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Anthony Mathur, MB, BChir, FRCP, PhD

• Consultant Cardiologist
• Department of Cardiology
• The London Chest Hospital
• London, England

If you would like additional assistance with funeral home planning spasms to right side of abdomen discount zanaflex 2mg with amex, your Hospice social worker is available to help muscle relaxant list purchase zanaflex without a prescription. Wright Chapel) also affiliated with Cremation Society Northwest and Queen Anne Columbarium spasms 5 month old baby buy zanaflex mastercard, Seattle: 206 muscle relaxant herniated disc order zanaflex 2 mg with visa. Includes printable pamphlets on Medicaid programs muscle relaxant trade names zanaflex 4 mg cheap, Dealing with Death muscle relaxant of choice in renal failure purchase zanaflex american express, After Death Occurs: a Checklist, Washington Probate Instructions and Forms, and How to Claim the Personal Property of Someone Who has Died: Affidavit Procedure for Small Estates. The Comfort Kit includes a small supply of a few key medications that are effective for treating many symptoms. Although they are not the only medications used for comfort, they are the most commonly needed. The following provides an overview of symptom management, including pharmacologic and non pharmacologic methods for relieving your symptoms. Pain While pain can be both a physical sensation and an emotional experience, it is important for your Hospice team to understand and trust your report of pain. Only you can best describe the pain, its intensity and the effectiveness of various pain relief measures. If you cannot express your pain verbally or reliably, your hospice team will rely on nonverbal indicators of pain such as facial and body expressions, heart rate and respiratory rate. Using the same system for evaluating pain each time will indicate how your pain is changing. This helps to determine how much relief you are getting from your current dosage of pain medicine. No Slight Moderate Severe Worst Pain 0 1 2 3 4 5 6 7 8 9 10 If your pain score is consistently low, your pain management plan is working. If your pain score is consistently high, perhaps you need more medication, a different schedule, or a different medication. Often this means taking pain medication on a regular basis instead of simply as needed. If you wait too long to take your pain medication, the pain can potentially become so severe that the medication is no longer effective. Therefore, maintaining a regular medication schedule is the best means of managing pain. Remember, too, that once you become pain free its important to continue the medication schedule as directed by your physician. You may need medication in addition to that used for pain to help in the management of your overall comfort. Your Hospice nurse and attending physician will help you establish the best times to use the medications. The Appendix includes useful tools to help monitor your pain (see Appendix F) and track medications and symptoms (see Appendix G). Your hospice nurse, in partnership with your attending physician, will determine the most effective medications for treating your discomfort. Depending on the type and severity of your pain, your hospice nurse in collaboration with your attending physician may recommend this medication. Misconceptions about Pain Medications Im afraid I might get addicted to these medications. If you are concerned about addiction, just ask yourself the following question: If I didnt have pain, would I be taking this medication The reality is that symptoms of pain and distress can cause people to hang on (inhibiting the ability to let go from the body). When severe symptoms of discomfort are treated (and morphine is generally very effective for these symptoms) the person is able to experience a peaceful state, allowing him/her to let go of the physical body as a natural consequence of the disease process. Additionally, its important to know that the doses of morphine and type of morphine (usually oral liquid concentrate) commonly used in hospice care ensure minimal potential for harm. In fact, studies show that the use of morphine in hospice care neither hastens nor prolongs life. Hospice philosophy promotes managing your pain because this is fundamental to improving quality of life. The key is using the right medication at the right dose throughout the course of the illness. These include, but are not limited to , facial grimacing, restlessness, inability to sleep and irritability. Anxiety Anxiety tends to be a feeling involving worry or nervousness; it is a natural human response to real or perceived uncertainties or fears. However, when anxiety is prolonged and ongoing, it has the potential to impact an individuals quality of life and, at times, even their safety. Anxiety can often intensify the perception of an existing symptom, especially pain and shortness of breath. Signs of anxiety may include feeling tense, fearful of being alone, frequently asking for help from your family or caregivers, shortness of breath for no apparent reason, difficulty sleeping and inability to concentrate. If you are experiencing anxiety, consider: o Calling the Hospice 24-hour number to discuss your concerns. Sometimes having a caring professional present on the phone listening to you can have a therapeutic impact. Pharmacological Methods for Relieving Anxiety Lorazepam (Ativan) is included in your Comfort Kit and may be used as instructed by your physician and/or hospice nurse. In low doses this anti-anxiety medication is generally effective and well-tolerated. Anxiety is usually a feeling whereas agitation is an action typically involving constant movement such as pacing, frequently shifting positions, repeatedly trying to get out of bed, or fidgeting with bedding or clothing. Pharmacological Methods for Relieving Restlessness/Agitation Your Comfort Kit contains Haloperidol (Haldol) to help manage symptoms of restlessness. For example, some people report experiencing nausea upon taking the first few doses of morphine. This initial side effect usually subsides and often completely goes away with subsequent doses. When the movement of food in the intestines is slowed or blocked, theback up can generate the feeling of nausea. Pharmacological Methods for Relieving Nausea Your Comfort Kit contains Haloperidol (Haldol) to help manage symptoms of nausea. Your hospice nurse can help determine if other anti nausea medications may be appropriate for your situation. Constipation Constipation is taken very seriously because although in most people it only causes intermittent discomfort, it can lead to severe pain and discomfort if not managed proactively. Although opioid analgesics are generally considered the most effective medications for severe pain, they have a constipating side-effect. For this reason, taking a laxative concurrently with opioid pain medication is generally recommended. Pharmacological Methods for Relieving Constipation Your hospice nurse will be proactive in implementing bowel medication(s) in order to prevent severe constipation. Your Comfort Kit includes Bisacodyl suppositories; a Bisacodyl suppository is indicated when a patient has not had a bowel movement in three days and should only be used if directed by a Hospice nurse. Shortness of Breath When someone is having trouble breathing, the term shortness of breath is often used to describe this symptom. Other terms used to describe breathing trouble include air hunger or labored breathing. For example, diseases that affect the lungs or cardiac system may cause shortness of breath. Anxiety, in turn, increases the oxygen demands of the body which then worsens the shortness of breath. Treating both the shortness of breath and its associated anxiety helps to break this cycle. Pharmacological Methods for Relieving Shortness of Breath Use oxygen as instructed by the hospice nurse. Morphine is known for its pain-relieving benefits but it is also very effective in relieving shortness of breath. Diseases that directly impact the brain (such as dementia or certain cancers) may cause confusion; also diseases that affect the liver may lead to an accumulation of toxins in the brain, causing confusion. Pharmacological Methods for Relieving Hallucinations and/or Delusions Hallucinations and/or delusions may or may not cause distress to you or your family/caregivers. Intervention(s) may only be necessary if you are disturbed or a safety risk develops. If the underlying cause is treatable (such as a urinary tract infection) your Hospice team will help you evaluate the benefits of a treatment such as antibiotics. This medication should only be initiated if you are instructed by a hospice nurse or your attending physician. Contents of the Standard Comfort Kit For safety, keep these medications secure and only use as directed by your Hospice nurse. Consult your hospice nurse before starting any new medication and before making any changes in dosage or frequency. Symptom Comfort Kit Contents Quantity Directions Agitation & Haloperidol 2 mg/mL 15mL Take 0. Constipation Bisacodyl 10 mg Three Insert one suppository rectally once suppository suppositories daily as needed for constipation. Record the time and dosing any time Comfort Kit medications are used (see Appendix E for the Comfort Kit tracking sheet). How to Administer Lorazepam under the Tongue 1) Crush the tablet into a powder by pressing it between two teaspoons 2) Mix with 0. How to Set-up and Administer Liquid Morphine 1) Uncap the bottle and cut out the thick silver seal (this may require a sharp knife or scissors). If the person is unable to swallow, administer the medication into the cheek pocket. Below is information for caregivers about how to provide mouth care, bathing, changing an occupied bed, toileting and incontinence care, skin care and feeding. If the person you are caring for can cough and spit, it is generally safe to brush their teeth, but ask your Hospice nurse if you are unsure. To help prevent choking, make sure his/her head and torso are upright (in a sitting or standing position) even if they are unable to get out of bed. It can be difficult to be as thorough with another person as you would with yourself, but try to brush their teeth twice a day and as needed in between. Know that there are other methods for cleaning the mouth if brushing seems too difficult. Toothettes are small sponges on a stick that can be moistened with mouth wash and/or water and used to clean a persons mouth when brushing is difficult. Oral Care after Meals It is common for people to need their mouth cleaned after meals, especially if they are having a hard time swallowing and tend to hold food in their mouth (aka, pocketing). Pocketed food can create a choking hazard so it is important to check all areas of the mouth after meals and remove any uneaten food. Keeping the Mouth Moist As a persons illness progresses, losing ones appetite is common; some may stop eating or drinking entirely. The ability to swallow will diminish as well, so giving a drink of water is not always an option, yet keeping the mouth moist is an important comfort measure. When a patient is unable to swallow, too much water introduced into the mouth at once may create an aspiration risk. For this reason, squeeze the Toothette against the inside of the cup and get some of the excess water out before attempting this task. Bathing and Washing Face/Hands Bathing is important to maintain cleanliness and provide a sense of well-being. If the individual you are caring for can no longer bathe themselves, giving them a bed bath is a safe and effective way to keep them clean. Daily attention to this area is especially important since bacteria tend to collect there. If or when the person you care for is too weak to get out of bed, it is possible to change the linen while he/she remains in bed.

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The carpal tun nel is a passageway between the carpal bones and the exor retinacu lum on the palmar side of the wrist spasms just below ribs 2mg zanaflex overnight delivery. Although the cause of this disorder in a given individual is often unknown muscle spasms zoloft purchase zanaflex online pills, any swelling caused by acute or chronic trauma in the region can compress the median nerve muscle relaxant liver disease discount 2 mg zanaflex free shipping, which passes through the carpal tunnel back spasms 7 weeks pregnant discount zanaflex 4mg amex, thus bringing on the syndrome spasms right arm zanaflex 2 mg line. Ten don and nerve movement during prolonged repetitive hand movement and incursion of the exor muscles into the carpal tunnel during wrist extension have been hypothesized as causes for carpal tunnel syndrome (39 muscle relaxant guidelines order cheap zanaflex on line, 75). Workers at tasks requiring large handgrip forces, repetitive movements, or use of vibrating tools are particularly susceptible to carpal tunnel syndrome (69, 76). Likewise, of ce workers who repeatedly rest the arms on the palmar surface of the wrists are vulnerable. Research indicates that modications in keyboard design can dramatically affect tendon motion at the wrist, with promis ing implications for reducing the incidence of overuse injuries (74). The goal of workstation modications in preventing carpal tunnel syndrome is enabling work with the wrist in neutral position (22, 44). Carpal tunnel syndrome has also been reported among athletes in badminton, baseball, cycling, gymnastics, eld hockey, racquetball, rowing, skiing, squash, ten nis, and rock climbing (16). The glenohumeral joint is a loosely structured ball-and-socket joint in which range of movement is substantial and stability is minimal. The sternoclavicular joint enables some movement of the bones of the shoulder girdle, clavicle, and scapula. Movements of the shoulder girdle contribute to optimal positioning of the glenohumeral joint for different humeral movements. Small movements are also provided by the acromioclavicular and coracoclavicular joints. Pronation and supination of the forearm occur at the proximal and distal radioulnar joints. The structure of the condyloid joint between the radius and the three carpal bones controls motion at the wrist. The joints of the hand at which most move ments occur are the carpometacarpal joint of the thumb, the metacarpo phalangeal joints, and the hinges at the interphalangeal articulations. Construct a chart listing all muscles crossing the glenohumeral joint according to whether they are superior, inferior, anterior, or posterior to the joint center. Construct a chart listing all muscles crossing the elbow joint according to whether they are medial, lateral, anterior, or posterior to the joint center with the arm in anatomical position. Construct a chart listing all muscles crossing the wrist joint according to whether they are medial, lateral, anterior, or posterior to the joint center with the arm in anatomical position. Identify the action or actions performed by muscles in each of the four categories. List the muscles that develop tension to stabilize the scapula during each of the following activities: a. List the muscles used as agonists, antagonists, stabilizers, and neu tralizers during the performance of a push-up. Explain how the use of an overhand as compared to an underhand grip affects an individuals ability to perform a pull-up. Select a familiar activity and identify the muscles of the upper ex tremity that are used as agonists during the activity. Which of the three segments in Problem 8 creates the largest torque about the shoulder when the arm is horizontally extended Explain your answer and discuss the implications for positioning the arm for shoulder-level tasks. Identify the sequence of movements that occur at the scapulothoracic, shoulder, elbow, and wrist joints during the performance of an over hand throw. Which muscles are most likely to serve as agonists to produce the movements identied in your answer to Problem 1 Select a familiar racket sport and identify the sequence of movements that occur at the shoulder, elbow, and wrist joints during the execution of forehand and backhand strokes. Which muscles are most likely to serve as agonists to produce the movements identied in your answer to Problem 3 Select ve resistance-based exercises for the upper extremity, and identify which muscles are the primary movers and which muscles assist during the performance of each exercise. Discuss the importance of the rotator cuff muscles as stabilizers of the glenohumeral joint and movers of the humerus. How much tension (Fm) must be supplied by the triceps to stabilize the arm against an external force (Fe) of 200 N, given dm 5 2 cm and de 5 25 cm What are the sizes of the rotary and stabilizing components of muscle force when the total muscle force is 500 N Be able to locate and identify the major bones, muscle attachments, and ligaments. Colas F, Nevoux J, and Gagey O:the subscapular and subcoracoid bursae: Descriptive and functional anatomy, J Shoulder Elbow Surg 13:454, 2004. Dayanidhi S, Orlin M, Kozin S, Duff S, and Karduna A: Scapular kinemat ics during humeral elevation in adults and children, Clin Biomech 20:600, 2005. Edelson G and Teitz C: Internal impingement in the shoulder: J Shoulder Elbow Surg 9:308, 2000. Endo K, Yukata K, and Yasui N: Inuence of age on scapulo-thoracic orienta tion, Clin Biomech 19:1009, 2004. Fagarasanu M, Kumar S, and Narayan Y: Measurement of angular wrist neu tral zone and forearm muscle activity, Clin Biomech 19:671, 2004. Ferretti A, Cerullo G, and Russo G: Subscapular neuropathy in volleyball players, J Bone Joint Surg 69-A:260, 1987. Goldberg B and Boiardo R: Proling children for sports participation, Clin Sports Med 3:153, 1984. In Hadler N, ed: Clinical concepts in regional musculoskeletal illness, Orlando, 1988, Grune and Stratton. Hurschler C, Wulker N, and Mendila M:the effect of negative intraarticular pressure and rotator cuff force on glenohumeral translation during simulated active elevation, Clin Biomech 15:306, 2000. Meister K: Internal impingement in the shoulder of the overhand athlete: pathophysiology, diagnosis, and treatment, Am J Orthop 29:433, 2000. Paraskevas G, Papadopoulos A, Papaziogas B, Spanidou S, Argiriadou H, and Gigis J: Study of the carrying angle of the human elbow joint in full extension: a morphometric analysis, Surg Radiol Anat 26:19, 2004. Prescher A: Anatomical basics, variations, and degenerative changes of the shoulder joint and shoulder girdle, Eur J Rad 35:88, 2000. Shiri R, Miranda H, Heliovaara M, and Viikari-Juntura E: Physical work load factors and carpal tunnel syndrome: a population-based study, Occup Environ Med 66:368, 2009. Reviews the research on pitching mechanics as related to elbow injuries in youth baseball pitcers. Includes a major section on the upper extremity with separate chapters on the shoulder, elbow and forearm, wrist, and hand, with full color illustrations and detailed descriptions of anatomy, muscle attachments, and innervations. Chapters on the shoulder, elbow, and wrist present detailed anatomical descrip tions, common injury mechanisms, and radiographs illustrating these. Identify factors infuencing the relative mobility and stability of lower-extremity articulations. Explain the ways in which the lower extremity is adapted to its weight-bearing function. Describe the biomechanical contributions to common injuries of the lower extremity. In contrast, the lower extremity is well equipped for its functions of weight bearing and locomo tion. Beyond these basic functions, activities such as kicking a eld goal in football, performing a long jump or a high jump, and maintaining bal ance en pointe in ballet reveal some of the more specialized capabilities of the lower extremity. This chapter examines the joint and muscle func tions that enable lower-extremity movements. The ball is the head of the femur, which forms approximately two-thirds of a sphere. The socket is the concave acetabulum, which is angled obliquely in an anterior, lateral, and inferior direction. The cartilage on the acetabulum is thicker around its periphery, where it merges with a rim, or labrum, of brocartilage that contributes to the sta bility of the joint. Hydrostatic pressure is greater within the labrum than outside of it, contributing to lubrication of the joint (31). The acetabu lum provides a much deeper socket than the glenoid fossa of the shoulderthe lower extremity is well joint, and the bony structure of the hip is therefore much more stable or structured for its functions less likely to dislocate than that of the shoulder. Tension in these stable than the shoulder because major ligaments acts to twist the head of the femur into the acetabulum of bone structure and the during hip extension, as when a person moves from a sitting to a standing number and strength of the position. Inside the joint capsule, the ligamentum teres supplies a direct muscles and ligaments crossing attachment from the rim of the acetabulum to the head of the femur. As with the shoulder joint, several bursae are present in the surround ing tissues to assist with lubrication. Iliofemoral (Y) ligament Iliofemoral ligament Pubofemoral ligament Ischium Ischium Femur Femur Ischiofemoral ligament Anterior view Posterior view bursa and the deep trochanteric bursa. The iliopsoas bursa is positioned between the iliopsoas and the articular capsule, serving to reduce the friction between these structures. The deep trochanteric bursa provides a cushion between the greater trochanter of the femur and the gluteus maximus at the site of its attachment to the iliotibial tract. The trochan teric bursae vary in number, position, and appearance among older individuals, suggesting that these bursae are formed to lessen friction between the greater trochanter and the gluteus maximus (24). The femur is a major weight-bearing bone and is the longest, largest, and strongest bone in the body. Its weakest component is the femoral neck, which is smaller in diameter than the rest of the bone, and weak internally because it is primarily composed of trabecular bone. The femur angles medially downward from the hip during the support phase of walking and running, enabling single-leg support beneath the bodys center of gravity. The pelvis facilitates positioning of the hip joint movement of the femur by rotating so that the acetabulum is positioned toward the direction of impending femoral movement. For example, poste rior pelvic tilt, with the anterior superior iliac spine tilted backward with respect to the acetabulum, positions the head of the femur in front of the hipbone to enable ease of exion. Likewise, anterior pelvic tilt promotes femoral extension, and lateral pelvic tilt toward the opposite side facili tates lateral movements of the femur. Movement of the pelvic girdle also coordinates with certain movements of the spine (see Chapter 9). Muscles of the Hip A number of large muscles cross the hip, further contributing to its stabil ity. The locations and functions of the muscles of the hip are summarized in Table 8-1. Iliac crest Ilium Sacrum Psoas Sacrum Iliacus major Ischium Ischium Femur Femur Anterior view a two-joint muscle active during both hip exion and knee extension, it functions more effectively as a hip exor when the knee is in exion, as when a person kicks a ball. Crossing from the superior anterior iliac spine to the medial tibia just below the tuberosity, the sartorius is the longest muscle in the body. The the biceps femoris, gluteus maximus is a massive, powerful muscle that is usually active only semimembranosus, and semitendinosus when the hip is in exion, as during stair climbing or cycling, or when extension at the hip is resisted 8-6). These two-joint muscles contribute to the position of the other joint both extension at the hip and exion at the knee, and are active during stretches the muscle slightly. Biceps Semimembranosus femoris Semitendinosus Posterior view Abductionthe gluteus medius is the major abductor acting at the hip, with the glu teus minimus assisting. These muscles stabilize the pelvis during the support phase of walking and running and when an individual stands on one leg. This allows the left leg to move freely swing phase of gait to prevent through the swing phase. The hip abductors are also active during the performance of dance movements such as the grande ronde jambe. Adductionthe hip adductors are those muscles that cross the joint medially and include the adductor longus, adductor brevis, adductor magnus, and grac ilis 8-7). The hip adductors are regularly active during the swing phase of the gait cycle to bring the foot beneath the bodys center of grav ity for placement during the support phase. The other three adductor muscles also contribute to exion and lat eral rotation at the hip, particularly when the femur is medially rotated. These are the piriformis, and medial rotation of the femur gemellus superior, gemellus inferior, obturator internus, obturator exter occur in coordination with pelvic nus, and quadratus femoris 8-8). The major medial rotator of the femur is the gluteus minimus, with assistance from the tensor fascia latae, semitendinosus, semimembrano sus, and gluteus medius. Medial rotation of the femur is usually not a resisted motion requiring a substantial amount of muscular force. The medial rotators are weak in comparison to the lateral rotators, with the estimated strength of the medial rotators only approximately one-third that of the lateral rotators (57).

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Typically, when accessing care outside our service area, you will obtain care from healthcare providers that have a contractual agreement. In some instances, you may obtain care from non-participating healthcare providers. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers. Whenever you access covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: the billed covered charges for your covered services; or the negotiated price that the Host Blue makes available to us. Often, this negotiated price will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over or underestimation of modifications of past pricing for the types of transaction modifications noted above. However, such adjustments will not affect the price we use for your claim because they will not be applied retroactively to claims already paid. Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any state laws mandate other liability calculation methods, including a surcharge, we would then calculate your liability for any covered healthcare services according to applicable law. In these situations, you may be liable for the difference between the amount that the non-participating healthcare provider bills and the payment we will make for the covered services as set forth in the State of Delaware contract. Allowable Charge:the price Highmark Delaware determines is reasonable for care or supplies. See "Allowable Charge Calculations Under the BlueCard Program" in General Conditions for more information. Birthing Center: Maternity centers that monitor normal pregnancies and perform deliveries. The Limit does not include: copayments, if any amounts over the allowable charge charges for non-covered care Consultation: An interview or exam by a doctor other than the doctor treating you. Non-Acute Hospitals must be approved by: Highmark Delaware the appropriate state or local agency (if required by law) Such hospitals charge for their care and receive payments from patients. Inpatient: A person in a hospital, skilled nursing home or other facility for an overnight stay. Inpatient Withdrawal Management: Services that are provided in an appropriately licensed Residential Treatment Facility, acute care general, psychiatric or specialty hospital for the purpose of completing a medically safe withdrawal from substances. Such services must be rendered by a mental health professional licensed or certified by the State Board of Licensing or a drug and alcohol counselor who has been certified by the Delaware Certified Alcohol and Drug Counselors Certification Board, or in a mental health facility licensed by the State or in a treatment facility approved by the Department of Health and Social Services or the Bureau of Alcoholism and Drug Abuse. Intensive Outpatient Programs: Medical, nursing, and therapeutic Outpatient services delivered on a structured and predetermined schedule to those patients determined as requiring more intensive levels of treatment than those typically available through traditional outpatient alcohol and/or drug abuse programs. Such Outpatient services must be rendered by a mental health professional licensed or certified by the State Board of Licensing or a drug and alcohol counselor who has been certified by the Delaware Certified Alcohol and Drug Counselors Certification Board, or in a mental health facility licensed by the State or in a treatment facility approved by the Department of Health and Social Services or the Bureau of Alcoholism and Drug Abuse. Network Provider also means any provider available to the Insured through the National Blue Cross Blue Shield BlueCard network. Participating Provider: A provider with a Highmark Delaware participating contract. Participating providers will not bill you over the allowable charge for a covered service. Pharmacopoeia or National Formulary, and approved by the Food & Drug Administration Provider:the organization or person giving care, supplies or drugs. Reopening Period/Open Enrollment Period:the time when you may make changes to your coverage. Residential Treatment Facility: A Facility Provider, which for compensation by its patients, is primarily engaged in providing intensive, structured psychological services, either directly by or under the supervision of a medical professional, to treat behavioral, emotional, mental, or psychological problems. This Facility must also meet the minimum standards set by appropriate government agencies. Spouse: A person to whom you are married or partnered in a civil union, pursuant to the laws of the State of Delaware. Substance Abuse Treatment Facility: A Facility Provider which, for compensation from its patients, is primarily engaged in providing detoxification and/or rehabilitation treatment for alcohol abuse and/or drug abuse. This facility must also meet the minimum standards set by appropriate government agencies. This Notice describes our privacy practices, which include how we may use, disclose, collect, handle, and protect our members protected health information. We are required by applicable federal and state laws to maintain the privacy of your protected health information. We are also required to notify affected individuals following a breach of unsecured health information. We will inform you of these practices the first time you become a Highmark Delaware customer. We must follow the privacy practices that are described in this Notice as long as it is in effect. This Notice becomes effective September 23, 2013, and will remain in effect unless we replace it. On an ongoing basis, we will review and monitor our privacy practices to ensure the privacy of our members protected health information. Due to changing circumstances, it may become necessary to revise our privacy practices and the terms of this Notice. We reserve the right to make the changes in our privacy practices and the new terms of our Notice will become effective for all protected health information that we maintain, including protected health information we created or received before we made the changes. Before we make a material change in our privacy practices, we will change this Notice and notify all affected members in writing in advance of the change. Any change to this notice will be posted on our website and we will further notify you of any changes in our annual mailing. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. Uses and Disclosures of Protected Health Information In order to administer our health benefit programs effectively, we will collect, use and disclose protected health information for certain of our activities, including payment and health care operations. Uses and Disclosures of Protected Health Information for Payment and Health Care Operationsthe following is a description of how we may use and/or disclose protected health information about you for payment and health care operations: Payment We may use and disclose your protected health information for all activities that are included within the definition of payment as set out in 45 C. We have not listed in this Notice all of the activities included within the definition of payment, so please refer to 45 C. Health Care Operations We may use and disclose your protected health information for all activities that are included within the definition of health care operations as set out in 45 C. We have not listed in this Notice all of the activities included within the definition of health care operations, so please refer to 45 C. In connection with our payment and health care operations activities, we contract with individuals and entities (called business associates) to perform various functions on our behalf or to provide certain types of services (such as member service support, utilization management, subrogation, or pharmacy benefit management). To perform these functions or to provide the services, business associates will receive, create, maintain, use, or disclose protected health information, but only after we require the business associates to agree in writing to contract terms designed to appropriately safeguard your information. In addition, we may use or disclose your protected health information to assist health care providers in connection with their treatment or payment activities, or to assist other covered entities in connection with certain of their health care operations. For example, we may disclose your protected health information to a health care provider when needed by the provider to render treatment to you, and we may disclose protected health information to another covered entity to conduct health care operations in the areas of quality assurance and improvement activities, or accreditation, certification, licensing or credentialing. Other Possible Uses and Disclosures of Protected Health Information In addition to uses and disclosures for payment and health care operations, we may use and/or disclose your protected health information for the following purposes. To Plan Sponsors We may disclose your protected health information to the plan sponsor of your group health plan to permit the plan sponsor to perform plan administration functions. For example, a plan sponsor may contact us regarding a members question, concern, issue regarding claim, benefits, service, coverage, etc. Required by Law We may use or disclose your protected health information to the extent that federal or state law requires the use or disclosure. Department of Health and Human Services upon request for purposes of determining whether we are in compliance with federal privacy laws. Public Health Activities We may use or disclose your protected health information for public health activities that are permitted or required by law. For example, we may use or disclose information for the purpose of preventing or controlling disease, injury, or disability. Health Oversight Activities We may disclose your protected health information to a health oversight agency for activities authorized by law, such as: audits; investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Oversight agencies seeking this information include government agencies that oversee: (i) the health care system; (ii) government benefit programs; (iii) other government regulatory programs; and (iv) compliance with civil rights laws. Abuse or Neglect We may disclose your protected health information to a government authority that is authorized by law to receive reports of abuse, neglect, or domestic violence. For example, we may disclose your protected health information in response to a subpoena for such information. Law Enforcement Under certain conditions, we also may disclose your protected health information to law enforcement officials. For example, some of the reasons for such a disclosure may include, but not be limited to: (1) it is required by law or some other legal process; or (2) it is necessary to locate or identify a suspect, fugitive, material witness, or missing person. Coroners, Medical Examiners, Funeral Directors, and Organ Donation We may disclose protected health information to a coroner or medical examiner for purposes of identifying a deceased person, determining a cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We also may disclose, as authorized by law, information to funeral directors so that they may carry out their duties. Further, we may disclose protected health information to organizations that handle organ, eye, or tissue donation and transplantation. Research We may disclose your protected health information to researchers when an institutional review board or privacy board has: (1) reviewed the research proposal and established protocols to ensure the privacy of the information; and (2) approved the research. To Prevent a Serious Threat to Health or Safety Consistent with applicable federal and state laws, we may disclose your protected health information if we believe that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Military Activity and National Security, Protective Services Under certain conditions, we may disclose your protected health information if you are, or were, Armed Forces personnel for activities deemed necessary by appropriate military command authorities. If you are a member of foreign military service, we may disclose, in certain circumstances, your information to the foreign military authority. We also may disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, and for the protection of the President, other authorized persons, or heads of state. Inmates If you are an inmate of a correctional institution, we may disclose your protected health information to the correctional institution or to a law enforcement official for: (1) the institution to provide health care to you; (2) your health and safety and the health and safety of others; or (3) the safety and security of the correctional institution. Workers Compensation We may disclose your protected health information to comply with workers compensation laws and other similar programs that provide benefits for work-related injuries or illnesses. Others Involved in Your Health Care Unless you object, we may disclose your protected health information to a friend or family member that you have identified as being involved in your health care. We also may disclose your information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. If you are not present or able to agree to these disclosures of your protected health information, then we may, using our professional judgment, determine whether the disclosure is in your best interest. Underwriting We may disclose your protected health information for underwriting purposes; however, we are prohibited from using or disclosing your genetic information for these purposes. Providers that do not provide services to you will not have access to your information. Information may be provided to others as necessary for referral, consultation, treatment or the provision of other healthcare services, such as pharmacy or laboratory services. Required Disclosures of Your Protected Health Informationthe following is a description of disclosures that we are required by law to make: A. Department of Health and Human Services We are required to disclose your protected health information to the Secretary of the U. Disclosures to You We are required to disclose to you most of your protected health information that is in a designated record set (defined below) when you request access to this information. We also are required to provide, upon your request, an accounting of many disclosures of your protected health information that are for reasons other than payment and health care operations. Other Uses and Disclosures of Your Protected Health Information Sometimes we are required to obtain your written authorization for use or disclosure of your health information. Used by the person who created the psychotherapy note for treatment purposes, or b. Used or disclosed for the following purposes: (i) the providers own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint family or individual counseling; (ii) for the provider to defend itself in a legal action or other proceeding brought by an individual that is the subject of the notes; (iii) if required for enforcement purposes; (iv) if mandated by law; (v) if permitted for oversight of the provider that created the note, (vi) to a coroner or medical examiner for investigation of the death of any individual in certain circumstances; or (vii) if needed to avert a serious and imminent threat to health or safety. Other uses and disclosures of your protected health information that are not described above will be made only with your written authorization. If you provide us with such an authorization, you may revoke the authorization in writing, and this revocation will be effective for future uses and disclosures of protected health information.

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