NOTICE OF PRIVACY PRACTICES

Effective Date: April 14, 2003

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact the practice’s Facility Privacy Official by dialing the main clinic number.

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all of the records generated by your physician, office medical or billing personnel, or Business Associates.

Our Responsibilities

We are required by law to maintain the privacy of your health information and provide a description of our privacy practices. We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction.

Uses and Disclosures

How we may use and disclose Health Information about you.

We may use and disclose your medical health information (clinical and billing) for:

• Payment, Treatment, Healthcare Operations

• Business Associates

• Appointment Reminders

• Treatment Alternative Education

• Health-related Benefits or Services

• As required by law to State/Federal Agencies

• Family or friends involved in your care

• Entities assisting in Disaster Relief

Your Health Information Rights

Although your health record is the physical property of the healthcare provider, you have the RIGHT to:

Access Information

Request Amendments

An Accounting of Disclosures

Request Privacy Restrictions

Request Alternate Communication

File Complaints

Obtain a Detailed Copy of this Notice

Please refer all requests to our Privacy Official.

• Access: You have the right to inspect and obtain a copy of the medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. We may deny your request to inspect and copy in certain very limited circumstances. These denials must be provided to you in writing, and you may request a second review in writing.

• Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend, or add to the information. You have the right to request an amendment for as long as the information is kept by or for the provider.

We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

• An Accounting of Disclosures: You have the right to request an accounting of disclosures of medical information about you. This does not include disclosures for treatment, payment, operations, or to you or your authorized representative.

• Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

• Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. The practice will grant reasonable requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by the facility and related correspondence regarding payment for services. Please realize we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

• A Paper Copy of This Notice: You have the right to a detailed paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

If the facility has a website you may print or view a copy of the notice by clicking on the Notice of Privacy Practices link.

To exercise any of your rights, please obtain the required forms from the Privacy Official and submit your request in writing.

CHANGES TO THIS NOTICE

We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the practice and include the effective date. In addition, we can provide additional copies of the notice when you check in for future appointments, at your request.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us by contacting the Privacy Official. You may also file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

FACILITY PRIVACY OFFICIAL

Call the main number of your provider