Ethics & Integrity Standards Conduct Confidentiality Values Gifts Attitude

Ethics & Integrity Standards Conduct Confidentiality Values Gifts Attitude Reinvestment Accountability Referrals Privacy Customer Etiquette Respect Helping Ethics & Integrity Patient Centered Reinvestment Compliance Purpose Confidentiality Standards of Values Attitude Conduct Communication Privacy Customer Etiquette Respect Helping Ethics & Integrity Patient Centered Reinvestment Serving COMPLIANCE the Community Ethics & Integrity Purpose Confidentiality Values Privacy Customer Etiquette Ethics & Integrity Ethics & Integrity Standards Conduct Standards Conduct TABLE OF CONTENTS ConfidentialityPresident’s Letter...... 3 Confidentiality Compliance Standards Values Gifts Attitudeof Conduct - Values Gifts Attitude Purpose ...... 4 ReinvestmentGovernmental and Reinvestment Tax Exempt Entity...... 5 AccountabilityCompliance Hotline...... 5 Dear Employees and Volunteers: Accountability Documentation and Record Retention...... 5 Lee Health’s mission is to be a trusted partner, empowering healthier Referrals lives through care and compassion. A key component of our mission is Referrals Billing and Claims...... 6 trust, and as such, Lee Health is committed to conducting our business in Privacy CustomerVendor Selection and Use...... 6 accordance with all applicable laws and regulations. In recognitionPrivacy of these Customer responsibilities, we have created our Compliance Standards of Conduct as Gifts and Items of Value...... 7 part of our business philosophy. Etiquette RespectBribes, Kickbacks, and Referrals...... 7 Etiquette Respect Solicitation and The Compliance Standards of Conduct summarize the virtues and principles Helping EthicsDistribution & in the Workplace...... 8 that guide our actions in providing outstanding patient care.Helping It helps us set Ethics & priorities and improve quality and outcomes in our daily work. It also serves Conflicts of Interest...... 8 as a reference guide to assist you in performing your job responsibilities. Integrity PatientContractor Integrity...... 9 Most importantly, it acts as a bridge to the ExceptionalLeeIntegrity Promise, We Patient promise to listen and communicate effectively, embrace empathy, act with Physicians’ Compliance Requirements...... 9 compassion and continually improve care – creating a safe, comforting and Centered ReinvestmentIneligible Entities and Individuals...... 9 healing environment for our patients, their familiesCentered and each other. If you Reinvestment encounter any situation you believe may violate the provisions outlined in our Comply With Copyright Laws...... 10 Purpose Confidentiality Compliance Standards of Conduct, or if you Purposehave any questions or concerns, Confidentiality Safe Work Environment...... 10 please consult your supervisor or the Lee Health Compliance Department at (239) 343-6432. You may also call the Compliance Hotline at (877) 807- Values AttitudeHIPAA - Privacy and Security...... 10 Values Attitude 5647. Be assured that you are protected against retribution or retaliation Avoid Anti-Competitive Activity...... 11 of any kind for asking questions or raising concerns about our Compliance CommunicationGovernment and Media Inquiries...... 11 Standards of Conduct, or for reporting possible improper conduct.Communication

Protection and Your conduct is a reflection on you and our health system. Your cooperation Privacy CustomerProper Use of Company Assets...... 12 Privacy Customer in following our Compliance Standards of Conduct is crucial to the delivery Protection from Reprisal...... 12 of safe, high quality, patient-centered care, and the fulfillment of our mission, Etiquette Respect vision, and values. Every member of our team plays a criticalEtiquette role in bringing Respect Helping Summary ...... 12 these powerful words to life. Helping Compliance Hotline Thank you for your commitment to being caring people, inspiring health. 1-877-807-5647 Ethics & Integrity Yours in Health, Ethics & Integrity Compliance Office Patient Centered 239-343-6432 Patient Centered

Reinvestment Serving Larry Antonucci, M.D. Reinvestment Serving the Community President/CEO, Lee Health the Community Ethics &2 Integrity Ethics & Integrity3 Purpose Confidentiality Purpose Confidentiality Ethics & Integrity Ethics & Integrity Standards Conduct Standards Conduct ConfidentialityCOMPLIANCE STANDARDS OF CONDUCT – PURPOSE GOVERNMENTAL ENTITY Confidentiality The Compliance Standards of Conduct provide guidance to Lee Health is a special district created by the Florida Lee Health team members, including employed physicians Legislature. A special district is a governmental entity that has Values Gifts Attitudeand volunteers to assist them in carrying out their daily a distinct purpose. Our health system’s specialValues purpose relates Gifts Attitude activities while complying with appropriate ethical and legal to the delivery of health care services to the community. Reinvestmentstandards. These standards govern our relationships with Like cities, counties or other special districts, such asReinvestment fire patients, third-party payers, contractors, vendors, consultants districts, Lee Health is governed by a publicly elected board Accountabilityand our co-workers. of directors that convenes at publicly noticed meetingsAccountability and We are committed to ethical and legal conduct that is maintains records open for public inspection. Lee Health Referralscompliant with relevant laws and regulations and to correct employees are considered public employees and must followReferrals wrongdoing wherever it may occur in the organization. Florida law governing the conduct of public employees, Policies and procedures have been created and are including the Florida Code of Ethics for Public Officers and Privacy Customeravailable on IntraLee to address many legal and regulatory Employees. Privacy Customer requirements and protect against fraud, waste, and abuse. Etiquette Respect WE ARE ALSO A TAX-EXEMPT ORGANIZATIONEtiquette Respect The most common type of health care fraud is the submission As a tax-exempt organization, we will conduct ourselves of false claims to the Medicare and Medicaid systems. The in compliance with IRS regulations specific to us, including Helping EthicsFederal False Claims& Act makes it illegal to knowingly or avoiding inappropriate private benefits. Helping Ethics & recklessly present a false claim for payment, use a false Integrity Patientrecord or statement on a false or fraudulent claim, or engage Integrity Patient in a conspiracy to defraud the U.S. government to obtain COMPLIANCE HOTLINE payment. The Florida False Claims Act prohibits knowingly or Centered Reinvestmentrecklessly causing the Florida government to pay claims that The Compliance Hotline is a toll-freeCentered number, staffed and Reinvestment are false. Persons and organizations in violation of either False run by an outside company dedicated to the confidential Purpose ConfidentialityClaims Act can be subject to penalties plus damages. reporting of serious concerns relatingPurpose to known or suspected Confidentiality violations of laws or regulations. To report any concerns Each member of the health care team has an obligation you may call our Compliance Hotline at (877) 807-5647 Values Attitudeto report any activity that appears to violate applicable (1-877-807-LMHS) to report any concerns. You mayValues remain Attitude laws, policies, or our Compliance Standards of Conduct. In anonymous if you wish. You may also call the Compliance Communicationaccordance with our policies, no adverse action will be taken Department at (239) 343-6432 if you wish to reportCommunication anything against an employee who in good faith has come forth with or have any concerns with these Compliance Standards of information or evidence of a violation. Federal and state Conduct. Privacy Customerlaws protect individuals who expose known or suspected Privacy Customer wrongdoing. Etiquette Respect DOCUMENTATION AND RECORD RETENTIONEtiquette Respect Helping Lee Health will maintain accurate records and accounts in Helping order to ensure legal and ethical business practices and to Ethics & Integrity prevent fraudulent activities. Ethics & Integrity Patient care must be necessary, appropriate and well documented. Records and accounts must be complete and Patient Centered not misleading. Accounting records and the reportsPatient produced Centered from those records must be retained in accordance with Reinvestment Serving applicable laws and relevant accountingReinvestment standards. See Policy Serving the Community S07 01 760 – Records Retention and Retrieval fromthe LeeSar. Community Ethics &4 Integrity Ethics & Integrity5 Purpose Confidentiality Purpose Confidentiality Ethics & Integrity Ethics & Integrity Standards Conduct Standards Conduct ConfidentialityCOMPLIANCE STANDARDS OF CONDUCT – PURPOSE GOVERNMENTAL ENTITY Confidentiality The Compliance Standards of Conduct provide guidance to Lee Health is a special district created by the Florida Lee Health team members, including employed physicians Legislature. A special district is a governmental entity that has Values Gifts Attitudeand volunteers to assist them in carrying out their daily a distinct purpose. Our health system’s specialValues purpose relates Gifts Attitude activities while complying with appropriate ethical and legal to the delivery of health care services to the community. Reinvestmentstandards. These standards govern our relationships with Like cities, counties or other special districts, such asReinvestment fire patients, third-party payers, contractors, vendors, consultants districts, Lee Health is governed by a publicly elected board Accountabilityand our co-workers. of directors that convenes at publicly noticed meetingsAccountability and We are committed to ethical and legal conduct that is maintains records open for public inspection. Lee Health Referralscompliant with relevant laws and regulations and to correct employees are considered public employees and must followReferrals wrongdoing wherever it may occur in the organization. Florida law governing the conduct of public employees, Policies and procedures have been created and are including the Florida Code of Ethics for Public Officers and Privacy Customeravailable on IntraLee to address many legal and regulatory Employees. Privacy Customer requirements and protect against fraud, waste, and abuse. Etiquette Respect WE ARE ALSO A TAX-EXEMPT ORGANIZATIONEtiquette Respect The most common type of health care fraud is the submission As a tax-exempt organization, we will conduct ourselves of false claims to the Medicare and Medicaid systems. The in compliance with IRS regulations specific to us, including Helping EthicsFederal False Claims& Act makes it illegal to knowingly or avoiding inappropriate private benefits. Helping Ethics & recklessly present a false claim for payment, use a false Integrity Patientrecord or statement on a false or fraudulent claim, or engage Integrity Patient in a conspiracy to defraud the U.S. government to obtain COMPLIANCE HOTLINE payment. The Florida False Claims Act prohibits knowingly or Centered Reinvestmentrecklessly causing the Florida government to pay claims that The Compliance Hotline is a toll-freeCentered number, staffed and Reinvestment are false. Persons and organizations in violation of either False run by an outside company dedicated to the confidential Purpose ConfidentialityClaims Act can be subject to penalties plus damages. reporting of serious concerns relatingPurpose to known or suspected Confidentiality violations of laws or regulations. To report any concerns Each member of the health care team has an obligation you may call our Compliance Hotline at (877) 807-5647 Values Attitudeto report any activity that appears to violate applicable (1-877-807-LMHS) to report any concerns. You mayValues remain Attitude laws, policies, or our Compliance Standards of Conduct. In anonymous if you wish. You may also call the Compliance Communicationaccordance with our policies, no adverse action will be taken Department at (239) 343-6432 if you wish to reportCommunication anything against an employee who in good faith has come forth with or have any concerns with these Compliance Standards of information or evidence of a violation. Federal and state Conduct. Privacy Customerlaws protect individuals who expose known or suspected Privacy Customer wrongdoing. Etiquette Respect DOCUMENTATION AND RECORD RETENTIONEtiquette Respect Helping Lee Health will maintain accurate records and accounts in Helping order to ensure legal and ethical business practices and to Ethics & Integrity prevent fraudulent activities. Ethics & Integrity Patient care must be necessary, appropriate and well documented. Records and accounts must be complete and Patient Centered not misleading. Accounting records and the reportsPatient produced Centered from those records must be retained in accordance with Reinvestment Serving applicable laws and relevant accountingReinvestment standards. See Policy Serving the Community S07 01 760 – Records Retention and Retrieval fromthe LeeSar. Community Ethics &4 Integrity Ethics & Integrity5 Purpose Confidentiality Purpose Confidentiality Ethics & Integrity Ethics & Integrity Standards Conduct Standards Conduct ConfidentialityBILLING AND CLAIMS GIFTS AND ITEMS OF VALUE Confidentiality We will generate billing and claims accurately reflecting that Since Lee Health is a governmental entity, the conduct of services rendered are supported by relevant documentation its employees is governed by the Florida Code of Ethics for Values Gifts Attitudeand are submitted in compliance with applicable laws, rules, Public Officers and Employees. EmployeesValues are prohibited Gifts Attitude regulations and program requirements. We never will make or from soliciting or accepting anything of value that might Reinvestmentpresent improper, false, fictitious or fraudulent claims. influence the performance of official duties. ItemsReinvestment of value Improper or fraudulent activity can include: may include meals, tickets to events (including charitable Accountability events), goods and services. Employees are prohibitedAccountability from • False claims and statements soliciting or accepting anything of value, such as a gift, loan, Referrals• Unapproved treatment or equipment usage reward, promise of future employment, favor or service thatReferrals • Misrepresentation of services is based on an understanding that their vote, official action or judgment would be influenced by such a gift. Any gift, which Privacy Customer• Duplicate billing may alter or affect the business judgment of thePrivacy recipient, Customer • Multiple coverage and secondary-payer fraud or be made in exchange for favorable treatment, should be Etiquette Respect• Improper coding (i.e., upcoding, unbundling) declined or donated to the Foundation. ReferEtiquette to Policy S23 Respect 00 835 – Solicitation or Acceptance of Gift or Gratuities from • Nonordered/nonperformed testing submission Patients and Vendors for specific guidance not addressed Helping Ethics• Improper physician& and other referrals here. Helping Ethics & Integrity Patient (Stark I & II, Anti-•Kickback) Integrity Patient • Improper discounting BRIBES, KICKBACKS, AND REFERRALS • Cost report falsification Centered Reinvestment Federal Anti-Kickback statutes stipulateCentered that no employee Reinvestment Billing data submitted to Medicare and Medicaid will comply within a health care organization will knowingly and willfully Purpose Confidentialitywith stated rules and regulations. offer, pay, solicit or receive compensationPurpose in connection with Confidentiality If you become aware of the submission of improper, false, the referral of patients or acquisition of items for services. Values Attitudefictitious or fraudulent claims, it is your obligation to Specific violations include: Values Attitude report this immediately to your supervisor, the Compliance • Soliciting, accepting or granting bribes or kickbacks (i.e., Department or the Compliance Hotline. cash or “in kind” considerations such as subsidies, discounts, Communication medical directorships, supplies or gifts). Communication Privacy CustomerVENDOR SELECTION AND USE • Granting direct or indirect improper rewardsPrivacy (i.e., bestowing Customer anything of value) to a representative of a government If you are involved in proposals, bid preparations or contract agency, union, or current or prospective business relationship. Etiquette Respectnegotiations, you must be certain that all statements, Etiquette Respect communications, and representations to potential partners • Accepting or granting gratuities in any form designated to Helpingor suppliers are accurate and truthful. Once awarded, secure favorable treatment. Helping all contracts must be performed in compliance with • Accepting or granting inappropriate referrals. specifications, requirements, and clauses. See Policy S07 04 No employee or physician may enter into any agreement Ethics & Integrity890 – Vendor Selection Criteria and Performance Evaluation. Ethics & Integrity or arrangement that calls for such action as previously If you buy goods or services for Lee Health or are involved described. If you become aware of or are involved in a Patient Centeredin the procurement process, you must treat all suppliers situation involving bribery, kickbacks or inappropriatePatient Centered uniformly and fairly. In deciding among competing suppliers, referrals, it is your obligation to report it immediately to your Reinvestmentyou Serving must weigh all facts objectively and impartially and avoid supervisor. Reinvestment Serving even the appearance of favoritism. Established routines and the Communityprocedures should be followed in the procurement of all the Community goods and services. Ethics &6 Integrity Ethics & Integrity7 Purpose Confidentiality Purpose Confidentiality Ethics & Integrity Ethics & Integrity Standards Conduct Standards Conduct ConfidentialityBILLING AND CLAIMS GIFTS AND ITEMS OF VALUE Confidentiality We will generate billing and claims accurately reflecting that Since Lee Health is a governmental entity, the conduct of services rendered are supported by relevant documentation its employees is governed by the Florida Code of Ethics for Values Gifts Attitudeand are submitted in compliance with applicable laws, rules, Public Officers and Employees. EmployeesValues are prohibited Gifts Attitude regulations and program requirements. We never will make or from soliciting or accepting anything of value that might Reinvestmentpresent improper, false, fictitious or fraudulent claims. influence the performance of official duties. ItemsReinvestment of value Improper or fraudulent activity can include: may include meals, tickets to events (including charitable Accountability events), goods and services. Employees are prohibitedAccountability from • False claims and statements soliciting or accepting anything of value, such as a gift, loan, Referrals• Unapproved treatment or equipment usage reward, promise of future employment, favor or service thatReferrals • Misrepresentation of services is based on an understanding that their vote, official action or judgment would be influenced by such a gift. Any gift, which Privacy Customer• Duplicate billing may alter or affect the business judgment of thePrivacy recipient, Customer • Multiple coverage and secondary-payer fraud or be made in exchange for favorable treatment, should be Etiquette Respect• Improper coding (i.e., upcoding, unbundling) declined or donated to the Foundation. ReferEtiquette to Policy S23 Respect 00 835 – Solicitation or Acceptance of Gift or Gratuities from • Nonordered/nonperformed testing submission Patients and Vendors for specific guidance not addressed Helping Ethics• Improper physician& and other referrals here. Helping Ethics & Integrity Patient (Stark I & II, Anti-•Kickback) Integrity Patient • Improper discounting BRIBES, KICKBACKS, AND REFERRALS • Cost report falsification Centered Reinvestment Federal Anti-Kickback statutes stipulateCentered that no employee Reinvestment Billing data submitted to Medicare and Medicaid will comply within a health care organization will knowingly and willfully Purpose Confidentialitywith stated rules and regulations. offer, pay, solicit or receive compensationPurpose in connection with Confidentiality If you become aware of the submission of improper, false, the referral of patients or acquisition of items for services. Values Attitudefictitious or fraudulent claims, it is your obligation to Specific violations include: Values Attitude report this immediately to your supervisor, the Compliance • Soliciting, accepting or granting bribes or kickbacks (i.e., Department or the Compliance Hotline. cash or “in kind” considerations such as subsidies, discounts, Communication medical directorships, supplies or gifts). Communication Privacy CustomerVENDOR SELECTION AND USE • Granting direct or indirect improper rewardsPrivacy (i.e., bestowing Customer anything of value) to a representative of a government If you are involved in proposals, bid preparations or contract agency, union, or current or prospective business relationship. Etiquette Respectnegotiations, you must be certain that all statements, Etiquette Respect communications, and representations to potential partners • Accepting or granting gratuities in any form designated to Helpingor suppliers are accurate and truthful. Once awarded, secure favorable treatment. Helping all contracts must be performed in compliance with • Accepting or granting inappropriate referrals. specifications, requirements, and clauses. See Policy S07 04 No employee or physician may enter into any agreement Ethics & Integrity890 – Vendor Selection Criteria and Performance Evaluation. Ethics & Integrity or arrangement that calls for such action as previously If you buy goods or services for Lee Health or are involved described. If you become aware of or are involved in a Patient Centeredin the procurement process, you must treat all suppliers situation involving bribery, kickbacks or inappropriatePatient Centered uniformly and fairly. In deciding among competing suppliers, referrals, it is your obligation to report it immediately to your Reinvestmentyou Serving must weigh all facts objectively and impartially and avoid supervisor. Reinvestment Serving even the appearance of favoritism. Established routines and the Communityprocedures should be followed in the procurement of all the Community goods and services. Ethics &6 Integrity Ethics & Integrity7 Purpose Confidentiality Purpose Confidentiality Ethics & Integrity Ethics & Integrity Standards Conduct Standards Conduct SOLICITATION AND DISTRIBUTION Policy S23 00 139 – Conflict of Interestrequires employees to Confidentiality sign a statement of compliance with conflict of interestConfidentiality policies IN THE WORKPLACE at the time of hire, annually thereafter or if your situation Values Gifts AttitudeTo avoid disruption in the provision of patient care and changes causing a conflict. Values Gifts Attitude business operations and prevent the disturbance of or inconvenience to staff, patients and visitors, Lee Health has Reinvestmentadopted a policy to regulate solicitation and distribution. CONTRACTOR INTEGRITY Reinvestment AccountabilityFundraising must be approved in advance by the Foundation Business integrity is a key principle for the selectionAccountability and in accordance with Policy S09 06 835 – Solicitation and retention of contractors at Lee Health. Those engaged to act Distribution in the Workplace. Employees must receive on behalf of the health system, such as agents, representatives, Referralsapproval from their supervisor for the permitted activities or consultants, must comply with our policies and proceduresReferrals identified in the policy and from Staff Activities in the Human and perform in a way that conforms to our values and ethics. Privacy CustomerResources department to post notices on the centralized Any contractor who acts in an illegal or unethicalPrivacy manner is Customer employee bulletin boards. Any suspected violations of this subject to immediate termination and disbarment from any policy should be reported to the employee’s supervisor, the future Lee Health contracts. Etiquette RespectCompliance Department or the Compliance Hotline. Etiquette Respect Helping Ethics & PHYSICIANS’ COMPLIANCE REQUIREMENTSHelping Ethics & CONFLICTS OF INTEREST Compliance with federal and state laws governing the Integrity PatientIt is your responsibility to act in the best interest of Lee Health physician’s ability to participate in government healthIntegrity Patient at all times. When performing your job, avoid any relationship, programs is required for all physicians who are granted Centered Reinvestmentinfluence or activity that might impair, or even appear to privileges to practice in Lee Health facilities.Centered Physicians Reinvestment impair, your ability to make objective and fair decisions. This employed by Lee Health are subject to termination of includes: employment in the same manner as other employees who are Purpose Confidentiality shown to be in violation of those laws.Purpose Confidentiality • Acceptance of gifts, payment or services from those seeking Values Attitudeto do business with Lee Health. Values Attitude • Purchase of goods or services by Lee Health from a firm INELIGIBLE ENTITIES AND INDIVIDUALS owned or controlled by an employee or a close relative of Communication Lee Health routinely will perform exclusion reviewsCommunication to ensure an employee. employees, vendors, contractors, and physicians are eligible Privacy Customer• Ownership of, or substantial interest in, a company that is a to participate in Federal health care programs.Privacy See Policy S23 Customer competitor or supplier. 00 807 – Screening for Exclusion from Federal Healthcare Etiquette Respect• Acting as a consultant to a customer or supplier of Lee Health. Program Participation. Etiquette Respect • Campaigning or soliciting campaign contributions for Helpingcandidates for political office is prohibited on Lee Health Helping premises. Political activity not related to campaigning for Ethics & Integritypolitical office, such as the gathering of petitions, may Ethics & Integrity be permitted if approved and sponsored by the Board of Directors. Contact Legal Services for direction prior Patient Centeredto engaging in activity at work that may be perceived as Patient Centered political in nature. Reinvestment• EmploymentServing by a competitor or potential competitor while Reinvestment Serving employed by Lee Health that would impede the full and the Communityfaithful discharge of duties. the Community Ethics &8 Integrity Ethics & 9Integrity Purpose Confidentiality Purpose Confidentiality Ethics & Integrity Ethics & Integrity Standards Conduct Standards Conduct SOLICITATION AND DISTRIBUTION Policy S23 00 139 – Conflict of Interestrequires employees to Confidentiality sign a statement of compliance with conflict of interestConfidentiality policies IN THE WORKPLACE at the time of hire, annually thereafter or if your situation Values Gifts AttitudeTo avoid disruption in the provision of patient care and changes causing a conflict. Values Gifts Attitude business operations and prevent the disturbance of or inconvenience to staff, patients and visitors, Lee Health has Reinvestmentadopted a policy to regulate solicitation and distribution. CONTRACTOR INTEGRITY Reinvestment AccountabilityFundraising must be approved in advance by the Foundation Business integrity is a key principle for the selectionAccountability and in accordance with Policy S09 06 835 – Solicitation and retention of contractors at Lee Health. Those engaged to act Distribution in the Workplace. Employees must receive on behalf of the health system, such as agents, representatives, Referralsapproval from their supervisor for the permitted activities or consultants, must comply with our policies and proceduresReferrals identified in the policy and from Staff Activities in the Human and perform in a way that conforms to our values and ethics. Privacy CustomerResources department to post notices on the centralized Any contractor who acts in an illegal or unethicalPrivacy manner is Customer employee bulletin boards. Any suspected violations of this subject to immediate termination and disbarment from any policy should be reported to the employee’s supervisor, the future Lee Health contracts. Etiquette RespectCompliance Department or the Compliance Hotline. Etiquette Respect Helping Ethics & PHYSICIANS’ COMPLIANCE REQUIREMENTSHelping Ethics & CONFLICTS OF INTEREST Compliance with federal and state laws governing the Integrity PatientIt is your responsibility to act in the best interest of Lee Health physician’s ability to participate in government healthIntegrity Patient at all times. When performing your job, avoid any relationship, programs is required for all physicians who are granted Centered Reinvestmentinfluence or activity that might impair, or even appear to privileges to practice in Lee Health facilities.Centered Physicians Reinvestment impair, your ability to make objective and fair decisions. This employed by Lee Health are subject to termination of includes: employment in the same manner as other employees who are Purpose Confidentiality shown to be in violation of those laws.Purpose Confidentiality • Acceptance of gifts, payment or services from those seeking Values Attitudeto do business with Lee Health. Values Attitude • Purchase of goods or services by Lee Health from a firm INELIGIBLE ENTITIES AND INDIVIDUALS owned or controlled by an employee or a close relative of Communication Lee Health routinely will perform exclusion reviewsCommunication to ensure an employee. employees, vendors, contractors, and physicians are eligible Privacy Customer• Ownership of, or substantial interest in, a company that is a to participate in Federal health care programs.Privacy See Policy S23 Customer competitor or supplier. 00 807 – Screening for Exclusion from Federal Healthcare Etiquette Respect• Acting as a consultant to a customer or supplier of Lee Health. Program Participation. Etiquette Respect • Campaigning or soliciting campaign contributions for Helpingcandidates for political office is prohibited on Lee Health Helping premises. Political activity not related to campaigning for Ethics & Integritypolitical office, such as the gathering of petitions, may Ethics & Integrity be permitted if approved and sponsored by the Board of Directors. Contact Legal Services for direction prior Patient Centeredto engaging in activity at work that may be perceived as Patient Centered political in nature. Reinvestment• EmploymentServing by a competitor or potential competitor while Reinvestment Serving employed by Lee Health that would impede the full and the Communityfaithful discharge of duties. the Community Ethics &8 Integrity Ethics & 9Integrity Purpose Confidentiality Purpose Confidentiality Ethics & Integrity Ethics & Integrity Standards Conduct Standards Conduct COMPLY WITH COPYRIGHT LAWS need the information in order to provide treatment, payment Confidentiality and health care operations. With the enactment ofConfidentiality the Lee Health complies with U.S. Copyright laws. Employees may Health Insurance Portability and Accountability Act (HIPAA), not reproduce any copyrighted work in print, audio, video, a patient’s right to have his or her health information kept Values Gifts Attitudecomputer software or other electronic form in violation of private and confidential became both anValues ethical and legal Gifts Attitude the Copyright laws. Examples include printed articles from obligation of health care workers. Reinvestmentpublications, TV and radio programs, music performances, Reinvestment photographs, Web pages, software programs, CD, DVD, All employee documents, communications and information Accountabilityand audio/video tapes. Copyright laws in the United States that are deemed confidential by law will remain strictlyAccountability protect works even if they are not registered with the U.S. confidential. Examples of such information include social Copyright Office and do not carry the copyright symbol © security or checking and savings account numbers. See Policy Referralsor permission notice. While the law makes an exception for S10 02 376 – HIPAA Patient Privacy Monitoring Process. Referrals “fair use” of the copyrighted work for limited purposes, this Privacy Customerexception is not automatic. Compliance with Copyright laws Privacy Customer is assured by obtaining prior written permission from the AVOID ANTI-COMPETITIVE ACTIVITY Etiquette RespectCopyright holder before reproducing; the Copyright holder Federal and state antitrust laws protect the integrityEtiquette of our Respect is usually the author or publisher of the work. Please refer free enterprise system. These laws address agreements and to Policy S24 00 145 – Copyright and Other Intellectual practices resulting in the restraint of competition including Helping EthicsProperty. & boycotting suppliers, discussing pricing or patientsHelping with Ethics & competitors, implementing unfair or deceptive business Integrity Patient practices, and misrepresenting services. Integrity Patient SAFE WORK ENVIRONMENT Such laws are vigorously enforced. Violations may result Centered ReinvestmentProviding a drug-free, safe and healthy work environment is in severe penalties for Lee Health andCentered its employees Reinvestment of the utmost importance. All employees must report to work responsible for the violations. If you are involved in any Purpose Confidentialityfree of the influence of alcohol, illegal drugs or impairment by dealings with physician groups, suppliersPurpose or competitors, Confidentiality prescription medications. Firearms, other weapons, explosive you are expected to know that laws prohibiting anti- devices or other dangerous materials are prohibited on competitive activity may apply to your activities, and you Values Attitudeour premises. Workplace violence including theft, stalking, should consult with Legal Services prior to negotiatingValues or Attitude terrorism and hate crimes will not be tolerated. On-the-job entering into any arrangement. Lee Health policies provide Communicationinjuries or other environmental or safety concerns should be that before any written contract is signed, the LegalCommunication Services brought to the immediate attention of your supervisor. departmentshould review it. Our policies also provide Privacy Customer direction and control regarding the negotiationPrivacy of contracts Customer HIPAA – PRIVACY AND SECURITY and define those authorized to sign contracts. Etiquette RespectLee Health always has upheld a strict confidentiality policy Etiquette Respect and requires all employees to sign a confidentiality statement GOVERNMENT AND MEDIA INQUIRIES Helpingupon hire and annually thereafter. Confidentiality means that Helping Legal Services should be made aware of any inquiries from communications with or about patients involving patient the Government so a proper response can be made. If health information will be private and limited to those who Ethics & Integrity anemployee at Lee Health is contacted by a representativeEthics & Integrity of a governmental agency seeking an interview or making a Patient Centered non-routine request for documents, that employeePatient should Centered immediately contact Lee Health Legal Services so that Reinvestment Serving appropriate arrangements can be madeReinvestment to fully comply with Serving the health system’s legal obligations. All media inquiries the Community should be referred to Media Relations. the Community Ethics &10 Integrity Ethics & 11Integrity Purpose Confidentiality Purpose Confidentiality Ethics & Integrity Ethics & Integrity Standards Conduct Standards Conduct COMPLY WITH COPYRIGHT LAWS need the information in order to provide treatment, payment Confidentiality and health care operations. With the enactment ofConfidentiality the Lee Health complies with U.S. Copyright laws. Employees may Health Insurance Portability and Accountability Act (HIPAA), not reproduce any copyrighted work in print, audio, video, a patient’s right to have his or her health information kept Values Gifts Attitudecomputer software or other electronic form in violation of private and confidential became both anValues ethical and legal Gifts Attitude the Copyright laws. Examples include printed articles from obligation of health care workers. Reinvestmentpublications, TV and radio programs, music performances, Reinvestment photographs, Web pages, software programs, CD, DVD, All employee documents, communications and information Accountabilityand audio/video tapes. Copyright laws in the United States that are deemed confidential by law will remain strictlyAccountability protect works even if they are not registered with the U.S. confidential. Examples of such information include social Copyright Office and do not carry the copyright symbol © security or checking and savings account numbers. See Policy Referralsor permission notice. While the law makes an exception for S10 02 376 – HIPAA Patient Privacy Monitoring Process. Referrals “fair use” of the copyrighted work for limited purposes, this Privacy Customerexception is not automatic. Compliance with Copyright laws Privacy Customer is assured by obtaining prior written permission from the AVOID ANTI-COMPETITIVE ACTIVITY Etiquette RespectCopyright holder before reproducing; the Copyright holder Federal and state antitrust laws protect the integrityEtiquette of our Respect is usually the author or publisher of the work. Please refer free enterprise system. These laws address agreements and to Policy S24 00 145 – Copyright and Other Intellectual practices resulting in the restraint of competition including Helping EthicsProperty. & boycotting suppliers, discussing pricing or patientsHelping with Ethics & competitors, implementing unfair or deceptive business Integrity Patient practices, and misrepresenting services. Integrity Patient SAFE WORK ENVIRONMENT Such laws are vigorously enforced. Violations may result Centered ReinvestmentProviding a drug-free, safe and healthy work environment is in severe penalties for Lee Health andCentered its employees Reinvestment of the utmost importance. All employees must report to work responsible for the violations. If you are involved in any Purpose Confidentialityfree of the influence of alcohol, illegal drugs or impairment by dealings with physician groups, suppliersPurpose or competitors, Confidentiality prescription medications. Firearms, other weapons, explosive you are expected to know that laws prohibiting anti- devices or other dangerous materials are prohibited on competitive activity may apply to your activities, and you Values Attitudeour premises. Workplace violence including theft, stalking, should consult with Legal Services prior to negotiatingValues or Attitude terrorism and hate crimes will not be tolerated. On-the-job entering into any arrangement. Lee Health policies provide Communicationinjuries or other environmental or safety concerns should be that before any written contract is signed, the LegalCommunication Services brought to the immediate attention of your supervisor. departmentshould review it. Our policies also provide Privacy Customer direction and control regarding the negotiationPrivacy of contracts Customer HIPAA – PRIVACY AND SECURITY and define those authorized to sign contracts. Etiquette RespectLee Health always has upheld a strict confidentiality policy Etiquette Respect and requires all employees to sign a confidentiality statement GOVERNMENT AND MEDIA INQUIRIES Helpingupon hire and annually thereafter. Confidentiality means that Helping Legal Services should be made aware of any inquiries from communications with or about patients involving patient the Government so a proper response can be made. If health information will be private and limited to those who Ethics & Integrity anemployee at Lee Health is contacted by a representativeEthics & Integrity of a governmental agency seeking an interview or making a Patient Centered non-routine request for documents, that employeePatient should Centered immediately contact Lee Health Legal Services so that Reinvestment Serving appropriate arrangements can be madeReinvestment to fully comply with Serving the health system’s legal obligations. All media inquiries the Community should be referred to Media Relations. the Community Ethics &10 Integrity Ethics & 11Integrity Purpose Confidentiality Purpose Confidentiality Ethics & Integrity Standards Conduct ConfidentialityPROTECTION AND PROPER USE OF COMPANY ASSETS Values Gifts AttitudeAll employees should protect our health system’s assets and promote their efficient use. All assets should be used for legitimate business purposes. Incidental and occasional Reinvestmentpersonal use of Lee Health assets such as computers, telephones, and supplies is allowed as long as such use does Accountabilitynot interfere with the security or effectiveness of any system or with job performance. Misuse or theft of assets should be Referralsreported to Security in accordance with Policy S09 06 767– Privacy CustomerReporting Thefts. Etiquette RespectPROTECTION FROM REPRISAL No adverse action will be taken against an employee at Lee Health who in good faith and without reckless intent has Helping Ethicscome forth with & information or evidence of a violation of state or federal law, policies, and procedures, or our Compliance Integrity PatientStandards of Conduct. For further information, consult Policy Centered ReinvestmentS23 00 944 – Whistle-blower Protection from Reprisal. Purpose ConfidentialitySUMMARY We realize that the Compliance Standards of Conduct do not cover every situation you will encounter at Lee Health. Values AttitudeThe Standards cannot help make every decision for you but instead provides a framework or guidance on how to make the Communicationbest decision for you and Lee Health. Our organization has many other resources to help you make those choices, such as Privacy Customeryour supervisor, Lee Health policies and procedures and the Compliance Department. We expect you to know about the Compliance Standards of Conduct, read them and use them Etiquette Respectas a guide to perform your job in accordance with our Values: Respect, Excellence, Compassion and Education. By living Helpingthe values you will help ensure that we live the ExceptionalLee Ethics & IntegrityPromise daily. Patient Centered

Reinvestment ServingP.O. Box 2218 • Fort Myers, FL • 33902 • 239-343-2000 leehealth.org the CommunityCompliance Hotline • 1-877-807-5647