare

operations purposes through a health information exchange in which we participate in order for

participants to efficiently access and use your pertinent medical information necessary for treatment and

other lawful purposes.

Appointment Reminders. We may contact you as a reminder that you have an appointment for

treatment or medical care at our Organization.

Treatment Alternatives. We may contact you about or recommend possible treatment options or

alternatives that may be of interest to you.

Health-Related Benefits and Services. We may contact you about health-related benefits or services

such as disease management programs and community-based activities in which we participate that may

be of interest to you.

Fundraising Activities. We may contact you as part of our effort to raise funds for our Organization.

You have a right to opt out of receiving fundraising communications and all fundraising communications

will include information about how you may opt out of future communications.

Research. Under certain circumstances, we may use and disclose your protected health information for

research purposes through a special approval process designed to protect patient safety, welfare, and

confidentiality. This process evaluates a proposed research project and its use of medical information,

trying to balance the research needs with patients' need for privacy of their medical information. For

example, a research project may involve comparing the health and recovery of all patients who received

one medication to those who received another, for the same condition. We may also disclose your

protected health information to people preparing to conduct a research project, for example, to help them

look for patients with specific medical needs, so long as the information they review does not leave the

Organization.

As Required By Law. We will disclose your protected health information when required to do so by

federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose your protected health

information 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.

SPECIAL SITUATIONS

Organ and Tissue Donation. If you are an organ donor, we may disclose your protected health

information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an

organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may disclose your protected health

information as required by military command authorities. We may also release health information about

foreign military personnel to the appropriate foreign military authority.

Workers' Compensation. We may disclose your protected health information for workers' compensation

or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose your protected health information for public health activities.

These activities generally include the following:

to prevent or control disease, injury or disability;

to report births and deaths;

to report to state and federal tumor registries;

to report child abuse or neglect;

to report reactions to medications or problems with products;

to notify people of recalls of products they may be using;

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 provide proof of immunization to a school that is required by state or other law to have such proof

with agreement to the disclosure by a parent or guardian of, or other person acting in loco parentis for

an un-emancipated minor;

to notify the appropriate government authority if we believe that a patient has been the victim of abuse,

neglect or domestic violence. We will only make this disclosure if you agree or when required or

authorized by law.

Health Oversight Activities. We may disclose your protected health information 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 civil rights laws.

Judicial and Administrative Proceedings. We may disclose your protected health information in

response to and in accordance with a court or administrative order. We may also disclose your protected

health information in response to a subpoena, discovery request, or other lawful process by someone else

involved in the dispute after we have received assurances that efforts have been made to tell you about the

request or to obtain an order protecting the information requested.

Law Enforcement. We may disclose your protected health information 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 victim's

agreement;

About a death we suspect may be the result of criminal conduct;

About criminal conduct at the Organization; and

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 disclose your protected health

information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased

person or to determine cause of death. We may also release health information about patients of the

Organization to funeral directors as necessary to carry out their duties.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement

official, we may disclose your protected health information to the correctional institution or law

enforcement official. This release would be permitted (1) for the institution to provide you with health

care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and

security of the correctional institution.

National Security and Intelligence Activities. We may release your protected health information to

authorized federal officials for intelligence, counterintelligence and other national security activities

authorized by law.

We may also use or disclose your protected health information in the following circumstances. However, except in

emergency situations, we will inform you of our intended action prior to making any such uses and disclosures and will,

at that time, offer you the opportunity to object.

Hospital Directory. We may include certain limited information about you in a hospital directory while

you are a patient at one of the participating hospitals. This information may include your name, location

in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory

information, except for your religious affiliation, may also be released to people who ask for you by name.

Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they

don’t ask for you by name. This is so your family, friends and clergy can visit you in the hospital and

generally know how you are doing.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your protected health

information to a friend or family member who is involved in your medical care. We may also give

information to someone who helps pay for your care. We may also tell your family or friends your

condition and that you are in a hospital. In addition, we may disclose your protected health information to

an entity assisting in a disaster relief effort so that your family can be notified about your condition, status

and location.

With few exceptions, we must obtain your written authorization for uses and disclosures of your protected health

information involving (1) certain marketing communications about a product or service and whether financial

remuneration is involved, (2) a sale of protected health information resulting in remuneration not permitted under

HIPAA; and (3) psychotherapy notes, except for certain treatment, payment and health care operations purposes, if the

disclosure is required by law or for health oversight activities, or to avert a serious threat .

Except as permitted under HIPAA or as described above, disclosures of your protected health information will be made

only with your written authorization. You may revoke your authorization at any time, in writing, unless we have taken

action in reliance upon your prior authorization, or if you signed the authorization as a condition of obtaining insurance

coverage.

YOUR RIGHTS:

You have the following rights regarding health information we maintain about you:

Right to Request Restrictions. You have the right to request a restriction or limitation on the health

information we use or disclose about you for treatment, payment or health care operations. You also have the right

to request a limit on the health information 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 surgery you had.

Except as provided below, 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 you emergency treatment.

Effective September 23, 2013, we will comply with any restriction request if (1) except as otherwise required by

law, the disclosure is to a health plan for purposes of carrying out payment or health care operations (and is not for

purposes of carrying out treatment); and (2) the protected health information pertains solely to a health care item or

service for which the Organization has been paid out-of-pocket in full. The Organization is not responsible for

notifying subsequent healthcare providers of your request for restrictions on disclosures to health plans for those

items and services, so you will need to notify other providers if you want them to abide by the same restriction.

To request restrictions, you must make your request in writing to Our Lady of Lourdes, Compliance Officer, 4801

Ambassador Caffery Parkway, Lafayette, LA 70508. 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.

Right to Request Confidential Communications. You have the right to request that we communicate with

you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you

at work or by mail.

To request communications, you must make your request in writing to Our Lady of Lourdes, Compliance Officer,

4801 Ambassador Caffery Parkway, Lafayette, LA 70508. Your request must specify how or where you wish to

be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.

Right to Inspect and Copy Health Information. You have the right to inspect and copy protected health

information that may be used to make decisions about your care. Usually, this includes medical and billing

records, but does not include psychotherapy notes, information complied in anticipation of or for use in civil,

criminal or administrative proceedings, or certain information that is governed by the Clinical Laboratory

Improvement Act. If the requested protected health information is maintained electronically and you request an

electronic copy, we will provide access in an electronic format you request, if readily producible, or if not, in a

readable electronic form and format we mutually agree upon. We may charge a reasonable cost-based fee

consistent with HIPAA and Louisiana law.

Despite your general right to access your protected health information, access may be denied in limited

circumstances. For example, access may be denied if you are an inmate at a correctional institution or if you are

a participant in a research program that is still in progress. Access may be denied if the federal Privacy Act

applies. Access to information that was obtained from someone other than a health care provider under a

promise of confidentiality can be denied if allowing you access would reasonable be likely to reveal the source

of the information. The decision to deny access under these circumstances is final and not subject to review.

Otherwise, we will provide a written explanation on the basis for the denial and your review rights.

To inspect and copy medical information that may be used to make decisions about you, you must submit your

request in writing to the Medical Records Department, 4801 Ambassador Caffery Parkway, Lafayette, LA

70508. If you request a copy of the information, in accordance with Louisiana state law, you will be charged a

fee for the costs of copying, mailing or other supplies associated with your request.

Right to Request Amendment. If you feel that protected health information we have about you is incorrect or

incomplete, you may ask us to amend the information. You have the right to request an amendment for as long

as the information is kept by or for the Organization.

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:

Was not created by us, unless the person or entity that created the information is no longer available to

make the amendment;

Is not part of the medical information kept by or for the Organization;

Is not part of the information which you would be permitted to inspect and copy; or

Is accurate and complete.

To request an amendment, your request must be made in writing and submitted to the Director of Medical

Records of Our Lady of Lourdes, 4801 Ambassador Caffery Parkway, Lafayette, LA 70508. In

addition, you must provide a reason that supports your request. If we deny your request, you have the right

to file a statement of disagreement with us and any future disclosures of the disputed information will

include your statement.

Right to an Accounting of Disclosures. You have the right to request an "accounting" of certain disclosures of

your protected health information made during the six-year period preceding the date of your request. However,

the following disclosures will not be accounted for: (i) disclosures made for the purpose of carrying out

treatment, payment or health care operations unless HIPAA provides otherwise, (ii) disclosures made to you,

(iii) disclosures of information maintained in our patient directory, or disclosures made to persons involved in

your care, or for the purpose of notifying your family or friends about your whereabouts, (iv) disclosures for

national security or intelligence purposes, (v) disclosures to correctional institutions or law enforcement officials

who had you in custody at the time of disclosure, (vi) disclosures that occurred prior to April 14, 2003,

(viii)disclosures made pursuant to an authorization signed by you, (viii) disclosures that are part of a limited data

set, (ix) disclosures that are incidental to another permissible use or disclosure, or (x) disclosures made to a

health oversight agency or law enforcement official, but only if the agency or official asks us not to account to

you for such disclosures and only for the limited period of time covered by that request. The accounting will

include the date of each disclosure, the name of the entity or person who received the information and that

person’s address (if known), and a brief description of the information disclosed and the purpose of the

disclosure for the period requested unless the period or right to receive the accounting is limited under HIPAA.

To request this list or accounting of disclosures, you must submit your request in writing to the Medical

Records Department of Our Lady of Lourdes, 4801 Ambassador Caffery Parkway, Lafayette, LA 70508.

Your request must state a time period. Your request should indicate in what form you want the list (for

example, on paper, electronically). The first list you request within a 12-month period will be free. For

additional lists, we will 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 a Paper Copy of This Notice. You have the right to a paper copy of this Notice.

You may obtain a copy of this Notice at our website, www.lourdesrmc.com

To obtain a paper copy of this Notice, contact the Compliance Officer at 337-470-2825

OUR DUTIES

We are required by law to make sure that health information that identifies you is kept private;

We are required to provide you this Notice of our legal duties and privacy practices;

We are required to notify you in the event that we discover a breach of unsecured protected health information,

as that term is defined under federal law; and

We are required to follow the terms of this Notice. We reserve the right to change the terms of this Notice and

to make those changes applicable to all protected health information that we maintain. Any changes to this

Notice will be posted on our website and at our facility, and will be available from us upon request.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S.

Department of Health and Human Services. To file a complaint with us, please contact the Lourdes Physician Group,

LLC at (337) 470-2990. All complaints must be submitted in writing. You will not be penalized, or in any other way

retaliated against, for filing a complaint.

CONTACT INFORMATION

You may contact the Compliance Officer at (337) 470-2825 for further information about the complaint process or for

further information about this document.

FMOLHS HIPAA NOTICE OF PRIVACY ACKNOWLEDGEMENT

I have received/been offered a copy of the Notice of Privacy Practices for the Franciscan Missionaries of Our Lady

Health System (FMOLHS) including all of its joint ventures and affiliates who own and operate a unified electronic

medical record system. These affiliates’ include healthcare entities throughout Louisiana including but not limited to,

Our Lady of Lourdes Regional Medical Center and Lourdes Physician Group. The Notice of Privacy Practices describes

how my health information may be used or disclosed by the participating providers which include my Lourdes Physician

Group provider and care received at a number of other Our Lady of Lourdes Regional Medical Center facilities. I

understand that I should read it carefully and I am aware that the Notice may be changed at any time.

NOTICE TO MINORS

Your healthcare provider has the right to disclose protected healthcare information to your parents/guardians should

he/she deem necessary.

Print Patient’s Name Date

Patient’s Signature

*As the representative of the above individual, I acknowledge receipt of the Notice of Privacy Practices on his or her

behalf

Print Representative’s Name Date

Relationship to the Patient

Representative’s Signature