ONE-TIME PAYMENT

Make a one-time payment directly on our website.

PAYMENT IN PERSON

You may pay your bill in person by visiting our Business Office located at:
145 Kimel Park Drive, Suite 120
Winston-Salem, NC 27103

PAYMENT BY PHONE

To make a credit card payment by phone, please call our office at (336) 768-3212. PTA accepts MasterCard, Visa and Discover.

PAYMENT BY MAIL

Please make your check payable to Piedmont Triad Anesthesia. Mail the payment to:
PTA
P.O. Box 602359
Charlotte, NC 28620-2359

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.

Notice of Privacy Practices

This Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
If you have any questions about this Notice, please contact our Compliance Director.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations, and for other purposes that are permitted or required by law. It also describes your right to access and control of your protected health information. Protected health information (PHI) is information about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health or condition, and related
health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our Notice at any time. The new Notice will be effective for all PHI that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised Notice by accessing our web site, www.ptanc.com, calling the office to have a revised copy sent to you in the mail, or asking for one at the time of your
next surgery.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information Based Upon Your Written Consent

You will be asked by your physician to sign a consent form. Once you have consented to the use and disclosure of your PHI for treatment, payment and health care operations by signing the consent form, your physician will use or disclose your PHI as described in this Section 1. Your PHI may be used and disclosed by your physician, our office staff, and others outside of our offices who are involved in your care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice.

Following are examples of the types of uses and disclosures of your protected health care information that the physician’s office is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent.

Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services, including the coordination or management of your health care with a third party that has already obtained your permission to have access to your PHI. For example, we would disclose your PHI, as necessary, to a home health agency that provides care to you. We will also disclose PHI to other physicians who may be treating you when we have the necessary permission from you to disclose your PHI. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

In addition, we may disclose your PHI from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

Payment: Your PHI will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as, making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health insurance plan to obtain approval for the hospital admission.

Health Care Operations: We may use or disclose, as-needed, your PHI in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fund-raising activities, and conducting or arranging for other business activities.

For example, we may disclose your PHI to medical school students who see patients at our office. In addition, we may use a sign-in sheet at the registration desk, where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment.

We will share your PHI with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your PHI.

We may use or disclose your PHI, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your PHI for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Compliance Officer to request that these materials not be sent to you.

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fund-raising activities supported by our office. If you do not want to receive these materials, please contact our Compliance Officer and request that these fund-raising materials not be sent to you.

Uses and Disclosures of Protected Health Information Based Upon Your
Written Authorization

Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in
the authorization.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object

We may use and disclose your PHI in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the PHI, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is relevant to your health care will be disclosed.

Others Involved in Your Health 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. If you are unable to agree or 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 PHI to notify or assist in notifying a family member, personal representative or any other person who is responsible for your care, of your location, general condition or death. Finally, 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 involved in your
health care.

Emergencies: We may use or disclose your PHI in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physician or another physician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your PHI to treat you.

Communication Barriers: We may use and disclose your PHI if your physician or another physician in the practice attempts to obtain consent from you, but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object

In the following situations we may use or disclose your PHI without your consent
or authorization:

Required by Law: We may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health: We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your PHI, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and
state laws.

Food and Drug Administration: We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, or track products; to enable product recalls; to make repairs or replacements, or to conduct post-marketing surveillance, as required.

Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include: (1) legal processes and others required by law; (2) limited information requests for identification and location purposes, pertaining to victims of a crime; (3) suspicion that death has occurred as a result of criminal conduct, in the event that a crime occurs on the premises of the practice, and (4) medical emergency (not on the Practice’s premises) and it is likely that a crime
has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his or her duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.

Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your PHI, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: We may use or disclose PHI of individuals who are Armed Forces personnel when the following conditions apply: (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to a foreign military authority if you are a member of that foreign military service. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: Your PHI may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally established programs.

Inmates: We may use or disclose your PHI if you are an inmate of a correctional facility and your physician created or received your PHI in the course of providing care to you.

Required Uses and Disclosures: Under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

2. Your Rights

Following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.

You have the right to inspect and copy your PHI. This means you may inspect and obtain a copy of PHI about you that is contained in a designated record set for as long as we maintain the PHI. A “designated record set” contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Compliance Officer if you have questions about access to your medical record.

You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or health care operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care, or for notification purposes, as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with
your physician.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled, or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Compliance Officer.

You may have the right to have your physician amend your PHI. This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Compliance Officer to determine if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter time frame. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this Notice from us, upon request, even if you have agreed to accept this Notice electronically.

3. Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

You may contact our Compliance Officer at (336) 768-3212 or compliance@ptanc.com for further information about the complaint process.

This Statement of Privacy applies to the Piedmont Triad Anesthesia Web site and governs data collection and usage. By using the Piedmont Triad Anesthesia web site, you consent to the data practices described in this statement.

Piedmont Triad Anesthesia is committed to protecting your privacy and developing technology that gives you the most powerful and safe online experience. This Statement of Privacy applies to the Piedmont Triad Anesthesia Web site and governs data collection and usage. By using the Piedmont Triad Anesthesia Web site, you consent to the data practices described in this statement.

Collection of Your Personal Information
Piedmont Triad Anesthesia collects personally identifiable information, such as your e-mail address, name, home or work address and telephone number. Piedmont Triad Anesthesia also collects anonymous demographic information, which is not unique to you, such as your zip code, age, gender, interests and favorites.

There is also information about your computer hardware and software that is automatically collected by Piedmont Triad Anesthesia. This information can include: your IP address, browser type, domain names, access times and referring Web site addresses. This information is used by Piedmont Triad Anesthesia for the operation of the service, to maintain quality of the service, and to provide general statistics regarding use of the Piedmont Triad Anesthesia Web site.

Please keep in mind that if you directly disclose personally identifiable information or personally sensitive data through Piedmont Triad Anesthesia public message boards, this information may be collected and used by others. Note: Piedmont Triad Anesthesia does not read any of your private online communications.

Piedmont Triad Anesthesia encourages you to review the privacy statements of Web sites you choose to link to from Piedmont Triad Anesthesia so that you can understand how those Web sites collect, use and share your information. Piedmont Triad Anesthesia is not responsible for the privacy statements or other content on Web sites outside of the Piedmont Triad Anesthesia and Piedmont Triad Anesthesia family of Web sites.

Use of Your Personal Information
Piedmont Triad Anesthesia collects and uses your personal information to operate the Piedmont Triad Anesthesia Web site and deliver the services you have requested. Piedmont Triad Anesthesia also uses your personally identifiable information to inform you of other products or services available from Piedmont Triad Anesthesia and its affiliates. Piedmont Triad Anesthesia may also contact you via surveys to conduct research about your opinion of current services or of potential new services that may be offered.

Piedmont Triad Anesthesia does not sell, rent or lease its customer lists to third parties. Piedmont Triad Anesthesia may, from time-to-time, contact you on behalf of external business partners about a particular offering that may be of interest to you. In those cases, your unique personally identifiable information (e-mail, name, address, telephone number) is not transferred to the third party. In addition, Piedmont Triad Anesthesia may share data with trusted partners to help us perform statistical analysis, send you e-mail or postal mail, or provide customer support. All such third parties are prohibited from using your personal information except to provide these services to Piedmont Triad Anesthesia, and they are required to maintain the confidentiality of your information.

Piedmont Triad Anesthesia does not use or disclose sensitive personal information, such as race, religion, or political affiliations, without your explicit consent.

Piedmont Triad Anesthesia keeps track of the Web sites and pages our customers visit within Piedmont Triad Anesthesia, in order to determine which Piedmont Triad Anesthesia services are the most popular. This data is used to deliver customized content and advertising within Piedmont Triad Anesthesia to customers whose behavior indicates that they are interested in a particular subject area.

Piedmont Triad Anesthesia Web sites will disclose your personal information, without notice, only if required to do so by law or in the good faith belief that such action is necessary to: (a) conform to the edicts of the law or comply with the legal process served on Piedmont Triad Anesthesia or the site; (b) protect and defend the rights or property of Piedmont Triad Anesthesia; and, (c) act under exigent circumstances to protect the personal safety of users of Piedmont Triad Anesthesia, or the public.

Use of Cookies 
The Piedmont Triad Anesthesia Web site uses “cookies” to help you personalize your online experience. A cookie is a text file that is placed on your hard disk by a Web page server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you, and can only be read by a Web server in the domain that issued the cookie to you.

One of the primary purposes of cookies is to provide a convenience feature to save you time. The purpose of a cookie is to tell the Web server that you have returned to a specific page. For example, if you personalize Piedmont Triad Anesthesia pages, or register with the Piedmont Triad Anesthesia Web site or services, a cookie helps Piedmont Triad Anesthesia to recall your specific information on subsequent visits. This simplifies the process of recording your personal information, such as billing addresses, shipping addresses, and so on. When you return to the same Piedmont Triad Anesthesia Web site, the information you previously provided can be retrieved, so you can easily use the Piedmont Triad Anesthesia features that you customized.

You have the ability to accept or decline cookies. Most Web browsers automatically accept cookies, but you can usually modify your browser setting to decline cookies if you prefer. If you choose to decline cookies, you may not be able to fully experience the interactive features of the Piedmont Triad Anesthesia services or Web sites you visit.

Security of Your Personal Information
Piedmont Triad Anesthesia secures your personal information from unauthorized access, use or disclosure. Piedmont Triad Anesthesia secures the personally identifiable information you provide on computer servers in a controlled, secure environment, protected from unauthorized access, use or disclosure. When personal information (such as a credit card number) is transmitted to other Web sites, it is protected through the use of encryption, such as the Secure Socket Layer (SSL) protocol.

Changes to This Statement
Piedmont Triad Anesthesia will occasionally update this Statement of Privacy to reflect company and customer feedback. Piedmont Triad Anesthesia encourages you to periodically review this Statement to be informed of how Piedmont Triad Anesthesia is protecting your information.

Contact Information
Piedmont Triad Anesthesia welcomes your comments regarding this Statement of Privacy. If you believe that Piedmont Triad Anesthesia has not adhered to this Statement, please contact Piedmont Triad Anesthesia at web.payments@ptanc.com. We will use commercially reasonable efforts to promptly determine and remedy the problem.

Piedmont Triad Anesthesia, P.A. (PTA) is an independent physician practice that provides the surgical anesthesia services at the following facilities:

• Forsyth Medical Center
• Medical Park Hospital
• Kernersville Medical Center
• Novant Health Hawthorne Outpatient Surgery Center
• Novant Health Orthopedic Surgery Center
• Clemmons Medical Center
• Piedmont Outpatient Surgery Center

You will receive a separate bill for anesthesia services rendered by PTA physicians.

PTA participates with the following Insurers, Networks, Payers and Plans:

• BCBS of NC (including out-of-state plans)
• Blue Medicare (BCBS)
• CIGNA
• MedCost
• Medicare
• Medicare Advantage Plans (All)
• Medicaid – NC
• Medicare – Railroad
• Medicaid – VA
• Novant Employee Health Plan
• Primary Physician Care
• United Healthcare

You may be responsible for additional fees related to your service if your Plan is not listed.

What you need to know if your insurance plan is not listed:

1. If you are covered under certain insurance plans (all HMOs, HMO/POS and some PPOs) issued by a carrier licensed and regulated by the NC Department of Insurance (DOI), the service invoice will be paid in full by the carrier, even if PTA is not a participating provider.

2. If your plan or payer is not regulated by the NC DOI, you may be financially responsible for part of the cost of your invoiced services.

3. If you have any questions about your benefits and coverage, please contact our business office at (336) 768-3212. Our staff will work with you to verify your benefits in advance of your admission, if possible.

As a courtesy and convenience to our patients, we will always bill the carrier, third party payer or guarantor listed on the admission form before invoicing the patient for our services. If you have a question regarding your invoice, please do not hesitate to call our office. Our staff will be glad to assist you.