Metairie Physician Services, Inc PATIENT REGISTRATION

Metairie Physician Services, Inc PATIENT REGISTRATION Today s Date: PATIENT: (Please Print) Patient Name: Last First Middle Initial Date of Birth: Social Security Number: Address: Home Phone Number:( ) Apartment Number/ Street Address City/State/Zip: Cell Phone Number:( ) Mailing Address (if not above): Email Address: Employer: Work Phone Number:( ) Sex: omale o Female Preferred Contact Number (circle): Cell Home Work Preferred method of contact for appointment reminders (circle): Call Text Email If you do not wish to provide your race and/or ethnicity, please select Decline. Race: owhite oafrican American/Black onative Hawaiian/Pacific Islander ohispanic onative American oother odecline Ethnicity: ohispanic or Latino onot Hispanic or Latino oother odecline Preferred Language: Marital Status: o Single o Married o Other Place of Birth: Religion: Employment Status: o Employed o Full-time Student o Part-time Student Chosen Physician within this Practice: Referral from: o Relative o Friend o Yellow Pages o Physician Finder o Insurance Directory o Employee o Physician Name Emergency Contact: ( Name Relationship Phone Number ) Preferred Pharmacy: GUARANTOR Name Person Responsible for Payment: Name (If not above): o Patient o Spouse o Parent/Guardian o Other Address (if not above): Social Security Number: Phone Number (if not above): Home:( ) Work:( ) List those we can speak with regarding your health: Address Signature of Patient or Legal Representative (Parent/Guardian/Power of Attorney) Date WHAT QUALIFIES YOU FOR MEDICARE SECONDARY? Please select one of the following: o Working Aged Beneficiary or Spouse with Employer Group Health Plan o Public Health Service (PHS) or Other Federal Agency o End Staged Renal Disease Beneficiary in the 12 months coordinated period with an employer s health group o Black Lung o Veteran s Administration o No-fault Insurance including Auto is Primary o Disabled Beneficiary Under 65 with Large Group Health Plan (LGHP) o Worker s Compensation WOULD YOU LIKE A COPY OF OUR PRIVACY NOTICE? o Yes o No Rev 07/2016

Patient s Name: (First Name, Middle Initial and Last Name) Patient Account #: EAST JEFFERSON GENERAL HOSPITAL Financial Responsibility Notice (Non-Medicare/Medicaid Covered Patients) Thank you for choosing East Jefferson Physicians Group for your healthcare needs. Please review the following notice and sign below to indicate you have read, understand and accept responsibility to pay any charges not paid by your health plan. 1. Unless arrangements have been made in advance, co-payments, co-insurance, and any outstanding balances are expected at the time of service. 2. Any check returned from the bank will result in an additional $25.00 charge that will appear on your account. 3. Patient accounts not paid promptly are subject to third party collections and/or legal procedures. 4. If your insurance carrier has not responded to a claim within 45 days, we reserve the right to formally transfer all associated liability for the claim to you. Failure to promptly resolve this balance may result in third party collection and/or legal procedures to be taken. 5. Your health insurance contract is between you and your insurance company. Any complaints regarding your coverage should be directed to your carrier. If you have obtained health insurance, your insurer may pay some or all of those charges on your behalf, depending upon the coverage you purchased. Pre-authorization by your health plan is not necessarily a guarantee of payment. Plans review the claim to determine eligibility and benefits for the services before payment is made. 6. Each health plan establishes its own rules and definitions of what is medically necessary or reimbursement by the plan and what is excluded from coverage. This may not be consistent with your expectations or reimbursement from prior visits and may not have been communicated to us or to you before your services are rendered. Accordingly, your health plan may or may not pay for all services you receive. 7. We will submit a claim on your behalf and advise if your health plan determines some or all of your care or testing is not eligible for coverage. You are financially responsible for charges your health plan determines are not covered. 8. Your health plan may also determine that your plan requirements were not met or that an approved provider of service was not used. You are welcome to receive care or testing, however if your health plan reduces or denies benefits because the provider you see is not a participating provider with your health plan, you will be financially responsible. 9. You are responsible for notifying our office of any change in name, address, phone or insurance information. Patient/Guarantor Signature Clinic Representative Date

Patient s Name: (First Name, Middle Initial and Last Name) Patient Account #: EAST JEFFERSON GENERAL HOSPITAL Patient Agreement A. Consent For Uses & Disclosures of Health Information I consent to (MPSI) and its affiliates using and disclosing my health information for Treatment, Payment and Health Operations. I also acknowledge I have received/been offered a copy of the hospital s Notice of Privacy Practices that describes in detail such uses and disclosures as well as my rights with respect to my personal health information. B. Assignment of Benefits and Reimbursement Rights I agree to assign all benefits and reimbursement rights to which I am entitled and which are otherwise payable to me, to MPSI and its affiliates to retain and treat me as a patient. My signature below affirms my understanding and acceptance of my financial responsibility to the hospital and its affiliates for all charges related to services not paid within thirty (30) days of the date billed, or for any amount unpaid by insurance. I also unconditionally guarantee payment of all costs for my physician services and other services and supplies provided to me as a patient. I further agree to pay attorney s fees of twenty five (25) percent of the amount due if the hospital or its affiliates have to refer my financial obligations for collection. This assignment shall include the authority and right to institute legal action to recover ALL amounts due as a result of said services rendered including any and all statutory penalties which may also be claimed and collected. C. Government Health Care Programs I understand that if I falsely represent and/or provide false documentation to claim eligibility for Medicare, Medicaid or other government health program benefits, I risk being charged by the government for fraud and if convicted, will be subject to fines and imprisonment. D. Patient s Right to Receive an Itemized Statement of Charges I have been advised that Louisiana Law entitles me to receive an itemized statement of billed services within ten (10) business days after services are rendered. I further understand the EJPG centralized billing office will provide my itemized statement only on my request. E. Consent for Medical and/or Surgical Treatment I am aware that medical and surgical treatments have inherent risks and outcomes are not always predictable despite appropriate care. I acknowledge that no guarantees have been made to me by the hospital or its affiliates as to the anticipated outcome of my pending medical and/or surgical treatment. I do hereby voluntarily consent to such diagnostic procedures and to such medical, surgical or other treatment as it deemed necessary by my physician. I HAVE READ ALL OF THE ABOVE AND CERTIFY I UNDERSTAND AND AGREE TO ALL PROVISIONS. Signature of Patient Date: Time: Signature of Authorized Patient Representative Relationship to the Patient: Signature of Witness: Reason Patient cannot sign on his/her own behalf:

MPSI Patient Health Information Notice of Privacy Practices Notice Effective Date: September 2013 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. OUR PLEDGE REGARDING YOUR HEALTH INFORMATION is dedicated to protecting your personal health information. We take those precautions reasonably necessary to ensure your health information is held in confidence and only used by and disclosed to those who have a justifiable need to know. When you receive care at we create a record set necessary for: your care and treatment our actions related to receiving payment for your treatment management of our hospital operations related to your treatment. REQUIRED BY LAW This notice applies to how we may use and disclose your health information in connection with receiving care at MPSI. It also describes your rights with respect to your personal health information. We are required by law to: make sure that medical information that identifies you is treated confidentially give you this Notice of our legal duties and privacy practices with respect to your medical information follow the terms of the Notice currently in effect. WHO WILL FOLLOW THIS NOTICE All (MPSI) employees and volunteers. Physicians with privileges at MPSI including contract physicians and other health care professional contract services including but not limited to emergency medicine, pathology, anesthesiology, radiation oncology, radiology, pulmonology and cardiology services. Health care professionals and others who are not employees of MPSI but who are authorized to enter information into the MPSI records system or authorized to use your health information already contained in the MPSI records system for treatment, payment or operations including Business Associates of MPSI. Health records may be created, used and disclosed by your personal doctor and other health care professionals who treat you at MPSI but who are not MPSI employees. These direct care providers have agreed to follow MPSI s privacy practices while you are a patient at MPSI. However they may have different policies regarding use and disclosure of your health information created, used or stored in their personal offices or clinics. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe different ways we use and disclose medical information. For each category of uses or disclosures we explain what we mean and give some examples. The ways we use and disclose information will fall within one of the categories. For Treatment We will use health information about you to provide medical treatment or services. We will disclose medical information about you to doctors, nurses, technicians, medical students, students in health care training programs, or other MPSI personnel who are involved in taking care of you. For example, a doctor treating you for flu may need to know if you have other health conditions that need to be considered in your treatment. Also, different departments of MPSI may share your health information in order to coordinate the different things you need, such as prescriptions and lab work. With your permission, we also may disclose your health information to new providers outside MPSI who may be involved in your health care after you leave MPSI, such as home care service or others you chose to provide services. We may also provide your physician or a subsequent healthcare provider with copies of various reports to assist in treating you once you have been discharged from MPSI. For Payment We may use and disclose health information about you so that the treatment and services you receive at MPSI may be billed and payment collected from you, an insurance company or a third party. For example, we may need to give your health insurance plan information about treatment you received at MPSI so your health insurance plan will pay us for the treatment. We also may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the proposed treatment. For Health Care Operations We may use and disclose your health information for MPSI operations. These uses and disclosures are necessary to run MPSI and to make sure all of our patients receive quality care. This may include an assessment of your satisfaction with our services. For example, we may use medical information to evaluate the performance of our staff in caring for you. We may also combine health information about many MPSI patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We also may disclose information to doctors, nurses, technicians, medical students, students in health care training programs and other MPSI personnel for review and learning purposes. We may remove the information that personally identifies you from this set of health information so others may use it to study health care and health care delivery without knowing anything about you. Appointment Reminders We may use and disclose health information to contact you as a reminder that you have an appointment for treatment at MPSI. You have the right to opt out of such reminders. If you want to opt out, you must advise the Registration personnel of your preference. Treatment Alternatives We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. You have the right to opt out of these special notices. If you want to opt out, you must advise the Registration personnel of your preference. Health-Related Benefits and Services We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you. You have the right to opt out of these special notices. If you want to opt out, you must advise the Registration personnel of your preference. Future Communications We may communicate with you via newsletters, mail or other means regarding treatment options, health related information, disease-management programs, wellness programs or other community based initiatives or activities our facility is participating in. You have the right to opt out of these special notices. If you want to opt out, you must advise the Registration personnel of your preference. Fundraising Activities We may use your contact information or disclose your contact information to the East Jefferson General Hospital Foundation so that the foundation may contact you in its money raising efforts for the hospital. Contact information consists of your name, address and phone number and the dates you received treatment or services at MPSI. If you do not want the East Jefferson General Hospital Foundation to contact you for fundraising, you must notify the EJGH Privacy Office, 4200 Houma Boulevard, Metairie, LA, 70006 in writing of your preference. MPSI will not condition treatment or payment on your choice with respect to the receipt of fundraising communications. Marketing Except if the communication is in the form of a fact-to-face communication made to you personally, or a promotional gif of nominal value provided by MPSI, your authorization is needed for use or disclosure of your health information for marketing purposes. It is not considered marketing to send you information related to your individual treatment, case management, care coordination or to direct or recommend alternative treatment, therapies, healthcare providers or settings of care. These may be sent without written permission, except your authorization is required if marketing is to result in financial payment or remuneration to MPSI by a third party. Hospital Directory While you are a patient, we may include certain limited information about you in a Hospital Directory. This information may include your name and information related to visiting you and may be released to people who ask for you by name. Your religious affiliation may also be released to members of the clergy, such as a priest, minister or rabbi, who share your religious affiliation. If you do not want the hospital to include your information in the Directory you must advise the Registration personnel of your preference. Individuals Involved in Your Care or Payment for Your Care If you agree, do not object or we reasonably infer that there is no objection, we may release health information about you to a family member or friend who is involved in your care. We also may tell your family or friends that you are in the hospital and your medical condition. We also may give information to someone who helps pay for your care. If you are incapacitated, we will exercise professional judgment and act in your best interest in making disclosure of your health information to family members or friends involved in your care. You have the right to request a restriction on our disclosure to someone involved in your care. If you want to object to such disclosures, you must advise the Registration personnel of your preference. Business Associates There are some services provided in our organization through contracts with business associates. Some examples of these include physician services for certain laboratory tests, a billing service for our owned physician practices, and a copy service we use when making copies of your health record. These business associates may have access to your health information so that they can perform the job we ve asked them to do on our behalf. These business associates may create or receive health information on our behalf. To protect your health information, however, we require them to agree to safeguard your information in their possession. Disaster Relief We may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. Research Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients with the same medical condition who received one medication to those who received another medication. All research projects are subject to a special approval process. This process evaluates a proposed research project and its use of health information to ensure patient health information is only used and disclosed as necessary for the research project. Normally we use or disclose health information for research only after the project has been approved through the research approval process. However, we may disclose health information about you to researchers to help them identify patients with specific medical needs. In these pre-research actions, we will not allow researchers to copy or otherwise transmit your identifiable health information outside MPSI. In some instances, the law allows us to do some research using your health information without your approval. As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law. To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone authorized to receive it. Psychotherapy Notes We must receive your authorization for any use or disclosure of psychotherapy notes, except: for the use by the originator of the notes for treatment or health oversight activities; for use or disclosure of our own training programs where students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills; for use or disclosure by us to defend ourselves in a legal action or other proceeding brought by you; to the extent required to investigate or determine MPSI s compliance with health care protection laws/regulations; to the extent that use or disclosure is required by law and the use or disclosure complies with and is limited by the law; for health oversight activities with respect to oversight of the originator of the notes; for disclosure to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law; or if disclosure is necessary to prevent or lessen a serious imminent threat to the health or safety of a person or the public and is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. SPECIAL SITUATIONS FOR RELEASE OF HEALTH INFORMATION Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority. If you are a member of the Armed Forces, we may disclose health information about you to the Department of Veterans Affairs upon your separation or discharge from military services. This disclosure is necessary for the Department of Veterans Affairs to determine if you are eligible for certain benefits. Workers' Compensation and Disability Insurance. We may release medical information about you for workers' compensation, disability insurance or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following: to prevent or control disease, injury or disability; to report births and deaths; to report child or elder abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you or your representative to afford you the opportunity to obtain an order protecting the information requested. Law Enforcement. We may release health information if asked to do so by a law enforcement official for law enforcement purposes: In response to a court order, subpoena, warrant, summons or similar process; To identify or locate a suspect, fugitive, material witness, or missing person; About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; About a death we believe may be the result of criminal conduct; About criminal conduct at or affecting MPSI; In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about a deceased person to funeral directors as necessary to carry out their duties. Organ and Tissue Donation. If you are a possible organ or tissue donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. National Security and Intelligence Activities. We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary for the following: for the institution to provide you with health care; to protect your health and safety or the health and safety of others; or for the safety and security of the correctional institution. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding medical information we maintain about you: Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the EJGH Health Information Management Department, 4200 Houma Boulevard, Metairie, LA, 70006 or East Jefferson Physician Network, 4200 Houma Boulevard, Metairie, LA, 70006. You do not have to provide any justification to exercise this right. If you request a copy of your health information, EJGH may charge a fee for the costs of copying, mailing or other expenses associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your health information you may appeal the denial. Your appeal will be considered by a licensed health care professional chosen by MSI and not previously involved in the denial of your original request for inspection and copy. MPSI will abide by the decision of the appeal reviewer. Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for MPSI. To request an amendment, your request must be made in writing and submitted to MPSI care of the EJGH Health Information Management Department or for records maintained by the MPSI physicians, sent requests to MPSI care of East Jefferson Physician Network, 4200 Houma Boulevard, Metairie, LA, 70006. You must provide justification and documentation that supports your amendment request. We may deny your request for an amendment if it is not in writing or does not include sufficient justification and documentation to support the request. In addition, we may deny your request if you ask us to amend information that: Was not created by us or the person or entity that created the information is no longer available to make the amendment; Is not part of the medical information kept by or for EJGH; Is not part of the information which you would be permitted to inspect and copy; or Is accurate and complete. If your request to amend is denied, your written statement of disagreement and your original request for amendment, denial, and any rebuttal will be filed in the designated record. Right to an Accounting of Health Information Disclosures. We maintain a record of disclosures of your health information that are made outside the purposes of treatment, payment and operations or without your authorization. We generally classify these type disclosures as non-routine and we control and track such disclosures. To request an accounting of these non-routine disclosures, you must submit your request in writing to MPSI care of EJGH Health Information Management Department, 4200 Houma Boulevard, Metairie, LA, 70006. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you prefer the accounting (paper, electronic or other form). The first accounting you request within a twelve (12) month period will be provided free of charge. For additional accountings within a twelve (12) month period, we may charge you for the costs of providing the accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not disclose information to them about your treatment by MPSI. To request restrictions, you must make your request in writing to MPSI care of EJGH Privacy Office, 4200 Houma Boulevard, Metairie, LA, 70006 or MPSI care of East Jefferson Physician Network, 4200 Houma Boulevard, Metairie, LA, 70006. In your request, you must tell us: what information you want to limit; whether you want to limit our use, disclosure or both; and to whom you want the limits to apply, for example, disclosures to your spouse. We are not required to agree to your request. If we do agree, we will comply with your request but only to the extent that we have not already acted or unless the information is needed to provide you emergency treatment. In addition to the above, you also have the right to restrict disclosures to health plans if the patient has paid for the services out of pocket in full. Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to EJGH Privacy Office, 4200 Houma Boulevard, Metairie, LA, 70006 or East Jefferson Physician Network, 4200 Houma Boulevard, Metairie, LA, 70006. Your request must specify how or where you wish to be contacted. You do not have to provide the reason for your request. East Jefferson General Hospital will honor all reasonable requests. Your request will not be accepted however if it unreasonably interferes with our efforts to collect for services already rendered. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. To obtain a paper copy of this notice, contact the MPSI care of EJGH Privacy Office, 4200 Houma Boulevard, Metairie, LA 70006. You may obtain an electronic copy of this notice at the website, www.ejgh.org. Even if you have an electronic version of the Notice, you are still entitled to a paper copy. CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any health information we create in the future. We will post a copy of the current notice at appropriate patient access points in our treatment facilities. The notice will contain its effective date on all pages. In addition, each time you register at or are admitted to MPSI or East Jefferson General Hospital for treatment as an inpatient or outpatient, you will have an opportunity to receive a copy of the current notice. Also, if we make a material change to this notice, we will provide a revised notice available on the website www.ejgh.org. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the East Jefferson General Hospital Privacy Officer or with the U.S. Secretary of the Department of Health and Human Services. Complaints submitted to MPSI care of the EJGH Privacy Officer must be in writing and may be mailed or hand delivered to EJGH Privacy Officer, 4200 Houma Boulevard, Metairie, LA, 70006. You must include your contact information in your request. The Privacy Officer will contact you about the complaint promptly after it is received. Your complaint actions will be held in the strictest confidence. Additionally, East Jefferson General Hospital will not take any actions to discourage you from filing a complaint nor will we act against you in any way if you file a complaint. AUTHORIZATION FOR OTHER USES OF YOUR MEDICAL INFORMATION Other uses and disclosures of medical information, not covered by this notice or otherwise required by law will be made only with your written authorization. The following uses and disclosures, if outside the conditions discussed in this notice, will be made only with authorization from the patient: Uses and disclosures for marketing purposes Uses and disclosures that constitute the sale of protected health information Most uses and disclosures of psychotherapy notes Other uses and disclosures not discussed or described in this notice. For uses and disclosures that require authorization: MPSI has a specific authorization form that identifies all of the required information necessary for a valid authorization to release your health information that requires your signature or the signature of your legally authorized personal representative. We caution you about authorizing release of your health information. You should always make sure you fully understand the purposes for the authorization and how your health information will be protected by the organization or individual you authorize to receive your health information. When MPSI acts on your authorization for use and disclosure of your health information, we are not responsible for how that information may be used by others after it is disclosed. MPSI will require detailed justification for any authorization that requests the disclosure of your complete medical record. We are required to do this by law. If you provide us authorization to use or disclose your medical information you may revoke the authorization at any time. You may revoke your authorization by writing to MPSI care of the EJGH Health Information Management Department, 4200 Houma Boulevard, Metairie, LA, 70006 or if this relates to an authorization given to a physician in MPSI, by writing to MPSI care of East Jefferson Physician Network, 4200 Houma Boulevard, Metairie, LA, 70006. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your original written authorization except to the extent we have already acted. We will be unable to take back any disclosures already made based on your original authorization. BREACH NOTIFICATION In the event of any Breach of Unsecured Protected Health Information protected by HIPAA by MPSI (or one of our Business Associates), MPSI will fully comply with the Breach notification requirements under federal law (HIPAA, HITECH, and amendments thereto), which will include notification to you of any impact that Breach may have had on you and/or your family member(s) and actions that MPSI undertook to minimize any impact of the Breach may or could have on you. Questions about this notice should be directed to MPSI care of the East Jefferson General Hospital Privacy Officer who can be reached by calling 504-454-4000.