Pediatric Sleep Disorders & Apnea Center The Kireker Center for Child Development

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1 Pediatric Sleep Disorders & Apnea Center The Kireker Center for Child Development Phone: Fax: Appointment Date: Time: Dear Parent: Thank you for contacting The Valley Hospital Pediatric Sleep Disorders & Apnea Center to schedule your child s consultation appointment with Dr. Mary T. Carbone. Consultation appointments may last approximately one hour. Late arrivals will necessitate rescheduling. Please assist us by completing and returning the enclosed forms. If you find it necessary to cancel or change you appointment, please notify us as soon as possible at The following information is provided to assist you in working with your healthcare insurance company. The information is intended as a guideline and is based upon previous patient encounters. You may refer to the attached codes when verifying your benefits and eligibility. Although Dr. Carbone participates with your insurance company, your plan may require a referral. Please have referrals prepared with the following information: Physician/Facility: Potential Codes: Dr. Mary T. Carbone Initial Consultation, new patient office visit/ 505 Goffle Road evaluation Ridgewood, NJ Monitor/receipts and physician download Infant Sleep Testing Acid Reflux Test Office Consultation, follow-up visit to discuss results and plan of care If diagnostic sleep testing is recommended by Dr. Carbone, it will be performed at The Valley Hospital. The Valley Hospital participates with most insurance companies. Prior to outpatient sleep testing, your insurance company will be contacted by our office to determine precertification requirements. Requested clinical information, along with diagnosis and procedure codes, will be provided for precertification. Please keep in mind that precertification or prior authorization is not a guarantee of payment. Little is a word that assumes gigantic responsibility when applied to children. Thank you for giving us the privilege of participating in your child s care. Staff of the Pediatric Sleep Disorders & Apnea Center

2 PLEASE COMPLETE Date of Appointment PATIENT: DATE OF BIRTH: SEX M/F PARENT S NAMES: ADDRESS: TOWN: STATE: ZIP: HOME PHONE: CELL #: ADDRESS: (Information For Person Who Holds Insurance): LEGAL NAME: DOB: PLACE OF EMPLOYMENT: ADDRESS OF EMPLOYER (must have): CITY & STATE: ZIP CODE: WORK PHONE #: SS#: INSURANCE CO: ID#: GROUP #: Does your insurance company require pre-certification or notification? If yes, did you pre-certify or notify the company? Did you receive the Summary of Notification Of Privacy Practices? May we contact you by phone/mail/ ? Do you need a sign language interpreter? Yes No Yes No Yes No Yes No Yes No PEDIATRICIAN/MEDICAL M.D.: MAILING ADDRESS (must have): TOWN: STATE: ZIP CODE: PHONE: FAX: PHARMACY: PHONE: YOUR SIGNATURE: DATE:

3 Important Insurance Information Fact Sheet The Valley Hospital participates in many health care plans. It is important to recognize, however, that the physicians are NOT employees of the Hospital. Their arrangements with insurance plans are COMPLETELY INDEPENDENT of those of the Hospital. Some physicians may elect to participate in certain plans, while others may have been excluded from certain plans due to limits set by the insurance companies. You may receive bills from physicians for care provided in the following areas: Bergen Anesthesia Billing Inquiries Valley Emergency Room Associates, P.A Ridgewood Pathology Radiology Associates Ridgewood Cardiology/EKG/Stress Test Radiation Therapy Neurology Group of Bergen County (201) Assisting Surgeons Please call your surgeon s office Hospitalist Service House Physicians Critical Care/ICU Maternal Fetal Medicine Pediatric Sleep Apnea Neonatology/NICU Pediatric Hospitalists Pediatric ICU Developmental Pediatrics Child Psychology Psychiatry Oncology Pediatric Endocrinology Pediatric Pulmonology PM&R Genetics Valley Hospital Billing Pediatric Neurology Interpretation of the following Diagnostic Tests EEG EMG Vascular studies Pulmonary Function Tests This is not a complete list; it may change or vary from time to time. There may be additional care rendered by other independent physicians during your hospitalization. You are responsible for payment for these services. In some cases, your insurance coverage MAY NOT constitute complete payment for some of these services. Check with your insurance company to determine whether a physician s service will be covered, and to determine what portion of the service you will be responsible for. In order for patients to be eligible for insurance benefits, some plans require: Pre-admission notification and approval; Second opinions for elective surgery; and/or Concurrent utilization review. Adding a newborn onto your insurance policy Please check with your employer or insurance carrier to determine the requirements of your particular insurance plan. Compliance with these requirements will result in more complete coverage of your hospital and physician bills, and will minimize the balance that you may be required to pay. AMT_ Important_Insurance_Info_Fact_Sheet_AMT_45_Rev_11_12.doc Page 1 of 1

4 THE VALLEY HOSPITAL Ridgewood, New Jersey AOBKHNGLGMFOAK AJMEEFGPIBANCK AAKBMLELAIGLPK DLDLDLLLLLLDLL PATIENT NAME PRINT IN BLOCK CAPITAL LETTERS ACCOUNT NUMBER: Authorization for Release of Patient Records and Information, Agreement to Pay for Services and Assignment of Reimbursement Benefits, Insurance Authorization. I. RELEASE OF PATIENT RECORDS AND INFORMATION In order to allow the Hospital and Hospital-based physicians providing services to obtain reimbursement, I authorize and consent to the disclosure of information or parts of my Medical Record (even if it includes diagnoses and treatment of AIDS, HIV Infection or HIV related illness and treatment of alcohol abuse and/or drug abuse). These disclosures may be made during the course of my treatment at the Hospital and after treatment. Disclosure may be made to any person or corporation which may be liable to the Hospital or Hospital-based physicians for all or part of their charges. Disclosures may be made to me, my spouse, hospital or medical service companies, my employer, HMOs, insurance companies, workers' compensation carriers, welfare fund or government agencies. Disclosures may include, but are not limited to, my identity, diagnosis, prognosis and/or treatment or procedures performed and costs, charges and expenses incurred. I authorize and consent to the Hospital and its representatives appealing, on my behalf, any utilization management determination made by my HMO, insurance company or a designated review agency, which results in a denial, termination, or other limitation of covered health care services. I authorize the Hospital and its representatives, during the course of my hospital stay, to discuss with and/or provide access to my medical records and information to any person or organization to facilitate the provision of post hospital care, treatment or services. I understand that this consent is revocable at any time, except to the extent that action has been taken in reliance upon this authorization. If not revoked, this consent will remain in force for a reasonable time in order to carry out the purposes for which it is given. II. AGREEMENT TO PAY FOR SERVICES AND ASSIGNMENT OF REIMBURSEMENT BENEFITS In consideration of the services rendered to me at or by The Valley Hospital, I hereby agree to pay the Hospital and all Hospital-based physicians/providers providing services to me, the entire amount due for all services I receive. I hereby assign insurance benefits directly to the Hospital and all Hospital-based physicians providing services to me which otherwise may be payable to me. I further understand that any recovery of a monetary settlement resulting from my present illness or injury from insurance, litigation or otherwise will first be applied toward payment of the cost of my Hospital care. If the amount of such settlement received by the Hospital is less than the value of its services, as set forth in the bill(s) rendered to me, I will pay the difference between the amount of such settlement and the total bill for Hospital services. I agree to pay the Hospital for services which I choose to receive even though my health insurer or payor has not, through its review process, approved the provision of such services. I agree to pay the Hospital for all non-covered charges, including, but not limited to, telephone, television and any private room differential. BU-20 THIS AUTHORIZATION IS RETAINED BY THE BUSINESS OFFICE Page 1 of 2 12/96, 7/99, 2/00, 3/03, 6/04, 7/05, 4/11, 6/12

5 PATIENT NAME PRINT IN BLOCK CAPITAL LETTERS III. INSURANCE AUTHORIZATION ACCOUNT NUMBER: I understand that my Health Insurance Company or payor may require me or my doctor to obtain precertification, admission notification review or a second opinion prior to obtaining Hospital services, Emergency Room treatment and/or admission. I understand that it is my responsibility to obtain all such authorizations and that failure to do so may result in a reduction, denial, or other limitation of covered health care services for which I may be liable. I also understand that the services must be, as defined by my insurance company, medically appropriate or necessary to be considered for payment. I also understand that my insurance will cover only the dependents listed under my insurance policy. Newborns or dependents must be added to the insurance policy to be covered (time frame is dependent on your insurance carrier). You must call your insurance to confirm the dependent coverage. IV. ADDITIONAL BILLS In addition to your bill from The Valley Hospital, you may receive other bills for services rendered during your inpatient stay or outpatient/same Day service for an interpretation of an exam or for a physician professional component. These bills will be mailed to you separately and are not part of the charges incurred for your hospital stay or outpatient service. I certify that I have read and that I understand this authorization; that any questions I had about this authorization were satisfactorily answered. I further certify that I am the patient or am duly authorized by the patient to act on the patient s behalf to sign this document and accept its terms. This Financial Consent will remain in effect for the duration of my treatment for this hospital stay or outpatient service. Date: Time: Patient s or Authorized Representative Signature Patient is unable to consent because: Witness to Signature(s) Name of Person Signing/Relationship to Patient (Print in Caps) I have received a copy of the Valley Hospital s Notice of Privacy Practices and Important Insurance Fact Sheet: Initials: Date: If it is determined by the Hospital that your records are protected by Federal or State law and regulations concerning confidentiality of alcohol and drug abuse patient records, the diagnosis and treatment of AIDS, HIV infection or HIV related illness, the following note will be attached to the information sent to the recipient. NOTE to Recipient of Information: This information has been disclosed to you from records protected by Federal or State confidentiality rules (42 CFR ' 2.1 et seq.; N.J.S.A. 25:5C-1, et. seq.). Federal or State rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR ' 2.1 et seq. or N.J.S.A. 25:5C-1, et. seq. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal or State rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. BU-20 THIS AUTHORIZATION IS RETAINED BY THE BUSINESS OFFICE Page 2 of 2 12/96, 7/99, 2/00, 3/03, 6/04, 7/05, 4/11, 6/12

6 THE VALLEY HOSPITAL Ridgewood, New Jersey AUTHORIZATION FOR THE VALLEY HOSPITAL CENTER FOR CHILD DEVELOPMENT TO RELEASE PATIENT MEDICAL RECORDS I,, born on do hereby consent and authorize (Name of Patient) (Date of Birth) The Valley Hospital Center For Child Development to disclose from my medical records and provide it to: PARENT NAME AND ADDRESS: (e.g., identify, diagnosis, prognosis and treatment) PEDIATRICIAN NAME AND ADDRESS: information ATTENTION: ATTENTION: The purpose or need for this disclosure is I understand that I have the right to revoke this Authorization at any time. I understand that in order to revoke this Authorization, I must do so in writing and present my written revocation to the Privacy Officer at The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, N.J I understand that the revocation will not apply to information that has already been released in response to this Authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this Authorization will expire on the following date, event, or condition: (If you fail to specify an expiration date, event or condition, this authorization will expire in 1 year.) Please indicate type of record(s) requested and approximate date(s) of service Inpatient ( ) Outpatient ( ) Date(s) Date(s) Date Emergency Room ( ) Date(s) Patient's Signature Clinic ( ) Date(s) Parent/Legal Guardian or Authorized Representative Type of Outpatient Test: Witness to Signature(s) If it is determined by the hospital that your records are protected by Federal or State law and regulations concerning confidentiality of alcohol and drug abuse patient records, the diagnosis and treatment of AIDS, HIV infection or HIV related illness; the following note will be attached to the information sent to the recipient. NOTE to Recipient of Information: This information has been disclosed to you from records protected by Federal or State confidentiality rules (42 CFR ' 2.1 et seq; N.J.S.A. 26:5c-1 et. Seq.) Federal or State rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR ' 2.1 et seq. or N.J.S.A. 25:5c-1, et seq. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal or State rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

7 The Kireker Center for Child Development 505 Goffle Road, 2 nd Floor Ridgewood, NJ From Route 17: Take Route 17 to Route 4 West to Route 208. Follow Route 208 directions. From Route 208: Take the Goffle Road/Ridgewood/Midland Park exit. 505 Goffle Road will be a half-mile on the right. From Route 287: Take exit 59 to Franklin Lakes, Route 208 South. Follow Route 208 directions. From the Garden State Parkway: Take exit 160 (Bergen Toll Plaza). Make a left and follow the signs to Route 4 West. Take Route 4 West to Route 208. Follow Route 208 directions. From the George Washington Bridge: Take Route 4 West to Route 208. Follow Route 208 directions. From the New Jersey Turnpike: Take the turnpike to Route 80 West (exit 18). Take Route 80 local to Route 17 North to Route 4 West. Take Route 4 West to Route 208. Follow Route 208 directions. From The Valley Hospital: Turn left onto North Van Dien Avenue. Turn right at traffic light onto Linwood Avenue. Take Linwood Avenue to the end. At blinking light, turn left onto Oak Street. Turn right at the traffic light onto Franklin Avenue. Proceed under the railway overpass, merge into left lane, and proceed through traffic light onto Godwin Avenue. At second traffic, light turn left onto Goffle Road. The building will be a half mile on the left.

8 New Jersey State Department of Health and Senior Services Health Care for the Uninsured Program Chris Christie Governor Lt. Governor NEW JERSEY HOSPITAL CARE PAYMENT ASSISTANCE FACT SHEET Kim Guadagno Mary E. O Dowd, M.P.H. Commissioner WHAT IS THE HOSPITAL CARE PAYMENT ASSISTANCE PROGRAM? The New Jersey Hospital Care Payment Assistance Program (Charity Care Assistance) is free or reduced charge care which is provided to patients who receive inpatient and outpatient services at acute care hospitals throughout the State of New Jersey. Hospital assistance and reduced charge care are available only for necessary hospital care. Some services such as physician fees, anesthesiology fees, radiology interpretation, and outpatient prescriptions are separate from hospital charges and may not be eligible for reduction. WHERE DOES FUNDING FOR HOSPITAL CARE PAYMENT ASSISTANCE COME FROM? The source of funding for hospital care payment assistance is through the Health Care Subsidy Fund administered under Public Law 1997, Chapter 263. WHO IS ELIGIBLE FOR HOSPITAL CARE PAYMENT ASSISTANCE? Hospital care payment assistance is available to New Jersey residents who: 1. Have no health coverage or have coverage that pays only for part of the bill: and 2. Are ineligible for any private or governmental sponsored coverage (such as Medicaid); and 3. Meet both the income and assets eligibility criteria listed below. Hospital assistance is also available to non-new Jersey residents, subject to specific provisions. Income Criteria Income as a Percentage of HHS Poverty Income Guidelines Percentage of Charge Paid by Patient less than or equal to 200% 0% greater than 200% but less than or equal to 225% 20% greater than 225% but less than or equal to 250% 40% greater than 250% but less than or equal to 275% 60% greater than 275% but less than or equal to 300% 80% greater than 300% 100% If patients on the 20% to 80% sliding fee scale are responsible for qualified out-of-pocket paid medical expenses in excess of 30% of their gross annual income (i.e. bills unpaid by other parties), then the amount in excess of 30% is considered hospital care payment assistance.

9 Assets Criteria Individual assets cannot exceed $7,500 and family assets cannot exceed $15,000. Should an applicant s assets exceed these limits, he/she may spend down the assets to the eligible limits through payment of the excess toward the hospital bill and other approved out-of-pocket medical expenses. HOW ARE INDIVIDUALS MADE AWARE OF THE AVAILABILITY OF HOSPITAL CARE PAYMENT ASSISTANCE? Hospitals post signs in English, Spanish and any language which is spoken by 10% or more of the population in the hospital s service area. These signs are posted in appropriate areas of the facility such as the admissions area, the business office, outpatient clinic areas, and the emergency room. The sign informs patients of the availability of hospital assistance and reduced charge care, gives a brief description of the eligibility criteria, and directs the patient to the business office or admissions office of the hospital. Every patient should receive a written notice of the availability of hospital care payment assistance and medical assistance. WHAT ARE THE SCREENING PROCEDURES FOR THIRD PARTY PAYERS AND MEDICAID? All charity care applicants must be screened to determine the potential eligibility for any third party insurance benefits or medical assistance programs that might pay towards the hospital bill. Patients may not be eligible for the hospital care payment assistance program until they are determined to be ineligible for any other medical assistance programs. Patients are responsible to obtain a financial screening from the hospital in a timely manner. Usually, a patient must apply for Medicaid within 3 months from the date of hospital services. Once the hospital has informed the patient about medical assistance and/or makes the referral properly, if the patient fails to cooperate or does not go for screening in a timely manner, the hospital has the option to bill the patient and pursue collection efforts, regardless of eligibility for hospital care payment assistance. HOW DOES SOMEONE APPLY FOR HOSPITAL CARE PAYMENT ASSISTANCE? The patient or prospective patient must apply for hospital care payment assistance at the hospital from which he/she plans to obtain or has obtained services. The patient should apply at the business office or admissions office of the hospital. The patient or responsible party must answer questions related to his/her income and assets, as well as provide documentation of the income and assets. The hospital will make a determination of whether the applicant is eligible as soon as possible, but no more than ten working days from the time a complete application is submitted. If the request does not include adequate documentation to make a determination, the request shall be denied. The applicant will then be allowed to present additional documentation to the hospital. The applicant has up to one year from the date of service to apply for hospital assistance and provide the hospital with a completed application. Applicants found ineligible may reapply at a future time when they present themselves for services and believe their financial circumstances have changed. The Department of Health and Senior Services has a toll-free number to assist with any questions or concerns. Please call the Health Care for the Uninsured Program during business hours at August, 2011

10 EXHIBIT A - #13.14 NOTICE OF PRIVACY PRACTICES Effective as of: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this Notice, please contact The Patient Relations Department at The Valley Hospital by calling WHO WILL FOLLOW THIS NOTICE. This Notice describes our hospital s practices and that of: Any health care professional authorized to enter information into your hospital chart. All departments and units of the hospital. Any member of a volunteer group we allow to help you while you are in the hospital. All employees, staff and other hospital personnel. The Valley Hospital, Valley Home Care, Valley Health Medical Group, Valley Medical Services and The Valley Hospital Foundation follow the terms of this Notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or hospital operations purposes described in this Notice. OUR PLEDGE REGARDING MEDICAL INFORMATION. We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the hospital. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by the hospital, whether made by hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic. This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to: make sure that medical information that identifies you is kept private; give you this Notice of our legal duties and privacy practices concerning medical information about you; and follow the terms of the Notice that is currently in effect. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU. We use and disclose medical information in many ways. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, nursing and medical students, or other hospital personnel who are involved in taking care of you at the hospital and who may call after discharge to see how you are doing. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as family members, clergy, rehabilitation centers or others we use to provide services that are part of your care. For Payment. We may use and disclose medical information about you so that the treatment and services you receive at the hospital may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also 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 treatment. For Health Care Operations. We may use and disclose medical information about you for hospital operations. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many hospital patients to decide what additional services the hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, nursing and medical students, and other hospital personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the hospital. Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you. Fundraising Activities. We may use demographic information about you to contact you in an effort to raise money for the hospital, home care or hospice. We may disclose certain information to The Valley Hospital Foundation so that the Foundation may contact you in raising money for the hospital, home care or hospice. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at the hospital. If you do not want the hospital to contact you for fundraising efforts, you must notify us by telephone at , via electronic mail VHF@valleyhealth.com or in writing at The Valley Hospital Foundation, 223 North Van Dien Avenue, Ridgewood, New Jersey Hospital Directory. We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who call or come to the hospital and ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi. The hospital directory allows your family, friends and clergy to visit you in the hospital and generally know how you are doing. Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the hospital. In addition, we may disclose medical information about you to an entity helping 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 medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the hospital. We will always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the hospital. 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 able to help prevent the threat. SPECIAL SITUATIONS. Organ and Tissue Donation. If you are an organ 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. Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. Workers' Compensation. We may release medical information about you for workers' compensation 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 abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; Adm-103 Notice of Privacy Practices Page 1 of 2 01/03; 01/11

11 EXHIBIT A - #13.14 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 medical 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 medical information about you in response to a court or administrative order. We may also disclose medical 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 about the request or to obtain an order protecting the information requested. Law Enforcement. We may release medical information if asked to do so by a law enforcement official: In response to a court order, subpoena, warrant, summons or similar process; To identify or locate a suspect, fugitive, material witness, or missing person; About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; About a death we believe may be the result of criminal conduct; About criminal conduct at the hospital; and In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors. We may release medical 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 medical information about patients of the hospital to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities. We may release medical 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. Correctional Institutions. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. 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, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to The Medical Records Department, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, New Jersey If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request, in writing, that the denial be reviewed. Another licensed health care professional chosen by the hospital will review your request and the denial. The person conducting the review will not be the person who previously denied your request. We will comply with the outcome of the review. Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to include additional information in your medical record. You have the right to request an amendment for as long as all the information, both old and new, is kept by or for the hospital. To request an amendment, your request must be made in writing and submitted to The Medical Records Department, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, New Jersey In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; Is not part of the medical information kept by or for the hospital; Is not part of the information which you would be permitted to inspect and copy; or Is accurate and complete. Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you, excluding disclosures for the purpose of treatment, payment and healthcare operations. To request this list or accounting of disclosures, you must submit your request in writing to the Medical Records Department, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, New Jersey Your request must state a time period, which may not be longer than six years and may not include dates before April 14, Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to The Valley Hospital Privacy Officer, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, New Jersey In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical 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 the Patient Relations Department, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, New Jersey We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must tell us how or where you wish to be contacted. If you do not tell us how or where you wish to be contacted, we do not have to follow your request. Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice at our web site, To obtain a paper copy of this Notice, please write to the Medical Records Department, The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, New Jersey 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 medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in the hospital. The Notice will contain on the first page, in the top lefthand corner, the effective date. In addition, each time you register at or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current Notice in effect. COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the Department of Health and Human Services at the Office Of Civil Rights, U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, New York To file a complaint with the hospital, please write to the Privacy Officer, c/o Patient Relations Department at The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, New Jersey All complaints must be submitted in writing. You will not be penalized for filing a complaint. OTHER USES OF MEDICAL INFORMATION. Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. For further information, please contact the Director of Patient Relations or the Privacy Officer, c/o Patient Relations Department at The Valley Hospital, 223 North Van Dien Avenue, Ridgewood, New Jersey , (201) Adm-103 Notice of Privacy Practices Page 2 of 2 01/03; 01/11