Developmental-Behavioral Pediatrics 8402 Harcourt Road, Suite 105 , IN 46260-2006 317-582-8290 PHONE 317-582-8291 FAX stvincent.org/peytonmanning

Welcome to Developmental-Behavioral Pediatrics,

Please arrive 15 minutes prior to your scheduled appointment in order to complete the registration process. Being late for your appointment might mean we will need to reschedule your appointment.

Your appointment is a Consultative Visit to become acquainted and for us to determine how your child's needs may best be met.

Enclosed you will find a Patient Information Packet which we ask you to review as soon as possible. This packet contains registration material, directions to our office, patient history forms and forms that must be completed by your child's school.

It is very important that you return the forms to our office prior to your appointment or bring to the office the day of the appointment. Having this information will allow us to address your concerns and provide recommendations in a more complete and efficient manner.

Please bring the following items with you to this appointment:

• Completed Patient Information Packet

• Insurance cards

• Driver's license or ID of parent/guardian

• Any other past medical, mental health, therapy, testing and school information pertaining to this appointment which you believe would be helpful

Please know that it is required by law that all children under the age of 18 must be present with a legal guardian unless written authorization is provided.

The appointment is scheduled to last 60-90 minutes. If you need to cancel or reschedule your appointment, please call our office at least 24 hours in advance so we may offer this time to another family.

We look forward to meeting you and your child. Please contact us if you have any questions.

Sincerely,

Developmental-Behavioral Pediatrics

2/2016

Patient Demographic Information Form Please fill out every space. If it does not pertain to you, please write N/A, for Not Applicable.

Patient Information Patient’s Name (Last, First, Middle) (Suffix) (Preferred) (Former Last Name)

If patient is a child, Parent’s Names

Sex Date of Birth Social Security # Marital Status: ❑ Married ❑ Single ❑ Divorced ❑ Male ❑ Female ❑ Widowed ❑ Separated ❑ Partner Address City State Zip code

Home Phone Mobile Phone Work Phone

Patient Email

Preferred Languag e Race Ethnicity ❑ Hispanic ❑ Non-Hispanic

Provider Information Primary Care Physician Referring Provider

Communication ❑ I authorize St.Vincent, and those parties acting on behalf of St.Vincent, to contact me about appointments and reminders for health services via: ❑ Home Phone ❑ Mobile Phone ❑ Email Is it OK to leave medical information on your answering machine or voice mail? ❑ Yes ❑ No

Guardian Name (Last, First, Middle, Suffix)

Emergency Contact Information Name Relationship

Home Phone # Mobile Phone #

Employment Employer’s name Phone

Address City State Zip code

2 SVPP Forms/Patient Demographics (7/15/2015) Page 1 of 2 WB-2BB

Guarantor Patient’s Relationship to G uarantor

Name (Last, First, Middle, Suffix) Date of Birth

Address City State Zip code

Employer Social Security #

Insurance Primary Insurance Company Subscriber’s Name (Policyholder)

Subscriber’s DOB Relationship to Subscriber

Secondary Insurance Company Subscriber’s Name (Policyholder)

Subscriber’s DOB Relationship to Subscriber

Clinical Information Preferred Pharmacy

Preferred Lab

Financial and Treatment Consent By signing my name below: • I hereby guarantee payment in full within thirty (30) days of all charges established by St.Vincent Health for services rendered to me or my dependent, unless other arrangements satisfactory to St.Vincent Health have been made. This includes any charges that a third-party payer may determine to exceed usual and customary limits. • I understand and acknowledge that if any unpaid amounts owed by me are assigned to a third party for collection, I will be responsible for paying attorney fees, interest, court costs, and other costs of collection, including but not limited to collection agency fees. • I authorize Medicare, Medicaid, all relevant commercial payers to pay St.Vincent Health on my behalf for any services furnished to me or my dependent. I certify that I have read this assignment of benefits, that the information given by me is correct, and that I agree to all of the provisions contained in it. • I understand that if I am facing financial difficulty I can apply for financial assistance from St.Vincent Health. • The insurance information I have provided is current and correct. If I sign this form and the insurance card is found later to be outdated or invalid, I understand that I am responsible for paying for the services in full and will need to file with the insurance carrier myself. • I hereby consent to treatment by my St.Vincent Health Provider(s). I understand that St.Vincent Health will release to my referring or subsequent healthcare provider, reports of my medical condition that will assist him or her in my continuing care and as needed to process claims and for general health care operations. I agree that this Consent is valid for all treatment and payment of said treatment for a period of twelve (12) months following execution of the Consent. • I understand my insurance co-pay is due at the time of service, per my insurance company policy.

I ACKNOWLEDGE RECEIPT OF THE NOTICE OF PRIVACY PRACTICES:______(Patient’s Initials)

Patient/Guarantor/Guardian Signature Date

**OFFICE USE ONLY** NPP Witness/Issued by: ______2 SVPP Forms/Patient Demographics (7/15/2015) Page 2 of 2 WB-2BB

Developmental -Be h a v i o r a l Pe d i a t r i c s

History form

8402 Harcourt Road, Suite 105 Indianapolis, IN 46260-2006

Tel: (317) 582-8290 • Fax: (317) 582-8291

Child’s Name ______Birth Date ______Child’s Nickname ______

Please feel free to use the backs of these pages to further explain answers, if needed.

I. PURPOSE OF EVALUATION

What are your questions or concerns regarding your child?

II. PREGNANCY AND BIRTH HISTORY

This section is to be completed by the mother of the child, if possible. Please indicate if answered by another person: ______.

Number of pregnancies you have had ______Number of live births ______Number of stillbirths ______Number of miscarriages ______Number of living children ______Number of deceased children ______This child was the product of pregnancy number ______Page 2 Child’s Name ______

Yes No Do Not Know Comments Did you have any health problems during pregnancy with this child? If yes, please describe the problem and the time it oc- curred during the pregnancy (such as infections, high blood pressure, diabetes, bleeding, weight loss, accidents, fever, etc.)

Did you take any medication, smoke, drink, or use drugs during this pregnancy? If yes, please list. Was your baby carried a full nine months? If no, please indi- cate length of the pregnancy. Were there any difficulties with delivery? If yes, please de- scribe the problems (such as Cesarean section, slow heart rate, fever, etc.)

How much did your baby weigh at birth? ______pounds, ______ounces

Did your baby need any special care during the first few days after delivery? If yes, please describe.

Did you have any difficulty caring for your child during the first few months of life? If yes, please describe.

III. PAST AND PRESENT HEALTH HISTORY

Yes No Do Not Know Comments Has your child ever been hospitalized? If yes, please de- scribe, including child’s age. Has your child ever had any serious accidents requir- ing medical care? If yes, please describe, including your child’s age.

Does your child have any serious or chronic illnesses? Please describe.

Has your child ever had a seizure or convulsion? If yes, please describe, including child’s age.

Has your child ever had tics? (Facial movements, eye- blinking, vocalizations, etc.)

Has your child ever had heart problems? If yes, please describe. Page 3 Child’s Name ______

Yes No Do Not Know Comments Is your child presently taking any medication, herbals, or vitamins? If yes, please list the medications, dosages, and why. Does your child have any known allergies? Please de- scribe. Do you feel your child has trouble hearing? If yes, please explain. Do you feel your child has trouble seeing? If yes, please explain. Has your child been or is your child now on a special diet? If yes, please describe.

IV. DEVELOPMENTAL HISTORY

Yes No Do Not Know Comments Was your child’s development any faster or slower than that of other children? Please explain. At what age did your child sit alone? At what age did your child crawl? At what age did your child walk alone? At what age did your child make sounds? At what age did your child say single words? At what age did your child combine words? Is your child toilet trained? If yes, age what age? Does your child have toileting accidents during the day? If yes, how often? Does your child have toileting accidents during the night? If yes, how often? Page 4 Child’s Name ______

Please describe what toys or activities your child enjoys:

Describe your child’s interactions with family members and other children:

Please describe what your consider to be your child’s strengths:

Has your child received or been evaluated for any of the following?

Yes No Date Educational Psychological Testing Speech/language therapy Physical therapy Occupational therapy Tutoring Individualized and/or Family Counseling Other (please list)

V. EDUCATIONAL/SOCIAL HISTORY

Please list the schools your child has attended:

Name Dates Attended

Preschool: ______Elementary: ______Middle School:______High School: ______

If you work outside your home, who provides care for your child while you are at work?

Please list extracurricular activities in which your child has participated: Page 5 Child’s Name ______

Please describe your child’s study habits:

Please describe your child’s present peer group.

Do you have concerns regarding possible alcohol and/or drug use? ___ Yes ___ No If yes, please explain.

VI. CHILD’S BEHAVIOR

***PLEASE COMPLETE THE VANDERBILT PARENT ASSESSMENT SCALE

Yes No Do Not Know Comments Does your child have any unusual fears? If yes, please explain. Do you have any concerns about the management of your child’s behavior at home (e.g., sleeping, tantrums, entertaining him/herself)? If yes, please explain.

VII. FAMILY HISTORY

Parents are:

Date Married ______Separated ______Divorced* ______*If parents are divorced, please describe current custody and Unmarried ______visitation arrangements: ______Widowed ______

Is your child a foster child? _____ Yes _____ No Length of time in your home ______

Is child adopted? _____ Yes _____ No Age at adoption ______

If a foster child or adopted, has this been discussed with your child? _____ Yes _____ No Who has legal guardianship of the child? ______Page 6 Child’s Name ______

Please list the persons presently living in your home: Name Sex Birth Date Relation to Child Present or Highest Grade Completed

Family members no longer in home: Name Sex Birth Date Relation to Child Present or Highest Grade Completed

During the past 12 months, has your family experienced any of the following difficulties? Yes No Do Not Know Comments Death of a family member Serious illness Marital problems Unemployment Other (please describe)

Have any other family members had any of the following? Yes No Do Not Know Comments Heart or blood pressure problems? If yes, please describe. Other medical problems? If yes, please describe. Tic, learning, developmental, or attention- deficit problems? If so, please describe.

Person completing questionnaire ______

Relationship to Child ______

Date ______NICHQ Vanderbilt Assessment Scale—PARENT Informant

To day’s Date: ______Child’s Name: ______Date of Birth: ______Parent’s Name: ______Parent’s Phone Number: ______

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months. Is this evaluation based on a time when the child was on medication was not on medication not sure?

Symptoms Never Occasionally Often Very Often 1. Does not pay attention to details or makes careless mistakes 0 1 2 3 with, for example, homework 2. Has difficulty keeping attention to what needs to be done 0 1 2 3 3. Does not seem to listen when spoken to directly 0 1 2 3 4. Does not follow through when given directions and fails to finish activities 0 1 2 3 (not due to refusal or failure to understand) 5. Has difficulty organizing tasks and activities 0 1 2 3 6. Avoids, dislikes, or does not want to start tasks that require ongoing 0 1 2 3 mental effort 7. Loses things necessary for tasks or activities (toys, assignments, pencils, 0 1 2 3 or books) 8. Is easily distracted by noises or other stimuli 0 1 2 3 9. Is forgetful in daily activities 0 1 2 3 10. Fidgets with hands or feet or squirms in seat 0 1 2 3 11. Leaves seat when remaining seated is expected 0 1 2 3 12. Runs about or climbs too much when remaining seated is expected 0 1 2 3 13. Has difficulty playing or beginning quiet play activities 0 1 2 3 14. Is “on the go” or often acts as if “driven by a motor” 0 1 2 3 15. Talks too much 0 1 2 3 16. Blurts out answers before questions have been completed 0 1 2 3 17. Has difficulty waiting his or her turn 0 1 2 3 18. Interrupts or intrudes in on others’ conversations and/or activities 0 1 2 3 19. Argues with adults 0 1 2 3 20. Loses temper 0 1 2 3 21. Actively defies or refuses to go along with adults’ requests or rules 0 1 2 3 22. Deliberately annoys people 0 1 2 3 23. Blames others for his or her mistakes or misbehaviors 0 1 2 3 24. Is touchy or easily annoyed by others 0 1 2 3 25. Is angry or resentful 0 1 2 3 26. Is spiteful and wants to get even 0 1 2 3 27. Bullies, threatens, or intimidates others 0 1 2 3 28. Starts physical fights 0 1 2 3 29. Lies to get out of trouble or to avoid obligations (ie,“cons” others) 0 1 2 3 30. Is truant from school (skips school) without permission 0 1 2 3 31. Is physically cruel to people 0 1 2 3 32. Has stolen things that have value0123

The information contained in this publication should not be used as a substitute for the Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s medical care and advice of your pediatrician. There may be variations in treatment that Healthcare Quality your pediatrician may recommend based on individual facts and circumstances. Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised - 1102 NICHQ Vanderbilt Assessment Scale—PARENT Informant

To day’s Date: ______Child’s Name: ______Date of Birth: ______Parent’s Name: ______Parent’s Phone Number: ______

Symptoms (continued) Never Occasionally Often Very Often 33. Deliberately destroys others’ property 0 1 2 3 34. Has used a weapon that can cause serious harm (bat, knife, brick, gun) 0 1 2 3 35. Is physically cruel to animals 0 1 2 3 36. Has deliberately set fires to cause damage 0 1 2 3 37. Has broken into someone else’s home, business, or car 0 1 2 3 38. Has stayed out at night without permission 0 1 2 3 39. Has run away from home overnight 0 1 2 3 40. Has forced someone into sexual activity 0 1 2 3 41. Is fearful, anxious, or worried 0 1 2 3 42. Is afraid to try new things for fear of making mistakes 0 1 2 3 43. Feels worthless or inferior 0 1 2 3 44. Blames self for problems, feels guilty 0 1 2 3 45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her” 0 1 2 3 46. Is sad, unhappy, or depressed 0 1 2 3 47. Is self-conscious or easily embarrassed 0 1 2 3 Somewhat Above of a Performance Excellent Average Average Problem Problematic 48. Overall school performance1 2 3 4 5 49. Reading 1 2 3 4 5 50. Writing 1 2 3 4 5 51. Mathematics 1 2 3 4 5 52. Relationship with parents1 2 3 4 5 53. Relationship with siblings 1 2 3 4 5 54. Relationship with peers 1 2 3 4 5 55. Participation in organized activities (eg, teams) 1 2 3 4 5 Comments:

For Office Use Only Total number of questions scored 2 or 3 in questions 1–9: ______Total number of questions scored 2 or 3 in questions 10–18:______Total Symptom Score for questions 1–18: ______Total number of questions scored 2 or 3 in questions 19–26:______Total number of questions scored 2 or 3 in questions 27–40:______Total number of questions scored 2 or 3 in questions 41–47:______Tot a l numb er of questions scored 4 or 5 in questions 48–55: ______Average Performance Score: ______D4 NICHQ Vanderbilt Assessment Scale—TEACHER Informant

Teacher’s Name: ______Class Time: ______Class Name/Period: ______Today’s Date: ______Child’s Name: ______Grade Level: ______

Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors: ______. Is this evaluation based on a time when the child was on medication was not on medication not sure? Symptoms Never Occasionally Often Very Often 1. Fails to give attention to details or makes careless mistakes in schoolwork 0 1 2 3 2. Has difficulty sustaining attention to tasks or activities 0 1 2 3 3. Does not seem to listen when spoken to directly 0 1 2 3 4. Does not follow through on instructions and fails to finish schoolwork 0 1 2 3 (not due to oppositional behavior or failure to understand) 5. Has difficulty organizing tasks and activities 0 1 2 3 6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained 0 1 2 3 mental effort 7. Loses things necessary for tasks or activities (school assignments, 0 1 2 3 pencils, or books) 8. Is easily distracted by extraneous stimuli 0 1 2 3 9. Is forgetful in daily activities 0 1 2 3 10. Fidgets with hands or feet or squirms in seat 0 1 2 3 11. Leaves seat in classroom or in other situations in which remaining 0 1 2 3 seated is expected 12. Runs about or climbs excessively in situations in which remaining 0 1 2 3 seated is expected 13. Has difficulty playing or engaging in leisure activities quietly 0 1 2 3 14. Is “on the go” or often acts as if “driven by a motor” 0 1 2 3 15. Talks excessively 0 1 2 3 16. Blurts out answers before questions have been completed 0 1 2 3 17. Has difficulty waiting in line 0 1 2 3 18. Interrupts or intrudes on others (eg, butts into conversations/games) 0 1 2 3 19. Loses temper 0 1 2 3 20. Actively defies or refuses to comply with adult’s requests or rules 0 1 2 3 21. Is angry or resentful 0 1 2 3 22. Is spiteful and vindictive 0 1 2 3 23. Bullies, threatens, or intimidates others 0 1 2 3 24. Initiates physical fights 0 1 2 3 25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others) 0 1 2 3 26. Is physically cruel to people 0 1 2 3 27. Has stolen items of nontrivial value 0 1 2 3 28. Deliberately destroys others’ property 0 1 2 3 29. Is fearful, anxious, or worried 0 1 2 3 30. Is self-conscious or easily embarrassed 0 1 2 3 31. Is afraid to try new things for fear of making mistakes 0 1 2 3

The recommendations in this publication do not indicate an exclusive course of treatment Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s or serve as a standard of medical care. Variations, taking into account individual circum- Healthcare Quality stances, may be appropriate. Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised - 0303

HE0351 D4 NICHQ Vanderbilt Assessment Scale—TEACHER Informant, continued

Teacher’s Name: ______Class Time: ______Class Name/Period: ______Today’s Date: ______Child’s Name: ______Grade Level: ______

Symptoms (continued) Never Occasionally Often Very Often 32. Feels worthless or inferior 0 1 2 3 33. Blames self for problems; feels guilty 0 1 2 3 34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her” 0 1 2 3 35. Is sad, unhappy, or depressed 0 1 2 3 Somewhat Performance Above of a Academic Performance Excellent Average Average Problem Problematic 36. Reading 1 2 3 4 5 37. Mathematics 1 2 3 4 5 38. Written expression 1 2 3 4 5 Somewhat Above of a Classroom Behavioral Performance Excellent Average Average Problem Problematic 39. Relationship with peers 1 2 3 4 5 40. Following directions 1 2 3 4 5 41. Disrupting class 1 2 3 4 5 42. Assignment completion 1 2 3 4 5 43. Organizational skills 1 2 3 4 5 Comments:

Please return this form to: ______

Mailing address: ______

______

Fax number: ______

For Office Use Only Total number of questions scored 2 or 3 in questions 1–9: ______Total number of questions scored 2 or 3 in questions 10–18: ______Total Symptom Score for questions 1–18: ______Total number of questions scored 2 or 3 in questions 19–28: ______Total number of questions scored 2 or 3 in questions 29–35: ______Total number of questions scored 4 or 5 in questions 36–43: ______Average Performance Score:______

11-20/rev0303 Developmental -Be h a v i o r a l Pe d i a t r i c s

TEACHER INFORMATION REQUEST

8402 Harcourt Road, Suite 105 Indianapolis, IN 46260-2006

Tel: 317-582-8290 ● Fax: 317-582-8291

(Patient Name)______(DOB: ______)

will see a developmental-behavioral pediatrician. In order to provide a comprehensive picture of his/her abilities, we request that you complete the information below. The completed form may be returned to the patient and/or directly to our office via the contact information above. We appreciate your time and assistance.

1. What is your relationship to the student? How long have you known him/her? ______

2. Please give a brief description of the student’s school program including setting, type of classroom, and any special services such as tutoring, resource support, speech/language therapy, counseling, etc. ______

3. Please describe the student’s developmental, adaptive, and/or academic performance. Include the results of any standardized test scores or annual reports. ______

4. Has this student had any developmental, special education, or psychological testing? If so, please include the results of these tests. ______

5. Please describe the student’s behavior, including mood, response to assignments, ability to concentrate, and peer/authority relationships. ______Developmental -Be h a v i o r a l Pe d i a t r i c s

TEACHER INFORMATION REQUEST

6. On the basis of your experience with other students this age/grade, do you feel this child is working up to his/her academic potential? ______

7. Do you have any other specific questions, concerns or additional information about this student that you feel would be particularly helpful in our evaluation? ______

______Teacher’s Name (Please print) Course or grade Date From Northwest of Indianapolis Take South to Interstate 865 to Interstate 465 East. Continue on Interstate 465 East to the /US421 exit (Exit 27). Turn right and head south to 86th Street. Turn left on 86th Street and head east. Turn right onto Harcourt Road. We are located in the 8402 Professional Building adjacent to St.Vincent Hospital on Harcourt Road.

From Northeast of Indianapolis Take South to Interstate 465 West. Continue on Interstate 465 West to the Meridian Street/US31 exit (Exit 31). Turn left and head south to 86th Street. Turn right on 86th Street and head west. Turn left onto Harcourt Road. We are located in the 8402 Professional Building adjacent to St.Vincent Hospital on Harcourt Road.

From East of Indianapolis Take West or West to Interstate 465 North. Continue on Interstate 465 North, which turns into Interstate 465 West. Continue on Interstate 465 West to the Meridian Street/US31 exit (Exit 31). Turn left and head south to 86th Street. Turn right on 86th Street and head west. Turn left onto Harcourt Road. We are located in the 8402 Professional Building adjacent to St.Vincent Hospital on Harcourt Road.

From South of Indianapolis Take Interstate 65 North to Interstate 465 West. Continue on Interstate 465 West, which turns into Interstate 465 North. Continue on Interstate 465 North, which turns into Interstate 465 East. Continue on Interstate 465 East to the Michigan Road/US421 exit (Exit 27). Turn right and head south to 86th Street. Turn left on 86th Street and head east. Turn right onto Harcourt Road. We are located in the 8402 Professional Building adjacent to St.Vincent Hospital on Harcourt Road.

From West of Indianapolis Take Interstate 70 East or Interstate 74 East to Interstate 465 North. Continue on Interstate 465 North, which turns into Interstate 465 East. Continue on Interstate 465 East to the Michigan Road/US421 exit (Exit 27). Turn right and head south to 86th Street. Turn left on 86th and head east. Turn right onto Harcourt Road. We are located in the 8402 Professional Building adjacent to St.Vincent Hospital on Harcourt Road.

Where to Park Free parking is available at Peyton Manning Children’s Hospital at St.Vincent and at the Indianapolis Hospital main parking lot on 86th Street between Harcourt Road and Naab Road. Parking is available for a nominal fee at the garage adjacent to the Professional Office building, 8402 Harcourt Road. Free parking is available at all other campus locations.

8402 Harcourt Road • Indianapolis, IN 46260 317.338.KIDS (5437) • stvincent.org/peytonmanning YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION WHO THIS NOTICE APPLIES TO You have the following rights regarding health information we This Notice describes St. Vincent Hospital and Health Care Center, Inc. maintain about you: practices and those of: Any health care professional authorized to enter information into or Right to Request Restrictions. You have the right to request a consult your medical record or who provides treatment to you while restriction or limitation on the health information we use or disclose you are at or in the facility including but not limited to, attending about you for treatment, payment or health care operations. You also physicians, radiologists, pathologists, anesthesiologists, surgeons, have the right to request a limit on the health information we dis- internal medicine physicians, emergency department physicians, close about you to someone who is involved in your care or the pay- staff members of such physicians, and any other physician or health ment for your care. care provider that is involved in your care at the facility. All locations, departments and units of St. Vincent Hospital and You have the right to restrict disclosures of your health information ST. VINCENT HOSPITAL AND to your health plan for payment and health care operations purposes Health Care Center, Inc. (and not for treatment) if the disclosure pertains to a health care item Any member of a volunteer group we allow to help you. HEALTH CARE CENTER, INC. or service for which you paid out-of-pocket in full. If requesting a All employees, staff and other St. Vincent Hospital and Health JOINT NOTICE OF PRIVACY PRACTICES restriction for a health care item or service for which you paid out- Care Center, Inc. personnel, and any resident, student or trainee of-pocket in full, we will honor your request, unless the disclosure is that we have allowed to train at the facility. necessary for your treatment or is required by law. For all other restriction requests, we are not required to agree to All of these entities, sites and locations follow the terms of this Notice your request. If we do agree, we will comply with your request while providing services at our facility. In addition, these entities, sites THIS NOTICE DESCRIBES HOW MEDICAL unless the information is needed to provide you emergency treatment. and locations may share health information with each other for treat- Any request for restrictions must be sent in writing to the Privacy ment, payment or operations purposes described in this Notice. INFORMATION ABOUT YOU MAY BE USED Official. AND DISCLOSED, AND HOW YOU CAN GET Right to Request Confidential Communications. You have the CHANGES TO THIS NOTICE: We reserve the right to change this right to request that we communicate with you or your responsible Notice. We reserve the right to make the revised Notice effective for ACCESS TO THIS INFORMATION. PLEASE party about your health care in an alternative way or at a certain health information we already have about you, as well as any informa- REVIEW IT CAREFULLY. location. To request confidential communications, you must make tion we receive in the future. The Notice will be posted in our facility your request in writing to the Privacy Official. We will not ask you and on our website and include the effective date. The Notice is also the reason for your request. We will accommodate all reasonable available to you upon request. In addition, if we revise the Notice, you requests. Your request must specify how or where you wish to be may request a copy of the Notice currently in effect. contacted. OUR RESPONSIBILITIES Right to Inspect and Copy, Right to Access. You have the right to COMPLAINTS: If you believe your privacy rights have been violat- inspect and obtain a paper or electronic copy of your medical infor- St. Vincent Hospital and Health Care Center, Inc. takes the privacy of ed, you may file a complaint with St. Vincent Hospital and Health Care mation that we use to make decisions about your care, when you your health information seriously. Center, Inc. or with the Secretary of the Department of Health and submit a written request. If you request a copy of the information, We understand the importance and sensitivity of your health informa- Human Services. To file a complaint with us, contact the Privacy we may charge a fee for the costs of copying, mailing or other sup- tion. We are required by law to maintain your privacy and to provide Official. All complaints must be submitted in writing. plies associated with your request. you with this Notice of Privacy Practices ("Notice"). We are required Right to Amend. You have the right to ask us to amend your health to abide by the terms of the Notice that is currently in effect. and/or billing information for as long as the information is kept by You will not be penalized, discriminated against, retaliated against, us. We may deny your request for an amendment and, if this occurs, or intimidated for filing a complaint. you will be notified of the reason for the denial and provided an HOW WE MAY USE AND DISCLOSE opportunity to appeal the denial. YOUR HEALTH INFORMATION Right to an Accounting of Disclosures. You have the right to We protect the privacy of your health information because it is the right request a list of certain disclosures that we have made of your health If you have any questions about this Notice, please contact: thing to do. We use your health information (and allow others to have information that were for purposes other than treatment, payment or it) only as permitted by federal and state laws. When we care for you, health care operations or were authorized by you. we gather and create some of your health information. This Notice Right to a Paper Copy of This Notice. You have the right to a St. Vincent Hospital and includes examples in each category below of how we will use and paper copy of this Notice. You may ask us to give you a copy of this Health Care Center, Inc. Privacy Official share your information. Not every use or disclosure is listed below; Notice at any time. Even if you have agreed to receive this Notice th however, all permissible uses and disclosures will fall within one of the electronically, you are still entitled to a paper copy of this Notice. 2001 West 86 Street categories. Indianapolis, IN 46260 317-338-7026 You may obtain a copy of this Notice at our web site at http://www.stvincent.org/legal.aspx or contact the Privacy Official.

20285 0813 Effective Date: September 2013 X For Treatment. We use information about you to understand your Department of Veterans Affairs, for patients who are in the military X Disclosures by Members of Our Workforce. Members of our health condition and to treat you when you are sick. We may share or veterans. workforce, including employees, volunteers, trainees or independent your health information with doctors, nurses, aids, technicians or • A correctional institution or law enforcement official if you are an contractors, may disclose your medical information to a health over- other employees who are involved in taking care of you. We might inmate in a correctional institution and if the correctional institution sight agency, public health authority, health care accreditation organ- use your health information to manage or coordinate your treatment, or law enforcement authority makes certain requests to us. ization or attorney hired by the workforce member, to report the health care or other related services. We might share your medical • The Secret Service or National Security Agency to protect, for workforce member's belief that we have engaged in unlawful con- information with your physician or other health care provider who is example, the country or the President duct or that our care or services could endanger a patient, worker or providing treatment to you, whether or not we are involved with the public. In addition, if a workforce member is a crime victim that • A medical device's manufacturer, as required by the Food and Drug your treatment at the time. For example, a doctor treating you for a you are involved with, the member may disclose your personal Administration, to monitor the safety of a medical device. broken leg may need to know if you have diabetes because if you do, information to a law enforcement official to report the crime. • Court officers, as required by law, in response to a court order or a this may impact your recovery. We may receive and share prescrip- X Research. Under certain circumstances, we may use and disclose valid subpoena. tion information to help you avoid harmful drug interactions. health information about you for research purposes. All research Different departments of the facility may also share health informa- • Governmental authorities to prevent serious threats to the public's projects are subject to a special approval process and information tion about you in order to coordinate different things you might need health or safety. released is only done so with your consent or with appropriate such as medications, x-rays, laboratory work, etc. • Governmental agencies and other affected parties, to report a breach authority as permitted by law. We may share medical information X For Payment. To receive payment for our services, we may send of health-information privacy or in the case of a compliance review about you with people preparing to conduct a research project. For your health information to an insurance company or other third to determine whether we are complying with privacy laws. example, we may share information to help them look for patients party. We may also disclose your medical information to another • To a worker's compensation program if a person is injured at work with specific medical needs. We will not allow the preparatory health care provider or payor of health care for their own payment and claims benefits under that program. researchers to remove your information from the hospital.

activities. For example, your insurance company may request infor- • To business associates or third parties that we have contracted with X Disclosures of Records Containing Drug or Alcohol Abuse mation about your surgery and we must provide that information to to perform agreed upon services. Information. Due to federal law, we will not release your medical obtain payment. The physician who reads your x-ray may need to information if it contains information about drug or alcohol abuse bill you or your insurance company for reading your x-ray; there- without your written permission except in very limited situations. X ADDITIONAL INFORMATION: fore, your billing information may be shared with the physician who X Psychotherapy Notes. If applicable, we must obtain your written read your x-ray. X Facility Directory. We may include certain limited information about you in our directory. This information may include your authorization before we may use or disclose your psychotherapy X For Health Care Operations. We may use and disclose your health name, location in your facility, your general condition (e.g., fair, sta- notes, except for: use by the originator of the psychotherapy notes information to enable St. Vincent Hospital and Health Care Center, ble, etc.) and your religious affiliation. The directory information, for treatment; use or disclosure by St. Vincent Hospital and Health Inc. to make sure you receive competent, quality health care, and to except for your religious affiliation, may also be released to people Care Center, Inc. to its own mental health training programs; or use maintain and improve the quality of health care we provide. We may who ask for you by name. Your religious affiliation may be given to or disclosure by St. Vincent Hospital and Health Care Center, Inc. to assess the care and outcomes in your case and others like it and then a member of the clergy, such as a priest or minister, even if they do defend itself in a legal action or other proceeding brought by the use the results to continually improve the quality of care for all not ask for you by name. If you do not wish to be included in the individual. patients we serve. We may also provide your health information to facility directory, you will be given an opportunity to object at the X Marketing. We must obtain your written authorization before we various governmental or accreditation entities such as the Joint time of admission. may use or disclose your health information for marketing purposes, Commission on Accreditation of Healthcare Organizations to main- except for face-to-face communications made by us to you or a pro- X Individuals Involved in Your Care or Payment for Your Care. tain our license and accreditation. For example, we may combine motional gift of nominal value provided by us to you. You may opt health information about many patients to evaluate the need for new We may release health information about you to a family member, or any other person identified by you who is involved in your health out of receiving such communications by following the opt-out services or treatment. We may combine health information we have instructions on the communication you receive. with that of other facilities to see where we can make improvements. care or helps pay for your care. We may also disclose health infor- mation about you to notify your family or an emergency contact that X Authorization Required. St. Vincent Hospital and Health Care you are at St. Vincent Hospital and Health Care Center, Inc. or to an Center, Inc. does not engage in selling your health information; how- The law sometimes requires us to share information for specific entity assisting in a disaster relief effort so that your family can be ever, if we do, we must obtain your written authorization before we purposes, including reporting to: notified about your condition, status and location. may sell your health information. Other uses and disclosures not • The Department of Health to report communicable diseases, trau- described in this Notice will be made only with authorization from X Disclosures to You. Upon a request by you, we may use or disclose matic injuries, or birth defects, or for vital statistics such as a baby's your medical information in accordance with your request. We may you or your personal representative. birth. contact you to remind you about appointments and tell you about X Breach Notification. We are required to notify you in the event • A funeral director or an organ-donation agency when a patient dies, possible treatment alternatives or health-related benefits or services. of a breach of your unsecured protected health information, and will or to a medical examiner when appropriate to investigate a suspi- do so. X Fundraising. We may contact you for fundraising purposes to raise cious death. money for the organization and its operations. You may opt out of • The appropriate governmental agency if an injury or unexpected receiving such communications by following the opt out instructions death occurs at our facility. on the communication you receive or by contacting the St. Vincent OTHER USES OF HEALTH INFORMATION • Public health authorities to report child or elderly abuse, or suspect- Foundation. Other uses and disclosures of health information not covered by this ed child or elderly abuse, if authorized or otherwise required to X Incidental Uses and Disclosures. We may occasionally inadver- Notice or the laws that apply to us will be made only with your written report by law. tently use or disclose your medical information. For example, while authorization. If you provide us authorization to use or disclose your • Law enforcement official if required to do so by law, for example, to we have safeguards in place to protect against others overhearing our health information, you may revoke that authorization, in writing, at any identify or locate a suspect, fugitive, material witness, or missing conversations that take place between doctors, nurses or other St. time. If you revoke your authorization, we will no longer use or disclose person or to report a crime or criminal conduct at the facility. Vincent Hospital and Health Care Center, Inc. personnel, there may health information about you for the reasons covered by your written • Governmental inspectors who, for example, make sure our facilities be times that conversations are in fact overheard. Please be assured, authorization. You understand that we are unable to take back any dis- are safe however, that we have appropriate safeguards in place to avoid these closures we have already made under the authorization, and that we are • Under certain conditions, to military command authorities or the types of situations, and others, as much as possible. required to retain our records of the care that we provided to you.