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OurCodeofEthicalBehavior

DearTannerHealthSystemColleague,

Tannerstrivestoprovidehigh-qualityhealthcareserviceswithinourresourcecapabilities.Wealsostrivetodeliverhealthcarecompassionatelyandtoactwithabsoluteintegrityinthewaywedoourworkandthewayweliveourlives.Therefore,wedevelopedacomprehensivevaluesbasedcomplianceprogram.

OurCodeofEthicalBehaviorreflectsthevaluesthatguideouractions.NoCodeofEthicalBehaviorcansubstituteforeachperson'sinternalsenseoffairness,honestyandintegrity.Therefore,ifyouhaveanyquestionsregardingthiscodeorbelievethatasituationviolatestheprovisionsofthiscode,pleasedonothesitatetoconsultyoursupervisor,amemberofthemanagementteam,theComplianceofficeortheCompliancehotline.

Weaskyoutoassistusinourcontinuedjourneyfrom"goodtogreat."

LoyHowardPresidentandCEO,TannerMedicalCenter,Inc.,andTannerMedicalCenterAlabama,Inc.

INTEGRITYshallneverbeII

OurCodeofEthicalBehavior

MISSION Toprovidequalityhealthcareserviceswithinourresourcecapabilities;toserveasaleaderinacollaborativeeffortwiththecommunityinprovidinghealtheducation,supportservices,andcareforallcitizens.

Everyplan,decisionandactionshallbeguidedbythesevalues:

1.RecognizethatourCUSTOMERScomefirst.

2.EDUCATIONwillbeencouraged,supportedandmadeavailable.Ifwearetofulfillourdreamsandreachourpotential,wemustallbelifetimelearners.

3.TEAMWORKisthebasisofourorganizationalstructure.

4.IndividualandcorporateINTEGRITYshallneverbecompromised.

5.ImprovingQUALITYmustalwaysbeourfocus.

6.OurrelationshipswithoneanothershallbefoundedonmutualRESPECT.

7.ThefoundationofeverythingwedoisCARINGforpeople.

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TABLEOFCONTENTS

IntroductionandPurpose....................................................2Everyone’sResponsibilities...................................................2Leadership’sResponsibilities.................................................3Physician’sResponsibilities.................................................4BusinessAssociates’Responsibilities.........................................4Hotline....................................................................5

CONTENTSPatientRights.....................................................................................................................6ProtectionofClinicalDecisionMaking...............................................................................6PatientReferrals/PhysicianArrangements........................................................................7ConfidentialInformation....................................................................................................8Billing..................................................................................................................................9FinancialRecords.............................................................................................................10PersonalUseofTannerHealthSystemProperty.............................................................10AdvertisingandMarketing ..............................................................................................11ConflictofInterest...........................................................................................................12GiftsandGratuities..........................................................................................................12Anti-trustLaws.................................................................................................................13EnvironmentalLaws.........................................................................................................13SafetyandHealth.............................................................................................................14EqualEmploymentOpportunity......................................................................................14PaymentstoGovernmentOfficials..................................................................................15GovernmentRequests.....................................................................................................15ComplianceAcknowledgement.......................................................................................16

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IndividualandcorporateINTEGRITYshallneverbecompromised.TheTannerMedicalCenter,Inc.,BoardofDirectorsandTannerMedicalCenterAlabama,Inc.,BoardofDirectorspublishthisCodeofEthicalBehavior(Code)toprovideguidancetoallofourTannerHealthSystemcolleaguesandaffiliatestoensurethatwemeetourethicalstandardsandcomplywithapplicablelawsandregulations.Wehaveconfidenceintheloyaltyandintegrityofourhealthcareteam.Weexpectourdirectors,managers,employees,affiliatedphysicians,contractors,consultantsandvendorstousetheseguidelinestocarryouttheirdailyactivities.

Thisbookletisdesignedtobecomprehensiveyeteasytounderstand.Itisoneofseveraltoolsavailabletohelpyouperformyourjob—professionallyandethically.OurCodeassistseveryonein:

§ Avoidingboththefactandtheappearanceofimproperactivities§ Assuringthatallapplicableregulationsandlawsarefollowedappropriately

Often,asubjectmayneedadditionalguidance.WedevelopedacomprehensiveComplianceResourceCenterlocatedonourinternalwebsite,tanner@work.ThebelowpoliciesexpandontheprinciplesexpressedinourCodeofEthicalBehavior.§ HIPAApolicies§ Patientrightsandresponsibilitiespolicies§ Determiningeligibilityforindigentcharitycare§ Freedomofchoice§ Billing, charging andcollectionpolicies§ Identificationofnon-allowableexpensesforcostreports

Everyone’sResponsibilityTeamworkisthebasisofourorganizationalstructure.

Everyonewilldisplaygoodjudgementandhighethicalstandardsintheirbusinessdealings.TheTannerHealthSystemCodeofEthicalBehaviorisdesignedtoeducateanddeterwrongdoing. AllTanner HealthSystemoperationsmustbeconductedwithhonesty, fairnessandintegrity. Pleaserememberthatthe foundationofeverythingwedoiscaringforpeople.

AllTannerHealthSystemcolleaguesandaffiliatesareobligatedtoperformtheirdutieswithintheprescribedlimitsoftheTannerHealthSystemEthicsandComplianceProgram. Itiseveryone’sresponsibilitytoreportanyconcernsorviolationsofthesepoliciestoany oneofthefollowing:

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§ Immediatesupervisor§ ComplianceOfficerValorieComley(770.812.8159)§ ComplianceHotline(1.800.648.1507) § PrivacyOfficerTerriLee(770.812.9602)§ MECchair

Failuretocomplywiththeseprovisionsmayresultin:§ Disciplinaryaction§ Terminationofemployment§ Revocationofprivileges§ Civilpenalties§ Criminalcharges§ Monetaryfines§ LossofconfidenceinTannerHealthSystem'sintegrity

Ourrelationshipwithoneanothershallbefoundedonmutualrespect.

TannerHealthSystem’sleadershipisexpectedtocreateanenvironmentwhereallcolleaguesfeelfreetoraiseconcernsandaskquestions.Managementensuresthatthepersonneltheysuperviseunderstandsandcomplieswiththehighstandardsofbusinessconductestablishedbythesepolicies.TheComplianceOfficeandallmanagementpersonnelareresponsibleformaintainingprogramstofamiliarizeemployeesandotherpersonnelwithmattersrelatingtoethicalbehavior.Disciplinaryactionsarenecessaryforcomplianceviolationswheninvolvinganyoneofthefollowing:§ Employee§ Employee’ssupervisor§ Anyonedirectingorapprovingimproperactions§ Anyoneawareofimproperactionsbutdoesnotactappropriatelytocorrectthem§ Anyonewhootherwisefailstoexerciseappropriatesupervision

ManagementisresponsibleforpromptlyadvisingtheComplianceOfficerofanyreportedorsuspectedviolationthatneedsinvestigationorresolution.ManagementthroughoutthehealthsystemshoulduseourCodetoincorporateethicsandcomplianceintoallaspectsofourorganization.

TheactionsofeachTannercolleagueoraffiliatearesignificantindicationsofjudgementandcompetence.Accordingly,thoseactionsconstituteimportantelementsintheannualevaluationoftheemployeeorcontractualarrangementaswellasforpositionassignmentsandpromotions.

Leadership’sResponsibility

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Physician’sResponsibility ThefoundationforeverythingwedoisCARINGforpeople.

MedicalStaffMissionStatementToprovidepatientswiththehighestqualityofcarethatensuresthehealthandsafetyofthecommunityitservesbymaintainingindividualcompetenceandsupportingTannerHealthSystem.

TannerHealthSystemiscommittedtoprovidingaworkenvironmentwithexcellentfacilities,modernequipmentandoutstandingprofessionalsupport.Accordingly,wewillnotallowanyphysiciantoworkwithoutavalidmedicallicenseorpropercredentials.

§ Anybusinessrelationshipwithaphysicianwillbeinwriting.§ TannerHealthSystemwillnotpayoroffertopayforreferrals.§ TannerHealthSystemacceptsandreferspatientsbasedontheirclinicalneedsandourability

renderneededservices.§ TannerHealth Systemwill not contractwith, employ or bill for services rendered by any

individualorentitythatisexcludedorineligibletoparticipateinfederalhealthprograms,orhas been convicted of a criminal offense related to the provision of healthcare items orservices.

§ TannerHealthSystemrequirescolleaguestoreporttousiftheybecomeexcluded,debarred,orineligible.

§ Toparticipateinfederalhealthprogramsorhavebeenconvictedofacriminaloffense.§ Tanner Health System collects information about the patient’s medical history,

condition,medicationandfamilyhistoryinordertoprovidequalityhealthcare.NoTanner Health System-affiliated physician has a right to access any patientinformationotherthanthatnecessarytoperformhisorherjob.

Vendor,Consultant,ContractorandBusinessAssociateResponsibilities OurrelationshipswithoneanothershallbefoundedonmutualRESPECT.

TannerHealthSystempromotesacompetitiveenvironmentandiscommittedtofaircompetition.OurbusinessdecisionsarebasedonourabilitytomeettheSystemneedsandnotonindividualpersonalrelationships.

§ Wewillnotcommunicateconfidentialinformationtothirdparties(i.e.,bids,pricing,financialinformation).

§ Patientinformationaccesswillbelimitedtoonlywhatisnecessarytoperformhisorherjob.

§ TannerHealthSystemwillnotdobusinesswithanyindividualorbusinessthatisexcludedfromparticipatingintheMedicare/Medicaidprogram.

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§ TannerHealthSystemwillnotcontractwith,employorbillforservicesrenderedbyanyindividualorentitythatisexcludedorineligibletoparticipateinfederalhealthcareprogramsorhasbeenconvictedofacriminaloffenserelatedtotheprovisionofhealthcareitemsorservices.

§ TannerHealthSystemrequirescolleaguestoreporttousiftheybecomeexcluded,debarred,orineligibletoparticipateinfederalhealthprogramsorhavebeenconvictedofacriminaloffense.

HOTLINEIndividualandcorporateINTEGRITYshallneverbecompromised.AnintegralpartofourcomplianceeffortsistheestablishmentofaconfidentialandanonymousComplianceHotline,throughwhichourTannerHealthSystemcolleaguesmayanonymouslyreportviolationsofanylawsorregulations.Everyoneisresponsibletopromptlyreportpossibleviolationstotheirsupervisor,theComplianceofficeortheComplianceHotline.

Callstothehotlinearetreatedconfidentially.Noretaliationorharassmentwillbetakenagainstanyoneforusingthehotlineorreportingconcernsofimproperconduct.HotlinecallswillbereportedtotheTMC,Inc.BoardofDirectorsortheTMCA,Inc.BoardofDirectors.

TheComplianceHotlinephonenumberis:1.800.648.1507Complianceconcernsare:§ Suspectedwrongdoing§ Illegalorunethicalacts§ BreachesoftheTannerHealthSystemLegalComplianceProgram§ BreachesofTannerHealthSystemCodeofEthicalBehavior§ LossesrelatedtoTannerHealthSystemoperations,propertiesoremployeesPatientcarerelatedconcernsmustalwaysbehandledimmediatelybytheappropriatestaff,patientrepresentativeordirectorofRiskManagement.OurTannerHealthSystemGrievancePolicywillbefollowed.

Examplesofhotlinecallsareasfollows:§ Breachesofconfidentiality(HIPAA

violations)§ EMTALAviolations(anti-dumping)§ Fraudandabuse(billingissues)§ Upcoding(codingforhigher

reimbursement)

§ Billingforservicesnotrendered§ Costreportfraud§ Anti-kickbackviolations§ Insurance

§ Fraud

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PatientRightsRecognitionthatourCUSTOMERScomefirst.

TheTannerHealthSystemhealthcareteamtreatsallpatientswithdignity,respectandcourtesy.Ourmissionistoprovidequalityhealthcareserviceswithinourresourcecapabilities.Wealsostrivetoserveasaleaderinacollaborativeeffortwiththecommunitytoprovidehealtheducation,supportservicesandcareforallourcitizens.

Each patient is provided with their rights andresponsibilitiesandaNoticeofPrivacyPracticesinvarious written formats as well as postedthroughoutthesystem.

Wearecommittedtoensuringahealthcareethicthatrespectstheroleofpatientsindecision-makingaboutcare,treatmentandserviceswithinourcapabilitiesandmissionandincompliancewithlawsandregulations.Also,wearesensitivetorespectcultural,psychosocial,spiritual,personalvalues,personalbeliefs,personalpreferences,racial,linguistic,religious,age,genderandotherdifferencesaswellastheneedsofpersonswithdisabilities.

ProtectionofClinicalDecisionMakingThefoundationforeverythingwedoisCARINGforpeople.TannerHealthSystemprotectstheintegrityofclinicaldecisionmakingregardlessofcompensationorsharedfinancialriskswithitsleaders,managersandclinicalstaffandlicensedindependentpractitioners.

InaccordancewiththeEmergencyTreatmentandActiveLaborAct(EMTALA),thehospitalprovidesamedicalscreeningexaminationandnecessarystabilizationtoallpatientswhopresenttotheemergencydepartmentwithanemergencymedicalcondition,includingwomeninlabor,suicidalpatientsandpatientsundertheinfluenceofcontrolledsubstances,regardlessoftheirabilitytopay.Therefore,treatmentwillbebasedonourcapacityandcapabilityandwewillnotdelaythemedicalscreeningexaminationordelaytheadmission,dischargeortransferofpatientssimplybasedonthepatients’abilityorinabilitytopay.

TannerHealthSystemdoesnotmakeadistinctiononadmission,transferanddischargepoliciesbasedonapatient’sage,gender,disability,race,color,religion,veteranstatusornationalorigin.

§ Patientswhosespecificconditionordiseasecannotbesafelytreatedaredivertedortransferredtoanacceptingorganizationonlywhenthetransferassuresthepatientofcontinuousappropriatecare.Therisks,benefitsandalternativeofthetransferareexplainedtothepatient.

§ Patientsaredischargedwhenacceptableguidelinesaremet.

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PatientReferrals/PhysicianArrangementsIndividualandcorporateINTEGRITYshallneverbecompromised.

TannerHealthSystemwillcomplywithfraudandabuselaws, StarkII, privateinurementIRSlawsandanti-kickbackstatute.

TannerHealthSystemprotectstheintegrityofclinicaldecisionmakingregardlessofcompensationorsharedfinancialriskswithitsleaders,managersandclinicalstaffandlicensedindependentpractitioners.

Thehealthsystemprohibitsthepaymentsofremunerationinreturnforthereferralofpatientsortoinducethepurchaseofgoodsorservicestobepaidfororbyanyfederallyfundedprogram—MedicareorMedicaid.TanneralsoprohibitssubmittingfalseclaimsinordertoobtainMedicareorMedicaidreimbursement.

§ Noemployeeshallsolicitorreceivepaymentofanytypeinexchangeforreferringanypersontoanotherforthepurchaseofgoodsorservices.

§ Noemployeeshallofferorgrantanybenefittoareferringphysicianorotherreferralsourceontheconditionthatsuchphysicianorreferralsourcereferoragreetoreferanypatientstothesystem.

§ EverytypeofarrangementthatinvolvescompensationorcrossreferralswithaphysicianorotherreferralsourcewillbereviewedbytheComplianceOfficerorlegalcounselpriortoitsexecution.

§ Alltransactionswithphysiciansmustbeinwriting.

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ConfidentialInformationOurrelationshipswithoneanothershallbefoundedonmutualRESPECT.

Informationregardingprotectedhealthinformation, bids, employmentrecordsandotherbusinessinformationwillnotbesharedwithotheremployeesoroutsideindividuals.

ConfidentialinformationdevelopedoracquiredbyTannerHealthSystemisnotgenerallyavailabletoothers.ItisavaluableassetofTannerandiskeptconfidentialandprotectedagainsttheft,lossorimproperdisclosure.

TannerHealthSystemcolleaguesmustneveruseordiscloseconfidentialinformationthatviolatestheprivacyrightsofourpatients.

§ Privilegedinformationisallinformationthatresultsfromphysician/patientrelationships.§ Protectedhealthinformation(PHI)isanyinformationthatisindividuallyidentifiableand

relatestothepast,presentorfuturephysicalormentalhealthorconditionofapatient.§ Confidentialinformationincludespricingandcostdata,financialdata,strategicplans,

supplierinformation,patientlistsandclinicalinformation.

Confidentialityisatrustvitaltothefreeandcandidcommunicationnecessaryforeffectivepatientcare.Nooneshalldiscuss,discloseorpermitthedisclosureofinformationwhichhasbeendeemedconfidentialunlessitdirectlypertainstotheirjob.§ Verbal,writtenandelectroniccommunicationsmustbeprotected.§ Conversationsregardingpatientsarediscouragedinpublicareasandarenotallowed

outsidethehospital.§ Informationgainedinthetreatmentofapatientisonlysharedwithothersona“needto

know”basis(directlypertainstoone’sjob).Examplesofindividuallyidentifiableinformation:§ Patientname§ Address§ Accountnumber§ Dispositionlocation§ Medicalrecordnumber§ Clinicaldata/diagnosis§ Financialinformation

§ Treatmentinformation§ Demographicinformation§ Picture/imageofpatient§ SocialSecurityNumber§ Dateofbirth/death§ Dateofadmission/discharge§ Telephone/faxnumbers

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Specialcareisgiventomaintaintheconfidentialityofpsychiatric/behaviorhealthtreatment,chemicaldependencetreatment,sexuallytreateddiseasesandHIV/AIDStesting/treatment—allofwhichareprivilegedinformation.AllrequestsforthereleaseofmedicalrecordinformationwillbesenttotheHealthInformationManagement(HIM)Departmentwhereanauthorizationmustbeproperlyexecuted.

§ Confidentialpatienthealthinformationwillbeshredded.§ Passwordswillnotbeshared.§ Confidentialinformationwillnotbeleftunattended.§ Nopatientinformationwillbesentthroughtheinternetwithoutencryption.

Confidentialityconcernsarereportedtoyoursupervisor,thePrivacyOfficerTerriLee,ortheComplianceOfficerValorieComley.

BillingIndividualandcorporateINTEGRITYshallneverbecompromised.

Alwaysbillcorrectlyforservicesrendered.TannerHealthSystembillsthird-partypayersforservicesrendered,andallbillsmustcomplywithbillingrequirementsforgovernment-sponsoredprogramsaswellasotherpayors.

§ Employeeswillexercisecareinassuringtheaccuracyofanyinformation,whetherwrittenororal,providedtoanygovernmentagencyorotherpayer.TannerHealthSystemprohibitsandwillnottoleratefalseinformationbyanyemployeetoagovernmentagencyoranyotherpayer.

§ Allindividualsthatcontributetothemedicalrecordmustprovidecomplete, accurateandtimely information.

§ Deliberatelyprovidingfalseorinaccurateinformationtogovernmentagenciesorotherpayerswill exposeanemployeetocivilandcriminalpenalties, aswellasterminationofemploymentandlossof benefits.

§ Allindividualsinvolvedinpatientcare,billingorcodingmustabidebyourCodeofEthicalBehavior.

TannerHealthSystemwillnotroutinelywaiveco-paymentsordeductibles.Waiversareonlygranteduponanalysisofthefinancialstatusofthepatient.Aspartofourmission,TannerHealthSystemmayprovidefreeorreducedchargecaretouninsuredorunderinsuredpatientswhoareunabletopayfortheseservicesbaseduponsetguidelines.

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FinancialRecordsIndividualandcorporateINTEGRITYshallneverbecompromised.

Keephonestandaccuratefinancialrecords.TannerHealthSystemisresponsiblefortheintegrityandaccuracyofourorganization’sdocuments.Associatesmustensurethatanyfinancialrecordforwhichtheyareresponsibleaccuratelyreflectsalltransactions.TannerHealthSystemhaswrittenpoliciestoensurethatourfinancialactivitiesreflectactualtransactions,areproperlyauthorized,fairlystatedandrecordedinaccordancewithgenerallyacceptedaccountingprincipals.

Documentsmustberetainedinaccordancetothelawandourrecordretentionpolicy.Noonemayremoveordestroyrecordspriortothespecifieddatewithoutfirstobtainingpermission.

Allexpensesdefinedas“non-allowable”costsforMedicare/MedicaidpurposesareexcludedfromreimbursablecostsontheMedicareCostReport.

Marketing, alcoholicbeverages, charitabledonations, civicsponsorshipsandnon-patient carerelatedflowersareexamplesof"non-allowable"Medicare/Medicaidcost.

PersonalUseofTannerHealthSystemPropertyIndividualandcorporateINTEGRITYshallneverbecompromised.

TannerHealthSystempropertyisforbusinessuseonly.TannerHealthSystemisanonprofitorganizationandnoneofitsearningsmayinuretothebenefitofprivateindividuals.Ourresourcesmustbeusedforourmissionofprovidingqualityhealthcareservicesandinacollaborativeeffortwiththecommunitytoprovidehealtheducation,supportservicesandcareforpatients.

Accordingly,propertywillnotbeusedforpersonalreasonsduringbusinesshoursorremovedfromthepremisesforpersonaluse.

§ ImproperuseofTannerpropertywouldinclude,butarenotlimitedto,personaluseofcomputersaswellaspersonaluseofclinical,dietaryorengineeringequipment.

§ Theelectronicandvoicemailsystemmaynotbeusedtosendchainlettersornon-organizationrelatedcommunications.o LimitedandreasonableuseofTannerHealthSystemcommunicationsystemsis

permitted,butusersshouldassumethesecommunicationsarenotprivate.

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o Foul,inappropriate,offensive,abusive,threateningorharassingemailorvoicemailmessages—includingbutnotlimitedtothoseofaracial,religiousorsexualnature—areprohibited.

MarketingandAdvertisingIndividualandcorporateINTEGRITYshallneverbecompromised.

TannerHealthSystem’sservicesandproductswillbeportrayedfairlyandhonestly,stressingtheirvalueandmerits.TannerHealthSystemwillmarketandadvertiseservicesinanon-deceptivemanner,stressingitsvalueandmeritstoeducatethepublic,provideinformationtothecommunityandincreaseawarenessofourservices.

§ Allmarketingmaterialsmustbefactual, easyforthereadertointerpret, andincludenolanguagethatintentionally misleadsthereader.

§ AllcostsassociatedwithmarketingTannerHealthSystem servicesareexcludedfromtheMedicareCostReport.

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ConflictofInterest

IndividualandcorporateINTEGRITYshallneverbecompromised.

EachemployeehasadutyofloyaltytoTannerHealthSystem.Tanner Health System associateswill avoid any actions that involve, or appear to involve, aconflictofinterestwiththeirobligationstotheorganization.

§ AnemployeewillnotrealizeanyprofitorgainasaresultoftheirpositionwithTannerHealthSystemapartfromTannercompensation/benefitprograms.

§ Associateswill notbecome involved innon-TannerHealth System related interestduringworkinghours.

Aconflictofinterestoccurswhenyouractivitiesorpersonalinterests:§ Appeartoinfluenceone’sbusinessdecisions§ AredetrimentaltothebusinessofTannerHealthSystem§ Resultinanimproperorillegalgainforyouorathirdparty

o Non-employedmedicalstaffphysiciansmaycontinuetohavecompetitivebusinesstransactionswithTannerHealthSystem.Thesesituationsareconsideredapartofanormal,healthycompetitiveenvironment.

TannerHealthSystemassociateswhodealwithsupplierswilldosoinareputable,professionalandlegalmanner.§ Donotdisclosepricing, finances, systems ordatatocompetitors/vendors.§ Donotacceptgiftsintendedtoinfluencedecisions.

Behavioral Health Department employees are restricted from conducting intimate, personaland/orfinancialrelationshipsofanykindwiththeirpatientsandtheirfamilieswhohavebeentreatedwithinthreeyearsofthepatient’sdischarge.

GiftsandGratuitiesIndividualandcorporateINTEGRITYshallneverbecompromised.

Usegoodjudgementwhengivingorreceivinggiftsthatareto/fromcustomers,vendors orphysicians.Employeesoftenreceiveacceptablegiftsfromotheremployeesorcolleaguesforappreciationorholidays.TannerHealthSystememployeesmayacceptnon-cashgiftsupto$50fromanyonewithacurrentorpotentialbusinessrelationship.Furthermore,entertainmentmaybeaccepteduptoa$100limitandshallnotincludetravelcosts.§ Cashorgiftcertificates(redeemableforcash)areconsideredinfluencesandarenever

acceptable.

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Employeeswillnotdirectlyorindirectlygive,acceptorsolicitanygifts,gratuities,favors,mealsorentertainmentto/fromanindividual/businesswhomtheassociateknowsorshouldknowbecauseofthenatureoftheassociate’sworkthatcan:

§ Inducereferrals§ Alterorappeartoalterbusinessoutcomesorrelationships§ Influenceorappeartoinfluenceassociate’s/recipient’sjudgementorconduct

onthejob

Acceptablegiftsincludeperishablegoods,promotionalitemsoranoccasionalbusinessmeal.

§ TannerHealthSystemgiftcertificatestoemployeesareacceptable.Theaccountingdepartmentshouldbecontactedpriortoinitiatingadepartmentalgiftinordertodeterminethetaxconsequences(i.e.,employertoemployeeholidaygiftcertificates).

§ Doorprizesareacceptable.

Anti-trustLawsIndividualandcorporateINTEGRITYshallneverbecompromised.

TannerHealthSystemwillnotshareinformationwithcompetitorsaboutmattersthatreducecompetition.TannerHealthSystemrecognizesthatroutinecommunicationswithcompetitorsareappropriateandreasonableinmanyinstances.Communicationwithcompetitorsaboutmattersthatcouldbeperceivedashavingtheeffectofreducingcompetitionwilltakeplaceonlyafterconsultationwithlegalcounsel.Onlylegalandethicalmeanswillbeusedtogatherinformationaboutexistingorpotentialcompetitors.

Associatesmay:§ Notrespondtoanyinquiryorrequestanyinformationfromacompetitorthatdealswith

informationonprices,wages,marketingactivity,acquisitionordevelopmentplansoranyothercompetitiveinformation.

§ Onlycollectcompetitiveinformationfromgenerallyavailableindustrysourcesandfrominformationwithinthepublicdomain.

§ ProvideinformationtothirdpartiessuchasTheJointCommission,agovernmententityorhospitalassociationaslongasitisgatheredconfidentially.

EnvironmentalLawsImprovingQUALITYwillalwaysbeourfocus.

TannerHealthSystemwillprotecttheenvironment.TannerHealthSystemiscommittedtopromotingsoundenvironmentalpracticesthat:§ Preventdamagetotheenvironment§ Enhancehumanandcommunityresources§ Reduceoravoidexposuretoenvironmentalliabilities

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Therearestandardsforthestorage,handling,transportationanddisposalofhazardousandinfectiouswaste.TannerHealthSystemanditsassociateswillcomplywithallfederal,stateandlocalhealthandsafetylawsandregulations,includingtheOccupationalSafetyandHealthAdministration(OSHA).Itisimportantthateachcolleagueimmediatelyadvisehisorhersupervisorofanyseriousworkplaceinjuryoranysituationpresentingadangersocorrectiveactionmaybetaken.

SafetyandHealthImprovingQUALITYwillalwaysbeourfocus.

TannerHealthSystemwillmaintainasafeandhealthfulworkplaceTannerHealthSystemanditscolleaguesareresponsibleformaintainingasafeandhealthfulworkenvironment.Wehaveanongoing,proactivepatientsafetyprogramfortheidentificationofrisktopatientsafetyandtheprevention,reportingandreductionofhealthcareerrors.

§ TannerHealthSystemisanon-smokingfacility.

EqualEmploymentOpportunityOurrelationshipswithoneanothershallbefoundedonmutualRESPECT

TannerHealthSystemwillnotdiscriminateinitsemploymentpractices. Employeeswillbetreatedwithrespect, trustandcompassion.Nopersonwillbediscriminatedagainstbecauseofsuchperson’srace,color,creed,religion,age,handicap,sex,nationalorigin,ancestry,disability,maritalstatus,statusasaVietnamveteranoranyotherfactorprohibitedbyfederal,stateorlocallaw.Thispertainstothefollowingsituations:recruitment,employment,promotion,terminationoranyothertermorconditionofemployment.

Wedonottolerateanyformofharassmentoforbyemployees,patients,membersofthemedicalstafforothers.

§ Harassmentincludesbutisnotlimitedtoslurs,jokesandotherverbal,graphicorphysicalconductrelatingtoanindividualsrace,color,sex,religion,nationalorigin,citizenship,ageorhandicap.

§ Italsoincludessexualadvances,requestsforsexualfavors,unwelcomeoroffensivetouchingandotherverbal,graphicorphysicalconductofasexualnature.

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PaymentstoGovernmentOfficialsIndividualandcorporateINTEGRITYshallneverbecompromised

TannerHealthSystemfundswillnotbeusedforimproperorillegalactivities.EmployeeswillnotmakepaymentsonbehalfofTannerHealthSystemtogovernmentofficialsinordertosecurecontractsorobtainfavorabletreatment.

§ Gifts,favorsorentertainmenttogovernmentofficialsareprohibitedbecausetheymaybeconstruedasattemptstoinfluenceadecision.

EmployeesareprohibitedfromusingTannerHealthSystemfundstocontributetoapoliticalparty,committee,organizationorcandidate.

§ Youmaymakepersonalpoliticalcontributionsofyourownchoice,butsuchcontributionsaremadeonavoluntaryandpersonalbasisandnotsubjecttoreimbursementbyTannerHealthSystem.

GovernmentRequestTEAMWORKisthebasisofourorganizationalstructure.

TannerHealthSystemcomplieswithalllegitimategovernmentrequests.EmployeeswillcooperatewithreasonablerequestsfromanygovernmentagencyconcerningTannerHealthSystem’soperations.TannerrequeststhatyouadvisethedirectorofRiskManagement,ComplianceOfficerorTannerHealthSystem’slegalcounselbeforerespondingtoanyrequeststhatareout-sidetheordinaryscopeofroutineinquiriesmadebygovernmentalauthorities.Ifalawenforcementagentseekstocontactyoudirectly,youareadvisedthat:

§ Youhavetherighttospeakordeclinetospeak,asallsuchconversationsareentirelyvoluntary.

§ Youhavetherighttospeaktoanattorneybeforedecidingtobeinterviewed.§ Youcaninsistthatanattorneybepresent,ifyouagreetobe

interviewed.§ Ifyouagreetobeinterviewed,youwillbetruthfulinallofyouranswers.

DirectorofRiskManagement•patientcarerelatedsituations

ComplianceOfficer•federal,stateandlocallawsandregulations

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ComplianceAcknowledgementIherebyacknowledgeandaffirmthatIreceived,read,understoodandwillabidebytheprovisionsincludedinTannerHealthSystem’s“CodeofEthicalBehavior”booklet.IunderstandtheprovisionsincludedintheCodeofEthicalBehaviorandrealizethatImayasktheComplianceOfficer,PrivacyOfficer,mysupervisororadministrativecontactanyquestionIhaveregardingtherequirements.InconsiderationofmyemploymentorassociationwithTannerHealthSystem,andasanintegralpartofthetermsandconditionsofmyemploymentorassociation,IherebyagreethatIwillnotat any time during my employment or association with Tanner Health System or after myemploymentorassociationends,accessoruseprotectedhealthinformationorrevealordisclosetoanypersonswithinoroutsidetheTannerHealthSystem,anyprotectedhealthinformationexceptasmayberequired in thecourseofmydutiesandresponsibilities inaccordancewithapplicable regulations and Tanner Health System policies governing proper release ofinformation. Furthermore, I understand that it is my responsibility to comply with therequirementsoftheCodeofEthicalBehavior.IalsorealizethatIamrequiredtoreportviolationstomysupervisor,theComplianceOfficer,thePrivacyOfficerortheHotline.IunderstandthatincludesthoseviolationsthatIwitnessmyselforaminformedofbyothers.IamfamiliarwithboththeHotlinetelephonenumber(1.800.648.1507)andthelocationoftheComplianceOfficer(ProfessionalParkBuilding,Suite305).IunderstandthatIwillnotbepunishedforreportingmisconductofanymagnitudeormisconductthatinvolvesanylevelofsystempersonnel.IhavebeeninformedthatImaybedisciplinedforfailingtoreportsuchviolations.Ialsounderstandthatunauthorizeduseordisclosureofsuchinformationwillresultindisciplinaryactionuptoandincludingterminationofemployment/contract/association/appointment,theimpositionoffinespursuantandareporttomyprofessionalregulatorybody.IfurtherunderstandthatmyobligationsconcerningtheprotectionoftheconfidentialityofpersonalhealthinformationrelatetoallprotectedhealthinformationwhetherIacquiredtheinformationthroughmyemployment/contract/association/appointmentwithTannerHealthSystemorwithinanyofthehealthcarefacilitieswithintheTannerHealthSystem.Iunderstandthatmyobligationoutlinedabovewillcontinueaftermyemployment/contract/association/appointmentwithTannerHealthSystemends.

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IcertifythatIhavenotbeenexcludedfromparticipationinanyfederalorstatehealthcareprogram.Ihavenotbeencriminallyconvictedofanycrimeregardingfederalorstatehealthcareprogramsoranyoffenseinvolvingfinancialmisconduct(suchasfraudorembezzlement).

Signature________________________________________Date______________________

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