Our family at Via OB/GYN would like to congratulate Dr. Hayes on the newest addition to her family... Dr. Hayes, her husband Jeff, and their daughter
Emma will be traveling to China on October 6th to adopt a little Chinese girl named Maya.

Maya is 18 months old and currently lives in Shantou City, China in the Guongdong Province. They will be there for approximately fourteen days and you can follow their journey to bring Maya home by visiting her adoption website.

We wish them safe travels and a happy home coming!

Via OB/GYN will be offering flu shots beginning the end of September 2010. Our high risk OB patients will be given the vaccine first at the time of their OB appointments. We ask all other patients to schedule a time for their vaccine during normal office hours.

Site Index

Below is a graphical representation of the Via OB/GYN Website... to visit a particular section, simply click on the page of your choice:

Home

About Us

• Meet Our Doctors
• Testimonials
• Philosophy of Care
  - Respect, Dignity and Comfort
  - An Excellent Experience
  - Informed Participation
• Affiliated Hospital Information

Services

• Women's Services
- Ultrasound Information
- Essure Permanent Birth Control
- da Vinci Surgical System
- Gynecare Thermachoice


• Maternity Services
- Ultrasound Information

Patient Resources

• Gynecology
  - Ultrasound Information
  - Prescription Refills
  - Birth Control Pill Instructions
  
  
• Obstetrics
  - Ultrasound Information
  - Prescription Refills
  - Pregnancy Due Date Calculator and Week by Week Calendar
  - Healthy Pregnancy Diet
  - OTC Meds - Safe During Pregnancy
  - Twenty Eight Week Blood Work

New Patients

• Letter to Our New Patients
• Registration Forms
  - Registration Form
  - Consent Form
  - History Summary Form
  - Care of Responsibility Form

Office Policies

• Fees and Payments
  - Pre-Pay Policy for Obstetric Patients
  - Self-Pay Policy for Obstetric Patients
• Appointments
• Accepted Insurance Plans

Contact Us

• Office Locations and Hours
• Maps and Driving Directions
• Call or Email Us

General

• Employment Opportunities
• Terms and Conditions
• Privacy Policy

Via OB/GYN offers a 25% discount to our self-pay patients. This documentation has been provided to you so that you may have a better understanding of our fees associated with your OB care and delivery. Please review the following and ask our staff any questions or concerns that you may have.

It is important to remember that the below quoted fees are only an estimate. Please note that these fees do NOT include any tests ordered such as a non-stress test, ultrasounds, laboratory test, hospital admissions, etc. These fees only include your routine OB visits and delivery.

Via OB/GYN requires your OB care and delivery to be paid in full by your 7th month of pregnancy. We can offer you flexible monthly payments or if you prefer you can pay the total amount due with one payment by your 3rd month of pregnancy. For your first OB visit, you will be required to make a payment of $300.00 at the time of service ( by cash or credit card).

Standard Fee for OB Care and Vaginal Delivery: $3,187.00
25% Discount Applied: -$796.75
Total Due: $2,390.25

* Initial payment at first appointment would be $300.00, and then 6 monthly payments of $348.38 would be required. (There may be a different monthly payment due depending on how far along you are in your pregnancy at your first OB visit.)

Standard Fee for OB Care and C-Section Delivery: $3,607.00
20% Discount Applied: -$901.75
Total Due: $2,705.25

* Initial payment at first appointment would be $300.00, and then 6 monthly payments of $400.88 would be required. (There may be a different monthly payment due depending on how far along you are in your pregnancy at your first OB visits.)

Via OB/GYN has provided you this document so that you may have a better understanding of our fees associated with your OB care and delivery. Please review the following and ask our staff any questions or concerns that you may have.

Our office has contacted your insurance to obtain this information, however it is important to remember that the below quoted fees are only an estimate of what your insurance will pay for your OB Care and delivery, this quote does not include any yearly deductible.

Please note that these fees do NOT include any tests ordered such as a non-stress test, ultrasounds, laboratory test, hospital admissions, etc. These fees only include your routine OB visits and delivery.

Our office requires your OB pre-pay amount be paid in full by your 7th month of pregnancy. We can offer you flexible monthly payments or if you prefer you can pay the total amount due with one payment by your 3rd month of pregnancy.

The following is an estimate of our standard fees for 2010. Via OB/GYN will honor the original fee quoted to you for your OB Care and Delivery should there be an increase in prices. All other charges will reflect any price increases.

Standard Fee For OB Care and Vaginal Delivery: $3,187.00
Standard Fee For OB Care and C-Section Delivery: $3,607.00
Ultrasounds (Range in fees according to type of U/S): $186.00-$420.00
Non-Stress Test: $83.00
Circumcision: $314.00

We are providing you with a lab requisition for blood work to be drawn at 28 weeks gestation.

This is a screening test for gestational diabetes and anemia. You may get the blood work drawn before the day of your next appointment or on the day of your next appointment.

We are obtaining results for a CBC, 1 hour Glucose test, and if your blood type is negative, we will draw an antibody screen and you will receive the Rhogam injection.

The 1 hour Glucose test is not a fasting blood draw, but you should decrease your simple sugar and carbohydrate intake prior to the test. If you will be doing your blood work the day of your appointment, you could stop by the lab to get the Glucola and drink it before you come up for your appointment.

You would then go back down to the lab after your appointment to get your blood drawn 1 hour after you have finished the drink.

• Regular or Extra-Strength Tylenol
• Regular or LA Sudafed, Tylenol Cold and Sinus, Claritin, or Benadryl Cold & Allergy (for congestion - please call us if no relief within 72 hours)
• Robitussin DM or Vicks 44-D (for cough)
• Maalox, Mylanta, Turns, Rolaids, Pepcid AC, Prilosec OTC, or Zantac (for heartburn, indigestion, or "acid stomach")
• Milk of Magnesia (for constipation)
• Throat Lozenges
• Imodium AD or Kaopectate (for diarrhea - followed by a clear liquid diet for 24 hours)
• Monistat 1, 3, or 7 day (inserted gently for yeast infections)
• Unisom 1 at bedtime; 2 in the A.M. (for nausea)
• Stool Softeners (docusate sodium)

You may use hair coloring, self tanning lotions, or get a perm AFTER 12 WEEKS, but keep in mind that with hormonal changes in your body, these may not give you the desired effect.

A healthy baby requires a healthy diet during pregnancy. Build a healthy diet around protein and calcium rich foods with a good balance of fruits, vegetables, and complex carbohydrates.

Each Day: Choose 4 servings of milk or milk products from this list. You need 1500 mg of Calcium a day. Each serving has 8 gm of protein plus 300 mg of calcium.

8 oz. glass 1% or skim milk
1 oz. piece of cheese
1 container of low fat yogurt, not sweetened with NutraSweet
1/2 cup cottage cheese

Choose at least 6 to 8 servings of protein foods from this list. You need at least 100 gms of protein a day. Each serving has 8 gm of protein.

1 oz. poultry (a cooked, boneless, skinless chicken breast is 3 oz.)
1 oz. beef, pork, or lamb
1 oz. fish, shell fish (limit to 12 oz. per week) or 2 restaurant-size portions of seafood. *See seafood note
1 egg
1 Tbs. of peanut butter
1 handful of peanuts
1/4 cup cooked legumes (kidney beans, lentils, etc.)

Choose 7-11 servings of carbohydrates. Focus on complex carbohydrates (whole grain). Labels should mention 100% whole grain as a first ingredient.

1/2 cup of cereal
1 slice bread
4 oz. baked potato
1/2 cup corn or peas
1/2 English muffin
1/2 small bagel
1/2 cup cooked pasta

Choose at least 5 servings of fruits and vegetables, including 2 servings of a Vitamin C rich food.

4 oz. orange juice
4 oz. grapefruit juice
1 cup tomato or V8 juice
1/2 grapefruit
1 small orange
1 kiwi
1/2 cantaloupe
1 tomato
1 green pepper
1 cup strawberries

Choose 2 servings of dark green leafy vegetables.

1/2 cup romaine lettuce
1/2 cup spinach
1/2 cup broccoli
1/2 cup Brussels spouts

Choose 2 to 3 servings of these healthy fat servings

1 Tbs. margarine
1 Tbs. oil (preferably canola or olive oil)
1 Tbs. mayonnaise
1 Tbs. butter
1 Tbs. peanut butter
1/4 avocado
1 Tbs. salad dressing

Eat 6-8 small meals a day or eat every few hours. Drink 6-8 glasses of water every day. Use salt to taste. Do not purposely limit salt. Your body requires salt. Avoid fast food, fried food, desserts, and junk food. Don't feed your baby things you shouldn't eat. Eliminate caffeine, nicotine, alcohol, and artificial sweeteners (no NutraSweet or Sweet & Low). You may use Splenda.

* Seafood Note: The Food and Drug Administration is urging pregnant and nursing women to avoid eating shark, swordfish, tilefish, and king mackerel to limit their exposure to mercury. According to some environment groups, mercury can harm a child's development. These groups also want the FDA to warn women against eating tuna steak, sea bass, Gulf Coast oysters, marlin, halibut, pike, walleye, and largemouth bass. Also, pregnant women should eat canned tuna no more than once a month.

In order to provide you with the most comprehensive ultrasound exam, we ask that you follow all of the instructions listed below. 

• Please silence your cell phone during the ultrasound procedure. 
• Please bring another adult with you to accompany any small children during the ultrasound procedure. 

An ultrasound examination is a painless procedure in which high frequency sound waves are used to visualize the pelvic organs. By using ultrasound, information is obtained about pelvic anatomy, fetal size and growth, fetal heart rate, placenta position, amniotic fluid volume, multiple pregnancy, major birth defects, and sometimes even the sex of the baby. Presently there is no known hazard from ultrasound to the mother or fetus. However, this is a relatively new field and additional long term studies may be required. Please review the following instructions.

• Obstetrical Patients (13 Weeks and Under)
  Please empty your bladder prior to your appointment. 
• Obstetrical Patients (Over 13 Weeks to Term)
  Please empty your bladder 1 1/2 hours prior to your appointment. Within the next 1/2 hour, drink three 8 oz. glasses of liquid other than milk and hold your bladder. You should be finished drinking liquid at least one hour before your appointment. Please do not empty your bladder until instructed to do so by ultrasonographer! 

Our office will be glad to file your ultrasound fee with your insurance company. If you have no insurance or your insurance company does not cover this procedure (in full or in part), you are responsible for the bill. If you have any questions regarding your coverage or payment, please ask our staff for assistance. 

PLEASE NOTE... If you wish to record your ultrasound, you will need to bring the following with you (depending upon the location of your appointment): 

Via OB/GYN - Community Hospital North Campus
You can bring a CD-R and/or DVD-R
7120 Clearvista Drive, Suite 5100
Indianapolis, Indiana 46256
Phone: 317.621.7120

Via OB/GYN - Fishers/Geist
This location's machine utilizes CD-R only
13121 Olio Road, Suite 220
Fishers, Indiana 46037
Phone: 317.621.7120

If you've been reluctant to talk to your friends or your doctor about your heavy periods, you
may not realize how common they are – or that you don't have to accept the limits heavy
periods can put on your lifestyle.

One effective treatment for heavy periods is a global endometrial ablation (GEA) procedure
called Gynecare Thermachoice® Uterine Balloon Therapy System. Gynecare Thermachoice is
an effective, non-hormonal, permanent treatment for heavy periods. It involves a minimally
invasive, eight-minute procedure that can be easily performed by either Dr. Hayes or Dr.
Lane in the Via OB/GYN Office.

A clinical study showed:

• 95% of women treated with Gynecare Thermachoice reported normal to no periods up to five years later
• Three out of four women treated had reduction of menstrual pain and cramping
• Nearly two out of three experienced either mild or no PMS symptoms after treatment
• 93% reported they were still satisfied with the results five years after treatment

How does Gynecare Thermachoice work?

Gynecare Thermachoice uses a method called global endometrial ablation (GEA) to remove the endometrium, the lining of the uterus by:

• A small, soft, flexible balloon attached to a thin catheter (tube) is first passed through the vagina and cervix, and then placed gently into the uterus. No incision is required. The balloon is made of silicone material, eliminating the risk of allergy for latex-sensitive women.
• The balloon is then filled with fluid so that it inflates to the unique
  contours of the uterus.
• The fluid is gently heated and circulated in the uterus for eight minutes while the lining of the uterus is treated.
• When the treatment is completed, all the fluid is withdrawn from the balloon and the catheter is removed. Nothing remains in the uterus. The treated uterine lining will shed, like during a period, over the next seven
  to ten days.

In most cases, patients can resume normal activities the next day. To learn more about this procedure, please visit the Gynecare Thermachoice Website or contact us to make an appointment. Remember you don't have to live with heavy periods.

Gynecare Thermachoice is registered by ETHICON Women's Health & Urology, a division of ETHICON, INC., a Johnson & Johnson Company

Pregnancy Due Date Calculator

Find out when the big day will be! The Community Health Network's Calculator will help you determine your pregnancy due date. Simply enter the date of your last period to calculate your estimated due date!

Pregnancy Week-by-Week Calendar

• To start your first package of birth control pills, begin taking your pills on the Sunday following the first day of your menstrual period, even if you are still on your period. If your period begins on Sunday and you are sure it is a normal period, take your first pill on that day. There are 28 pills in your package, so you will take your last pill on Saturday and begin a new pack the very next day on Sunday.
• Take your pills in order, one pill a day at the same time each day to keep the hormones at the same level. You might find it helpful to associate taking your pill with something else you do at the same time every day, like eating a meal or brushing your teeth.
• When you first start taking birth control pills, you are not protected from pregnancy until you have taken 2 weeks of pills. Therefore, for the first 2 weeks, you should use a backup method of birth control (foam and condoms, or condoms and sponges), or you should abstain from having intercourse.
• While you are taking birth control pills, you might find that your period is lighter, somewhat different in color, or shorter in the number of days.
• Severe diarrhea, vomiting, and some prescription medications might change the effectiveness of your birth control pills. If you experience one of these conditions and have breakthrough bleeding, you may not be protected from pregnancy. Use a backup method of birth control until your next period.
• Remember that birth control pills are a prescription medication. If you are hospitalized or seen by a doctor, you need to be sure they are aware that you are taking birth control pills.

You must learn the following pill danger signs:

• Severe abdominal pain
• Severe chest pain or shortness of breath
• Severe headaches
• Severe leg pain in the calf or thigh
• Eye problems (blurred vision or blindness)

What to do if...

• I have bleeding or spotting between my periods?
  This condition is called breakthrough bleeding. It is not serious and might occur while you are taking your first few package of pills.
• I feel nauseated after taking my pills?
  Sometimes people experience nausea if they take pills on an empty stomach. You might want to change your schedule to take your pill with a meal or to eat a snack when you take your pill.
• I miss a period?
  If you have taken a pill at the same time every day and you miss a period, DO NOT WORRY. This might happen from time to time. However, if you have not taken your pills at the same time each day or if you miss TWO periods, call to make arrangements for a pregnancy test and pelvic examination.
• I miss two pills in a row during the first two weeks?
  Take two pills on the day you remember, and take two pills again the next day. Then take one pill per day until the pack is finished. Use a backup method of contraception (preferable condoms plus foam) until the package is finished.

Phone requests for refills of routine medication may be left on voice mail by calling our office and letting our office staff know that you need a prescription refill. With your request, please be prepared to leave the following information:

• Your Name
• Your Birth Date
• Prescription Name and Spelling
• Dosage
• Pharmacy Name
• Pharmacy Phone Number
• Phone Number Where You Can Be Reached

In order to provide you with the most comprehensive ultrasound exam, we ask that you follow all of the instructions listed below:

• Please silence your cell phone during the ultrasound procedure.
• Please bring another adult with you to accompany any small children during the ultrasound procedure.
• An ultrasound examination is a painless procedure in which high frequency sound waves are used to visualize the pelvic organs. By using ultrasound, information is obtained about pelvic anatomy.

Presently there is no known hazard from ultrasound. However, this is a relatively new field and additional long term studies may be required. Please review the following instructions:

• Infertility Patients please empty your bladder prior to your appointment.
• Gynecological Patients please empty your bladder prior to your appointment.

Our office will be glad to file your ultrasound fee with your insurance company. If you have no insurance or your insurance company does not cover this procedure (in full or in part), you are responsible for the bill. If you have any questions regarding your coverage or payment, please ask our staff for assistance.

Via OB/GYN - Community Hospital North
Campus7120 Clearvista Drive, Suite 5100
Indianapolis, Indiana 46256
Phone: 317.621.7120

Via OB/GYN - Fishers/Geist
13121 Olio Road, Suite 220
Fishers, Indiana 46037
Phone: 317.621.7120

The da Vinci® Surgical System is powered by state-of-the-art robotic
technology. It is the most effective, least invasive, and least expensive
surgical treatment option available today. The system allows Dr. Hayes and
Dr. Lane's hand movements to be scaled, filtered, and translated into precise
movements of micro-instruments within the operative site. The magnified,
three-dimensional view the surgeon experiences enables her to perform
precise surgery in complex procedures, such as hysterectomy and myomectomy, through small surgical incisions providing more increased accuracy and faster patient recovery.

The da Vinci System enhances the surgical capabilities of Dr. Hayes and Dr. Lane by
enabling the performance of complex surgeries. The system cannot be programmed
nor can it make decisions on its own. The da Vinci System requires that every
surgical maneuver be performed with direct input from your surgeon.

The da Vinci Surgical System has been successfully used in thousands of procedures
worldwide, including hysterectomy and myomectomy. For more information on this
amazing treatment offered by Via OB/GYN, please visit eCommunity.com.

Essure is a permanent birth control procedure that works with your body
to create a natural barrier against pregnancy. This gentle procedure can
be performed in our office by either Dr. Hayes or Dr. Lane, both trained
Essure Physicians, in less than an hour. This procedure and device has
been trusted by women and doctors for over five years, Essure is covered
by most insurance providers. Depending on your specific insurance plan,
payment may be as low as a simple co-pay.

Essure offers women what no birth control ever has:

• No cutting
• No going under general anesthesia
• No slowing down to recover
• No hormones
• No guessing - your doctor can confirm when you can rely on Essure for birth control
• Short procedure time - Essure only takes about 13 minutes to perform*
• Trusted by women and doctors for over five years
• And, you'll never have to worry about unplanned pregnancy again

The Essure Procedure is permanent and is NOT reversible. Therefore, you should be sure you do not want children in the future.

About The Essure Procedure

The Essure Procedure does not require any cutting into the body. Instead, Doctors Hayes and Lane, Essure-trained physicians, insert small flexible micro-inserts™ through the body's natural pathways (vagina, cervix, and uterus) and into your fallopian tubes.

The procedure can be performed in the comfort of our office without general anesthesia, and most women resume their normal activities within one day.

During the three months following the procedure, your body and the micro-inserts work together to form a natural barrier that prevents sperm from reaching the egg. During this period, you must continue using another form of birth control (other
than an IUD or IUS).

Three months after The Essure Procedure, an Essure Confirmation Test will be performed, to confirm that the tubes are fully blocked and that the women can rely
on Essure for permanent birth control.

Unlike birth control pills, patches, rings, and some forms of IUDs, Essure does not contain hormones to interfere with your natural menstrual cycle. Your periods
should more or less continue in their natural state.

Additional information about The Essure Procedure is available at www.essure.com
or by watching The Essure Procedure Informational Video. Please contact us at Via OB/GYN with any questions.

We want you to have an excellent experience with Via OB/GYN, a part of Community Physicians of Indiana.

Please contact us and let us know how satisfied you are. Tell us when you have had an excellent experience, when there is a problem, let us know how you feel, what you think about it, and what you want. We will work with you to resolve the problem as best we can and learn from the opportunities. In the event you wish to remain anonymous, we have a concern/complaint hotline you can call. That number is 1.800.638.5071.

Regardless of the communication method you use, we will respond to your concerns in a timely fashion. We do make changes to give better care. If you have brought your concern to our attention and would like an additional resource, you may always contact the Indiana Department of Health at 317.233.1325.

When you leave any of our medical offices, we hope you will say, "The care that I received was excellent!" In order to accomplish that, we want to be sensitive to your personal values and beliefs, as well as your unique cultural, ethnic, racial, and religious identity. Equally important, we want you to help us with your care. For example, if you are experiencing pain or discomfort, please let your caregiver know so we can attempt to alleviate it.

Information about your care is very private, and is protected by state and federal laws. We work hard to respect your privacy, while, at the same time, complying with the laws applicable to us. In most cases, it's up to you whether we give out your information. By using our consent form, you may request that information go to family members or friends involved in your care. Alternatively, you may request that information not be shared.

We pride ourselves on patient-focused medicine. But to do so, we need your help. Our caregivers are seeking to give all of our patients the same level of professional, personalized care that you can and should expect from us. We ask that you respect your caregivers and our other patients.

There are many ways that we will ask you to help us meet your health needs. We will need your complete health history, including all medications you are currently taking and any allergies that you have. We will need to know your current symptoms and we will want your input as we develop your plan of care.

You will be informed of the benefits, as well as any risks, of the treatment you will receive. There will be many ways that you can help with your health care. For example, your medications will be reviewed each time you visit one of our medical offices, so please make certain you have a current medication list with you.You may refuse treatment at any time during your care. Your health care provider will tell you what the health-related outcomes of your refusal might be. The responsibility for the outcomes due to your decision would, of course, be yours.

As a part of your care, we may want to refer you to another medical office or health care facility for care we do not provide. Or, you may want information about a referral to another service or care provider.

Again, please ask if you need more information about your care. If you are not satisfied with your options for treatment, we will respect your wish for a second opinion.

If you have questions about your health records, your physician can discuss these with you. If you want to know more about your care or your caregivers, please ask. Our financial advisors will answer your questions about your bill. Please take responsibility to pay your bill.

Via OB/GYN now has the H1N1 Vaccine available for our OB patients.
In order to meet the high demands of the H1N1 Vaccine, we will be
offering clinic hours each week on Thursdays and Fridays from 8:00
to 11:30 a.m. and 1:00 to 4:30 p.m.

All OB patients will need a separate appointment to receive the
vaccine. Please call our office at 317.621.7120 to schedule this
appointment. Due to limited supply, we are currently offering the
H1N1 Vaccine to our OB patients only.

It is expected that cases of H1N1 influenza will rapidly multiply in the U.S.
during the fall months. Unlike seasonal flu, the infected people
experiencing the highest complications with H1N1 flu are children and
young adults. Pregnant women (particularly those in the third trimester)
and infants are at very high risk of influenza-related difficulties. A recent report noted that one-third of pregnant women with confirmed cases of pandemic H1N1 were hospitalized, mostly with severe respiratory distress, and deaths of otherwise healthy pregnant women are being reported.

Additionally, it is quite possible for an individual to experience both seasonal influenza and H1N1 influenza simultaneously, or in tandem, with serious results. As people gather together for school and other activities, the likelihood of influenza transmission will increase.

It is for these reasons that The American College of Obstetricians and Gynecologists (ACOG) have joined with a coalition of prenatal health care providers, like Via OB/GYN, to urge pregnant women to take steps to prevent influenza by being vaccinated. All pregnant women are being advised to receive both the H1N1 immunization and immunization for seasonal flu.

In addition to vaccinations, it is important to take preventive steps against the flu: wash your hands frequently; use an alcohol-based antibacterial; try to avoid contact with sick people; avoid touching your face, mouth, eyes, or nose, as this is how germs are transmitted. If you are pregnant and have been in close contact with someone who has a confirmed case of H1N1, consult your physician immediately. If you have questions, please contact us at Via OB/GYN.

For the latest guidelines from the Centers for Disease Control and Prevention (CDC) for pregnant women, please visit www.cdc.gov/h1n1flu/pregnancy/. Also, please read the PDF "Take 3 Steps To Fight The Flu".

January is dedicated to raising awareness about the prevention of cervical cancer. Cervical cancer is currently the second-leading cause of cancer death among women worldwide. The good news is that most cases of cervical cancer can be prevented! From the Pap Smear to
the HPV vaccine, cervical cancer can be eradicated. So, here's to a healthy cervix in 2010!

1. Get a Pap Smear. Many women don't realize how important having a regular Pap Smear can be in preventing cervical cancer. 11% of United States women report that they do not have their Pap Smear screenings.

2. Follow your doctor's recommendations. In order to prevent cervical cancer, women must be proactive in their healthcare. Never leave the doctor's office until you have a complete understanding of the follow-up plan. Know the what's, when's, and why's of your plan!

3. Get vaccinated with the HPV vaccine. You may be wondering how a vaccine can help keep your cervix healthy. The HPV vaccine protects against common sub-strains of the human papillomavirus known to cause cervical cancer in women. Women infected with these high risk strains develop cervical dysplasia. When left unmonitored and untreated, high risk cervical dysplasia can develop into cervical cancer.

Who should not receive GARDASIL?

Anyone who:
is allergic to any of the ingredients in the vaccine. A list of ingredients can be found on the GARDASIL leaflet.
has an allergic reaction after getting a dose of the vaccine.

How is GARDASIL given?

GARDASIL is given as an injection. You or your child will receive 3 doses of the vaccine. Ideally the doses are given as:

• First dose: at a date you and your health care professional choose.
• Second dose: 2 months after the first dose.
• Third dose: 6 months after the first dose.

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.

This Notice describes privacy practices of Community Hospitals of Indiana, Inc.; The Indiana Heart Hospital; Community Hospital South; Indiana Surgery Centers; Indianapolis Endoscopy Center, LLC; Community Endoscopy Center, LLP; Community Physicians of Indiana, Inc.; MedCheck facilities; Community Home Health Services; and their affiliates, including: any employees; volunteers; health care professionals authorized to enter information into your health/medical records; and medical staff members (hereinafter referred to as Community Health Network or Network).

I. Our Duty to Safeguard Your Protected Health Information:

Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for your health care is considered "Protected Health Information" ("PHI"). We understand that medical information about you and your health is personal and we are committed to protecting medical information about you. We are required by law to make sure that your PHI is kept private and to give you this Notice about our legal duties and privacy practices, that explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the purpose of the use or disclosure.

We must follow the privacy practices described in this Notice, though we reserve the right to change the terms of this Notice at any time. We reserve the right to make new Notice provisions effective for all PHI we currently maintain or that we receive in the future. If we change this Notice, we will post a new Notice in patient registration and/or patient waiting areas. You may request a copy of the new notice from the Patient Access Department and it will also be posted on our website at www.eCommunity.com. We will also make available a copy of the Notice in effect each time you are admitted to the hospital as an inpatient or outpatient, or receive health care services from other health care providers within the Community Health Network, listed above.

II. How We May Use and Disclose Your Protected Health Information:

We use and disclose PHI for a variety of reasons. For certain uses/disclosures, we must get your written authorization. However, the law provides that we may make some uses/disclosures without your authorization. The following section offers more description and examples of our potential uses/disclosures of your PHI.

» Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations. Since we are an integrated system, we may share your PHI with designated staff within the Community Health Network, for treatment, payment or operations purposes. Generally, we may use/disclose your PHI:

• For treatment: We may disclose your PHI to doctors, nurses, and other health care personnel who are involved in providing your health care. For example, your PHI will be shared among members of your treatment team, our central pharmacy staff, or with a specialist to whom you have been referred. If you are an inpatient, your name may be posted outside the door of your room.
• To obtain payment: We may use/disclose your PHI in order to bill and collect payment for your health care services. For example, we may release portions of your PHI to Medicare/Medicaid, a private insurer or group health plan to get paid for services that we delivered to you. Release of your PHI to the state Medicaid agency might also be necessary to determine your eligibility for publicly funded services.
• For health care operations: We may use/disclose your PHI in the course of our operations. For example, we may use your PHI or your answers to a patient satisfaction survey in evaluating the quality of services provided by our staff, or disclose your PHI to our auditors or attorneys for audit or legal purposes. We may also share PHI with health care provider licensing bodies like the Indiana State Department of Health.
• Appointment reminders: Unless you provide us with alternative instructions, we may send appointment reminders and other similar materials to your home. We may also call your home and leave a message on your answering machine or voice mail. (See Section III about confidential communication.)
• Treatment alternatives: We may contact you about possible treatment options or alternatives, or other health-related benefits or services that may interest you.
• Fundraising: We or our Foundation may contact you to raise money for the Network and its operations, unless you tell us in writing not to contact you for this purpose.

» Uses and Disclosures Requiring Authorization: For uses and disclosures other than treatment, payment and health care operations purposes, we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. You may revoke an authorization, in writing, any time to stop future uses/disclosures. If you revoke your authorization, we will stop using/disclosing your PHI for the purposes or reasons covered by your written authorization. You understand that we are unable to take back disclosures we have already made with your permission. (See Section VI for instructions for revoking an authorization.) We cannot refuse to treat you if you refuse to sign an authorization to release PHI, unless services provided are solely to create health records for a third party, such as physical and drug testing for an employer or insurance company; or if treatment provided is research-related and authorization is required for the use of health information for research purposes. We will not use or disclose your PHI for marketing purposes without your authorization.

» Uses and Disclosures Not Requiring Authorization: The law provides that we may use/disclose your PHI without your authorization in the following circumstances:

• When required by law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, for FDA-regulated products or activities, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.
• For public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority, such as reports of tuberculosis cases or births and deaths.
• For health oversight activities: We may disclose PHI to the Indiana State Department of Health or other agencies responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents.
• Relating to decedents: We may disclose PHI relating to an individual's death to coroners, medical examiners, or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.
• For research purposes: In certain circumstances, and under supervision of our Institutional Review Board, we may disclose PHI in order to assist medical research, such as comparing the health and recovery of all patients who received one medicine to those who received another. Generally, we will ask you for your specific permission if the researcher will have access to your name, address and other PHI, or will be involved in your care.
• To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.
• Law enforcement: We may disclose PHI to a law enforcement official in circumstances such as: in response to a court order; to identify a suspect, witness or missing person; about crime victims; about a death that we may suspect is the result of criminal conduct; or criminal conduct at the hospital or health care facility.
• For specific government functions: We may disclose PHI of military personnel and veterans in certain situations; to correctional facilities in certain situations; and for national security and intelligence reasons, such as protection of the President.
• Workers' Compensation: We may disclose your PHI to your employer for Workers' Compensation or similar programs that provide benefits for work-related illness or injuries.
• Inmates: An inmate of a correctional institution does not have the rights listed in this Notice of Privacy Practices.

» Uses and Disclosures Requiring You to Have an Opportunity to Object: In the following situations, we may disclose your PHI if we tell you about the disclosure in advance and you have the opportunity to agree to, prohibit, or restrict the disclosure. However, if there is an emergency situation and you cannot be given the opportunity to agree or object, we may disclose your PHI if it is consistent with any prior expressed wishes and the disclosure is determined to be in your best interests. You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so.

» Patient Directories: If you are hospitalized, your name, location, general condition, and religious affiliation may be put into our patient directory for use by callers or visitors who ask for you by name and by clergy. If you ask to be a "No Information" patient, volunteers, employees, and telephone operators will not tell anyone that you are in the facility and flowers, mail, phone calls, and visitors will be turned away and not accepted if your room number is not provided.

» To families, friends, or others involved in your care: We may share with these people information directly related to your family's, friend's or other person's involvement in your care, or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or your death.

» Disaster relief: We may release your PHI to a public or private relief agency for purposes of coordinating notifying your family and friends of your location, condition or death in the event of a disaster.

III. Your Rights Regarding Your Protected Health Information:

You have the following rights relating to your protected health information:

• To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. You must make your request in writing. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. If agreed upon, these restrictions will only apply to the Community Health Network affiliates listed in the beginning of this Notice. You understand that we are not able to take back disclosures already made. We cannot agree to limit uses/disclosures that are required by law.
• To request confidential communication: You have the right to ask that we send you information at an alternative address or by an alternative means, such as contacting you only at work. You must make your request in writing. We must agree to your request as long as it is reasonably easy for us to do so.
• To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your protected health information if you put your request in writing. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed. You have a right to choose what portions of your information you want copied and to have information on the cost of copying in advance.
• To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in writing, that we correct or add to the record. Written requests must include a reason that supports your request. We will respond within 60 days of receiving 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. We may also deny your request if we determine that the PHI is: (1) correct and complete; (2) not created by us and/or not part of our records, or; (3) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial reviewed, along with any statement in response that you provide, added to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in the PHI.
• To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure for which you gave your written authorization. (This is called an accounting of disclosures.) Your request can relate to disclosures going as far back as six years. The list will not include any disclosures made: before April 14, 2003; for national security purposes; for treatment, payment or health care operations purposes; through a facility directory; or to law enforcement officials or correctional facilities. Your request must be in writing. We will respond to your written request for such a list within 60 days of receiving it. There will be no charge for the first list requested each year. There may be a charge for subsequent requests.
• To receive a paper copy of this Notice: You have a right to receive a paper copy of this Notice and/or an electronic copy by email upon request. To obtain a copy of this Notice, contact: one of the individuals identified in Section V. below.

IV. How to Complain About Our Privacy Practices:

If you think we may have violated your privacy rights, or if you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed in Section V. below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized if you file a complaint.

V. Contact Persons for Information or to Submit a Complaint:

If you have questions about this Notice or complaints about our privacy practices, please contact: Marti A. Baker, Network Privacy & Compliance Consultant, 8180 Clearvista Pkwy., Suite 101 Indianapolis, IN 46256, 317/621-7321; Mary Gamache, Privacy Official, The Indiana Heart Hospital, 8075 N. Shadeland Ave., Indianapolis, IN 46250, 317/621-8057; Gail Mahoney, Privacy Official, Community Home Health Services, 9894 E. 121st St., Fishers, IN 46038, 800/404-4852; or Jackie Smith, Network Privacy & Compliance Officer, Clearvista Pkwy., Suite 101 Indianapolis, IN 46256, 317/621-7324.

VI. Instructions for Revoking an Authorization:

You may revoke an authorization to use or disclose your PHI, in writing, except: 1) to the extent that action has been taken in reliance on the authorization, or 2) if the authorization was obtained as a condition of obtaining insurance coverage and other law provides the insurer with the right to contest a claim under the policy. Your written revocation must include the date of the authorization, the name of the person or organization authorized to receive the PHI, your signature and the date you signed the revocation, addressed to the contact person listed on your original authorization.

VII. Effective Date:

This Notice was effective on 4/14/03; updated on 10/15/04; updated on 1/1/05; updated on 1/21/05; updated on 3/30/07.

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