NOTICE TO PATIENTS

The privacy of your medical information is important to us. You may be aware that the U.S. government regulators established a privacy rule (“HIPAA”) governing protected health information.

We are required to give you this notice of our legal duties and privacy practice and your rights, and to follow the terms of this notice. We may disclose information to other persons and companies who perform services for us, and we require them to protect your privacy too. There are other laws that provide additional protection for medical information related to treatment for mental health, alcohol, and other abuse and HIV/Aids.

We will follow the requirements of these laws. This notice tells you about how your medical record (protected health information) may be used (in our office) and disclosed (sent out of our office) and how you can have access to this information. Please review it carefully. Uses and Disclosures: We will use and disclose elements of your medical record (Protected health information-PHI) in the following ways;

Treatment — Any activity related to your care.

Payment – determine eligibility, billing, claims management, collections, medical necessity review, and utilization review.

Health Care Operations — Quality assessment and improvement, credentialing and re-credentialing, arranging for medical review, certain legal and accounting services, resolution of grievance, HIPAA remediation-this will be used in the effort to continually improve the quality and effectiveness of the health care and service we provide.

To give or discuss your medical record with individuals whom you have given permission for us to disclose information about you. To contact you about appointment reminders, treatment alternatives and other health related benefits and services. In emergency situations or to avert serious health/safety situations. When release is required by law (i.e.: requested by government agency or court order). Other:

All other uses and disclosure by us will require us to obtain a written authorization from you. Workers’ compensation and no fault (MVA) injuries are not subject to this policy.

Your Rights: You have the following rights concerning your medical record:

1.) Access: To inspect or obtain copies of your medical record. To inspect your record, you must request an appointment to do so. We will provide a room and staff member to be in attendance while you inspect your record. To obtain copies of your record, you should request them either orally (in person or via telephone), or in writing. We deserve the right to supply these copies to you within 30 days of your request. We will mail them to you at the address we have on file for you. We will only give them to a messenger (this includes spouse or friend) if we have specific dated written permission to do so (indicating the name of the person/or messenger service who we are to release the information to) from you. If you request the record in writing, the request must be dated and signed. It should state exactly what part of your record you are requesting and where or to whom you want the record sent. Again we reserve the right to supply these copies to you within the 30 day time period, we will notify you in writing and continue to attempt to retrieve the records. There may be a 075 per page fee for the copying of records.

2.) Amendments: To request changes be made to your medical record. To do this, you must submit the request in writing, stating exactly what part of the record you believe is incorrect or has been omitted. You should state what you want the correction to say. We are not required to grant your request. If not erase the error from the record but will document that it was an error. If the Physician does not agree to the amendment, we will attach your request to the record and it will become part of the permanent record. You may also file a complaint with our office.

3.) Alternate Communications: To receive communication of information by alternate means or at a locatior,(id; fax, mail to an address other than that which we have on file). To do this, you should submit the request in writing, dated and signed, stating the fax number and/or address to which you are requesting the information be forwarded.

4.) Accounting of Disclosures: To request and receive an accounting of disclosures of your health information for purposes other than treatment, payment or health care operations.

5.) Restrictions: To request the restricted release of all or part of your medical record. To do this, you should submit the request in writing, dated and signed, which explains exactly what part of your record is to be sent/or not sent and who/what entity is to be restricted from receiving your record. We are not required to grant your request.

6.) Complaints: To complain to us if you feel your privacy rights have been violated. To register a complaint with us, you should submit your complaint in writing to the office addressed to the administrator. We will investigate your complaint and you will receive an answer within a reasonable time period, either by telephone or in writing. You may also complain to the US Dept of Health and Human Services (contact our office for the address). We will not take retaliatory action against you if you register a complaint.

This Notice: To get updates or reissue of this notice at your request.

Our Duties: We are required by law to maintain the privacy of your protected health information. We must abide by the terms of this notice or any update of this notice.

We reserve the right to amend this notice. We reserve the right to make the revised or changed notice effective for information we already have about you, as well as information we receive in the future. We post a copy of the current notice in our office and it is available to you upon request.

Security: In an effort to ensure security, we will verify patients’ date of birth when they call for results of tests or personal information.

Effective Date: This notice is effective April 14, 2003.