Notice of Privacy Practices

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 takes effect on April 14, 2003 and remains in effect until we replace it.

1. OUR PLEDGE REGARDING MEDICAL INFORMATION

   The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protect it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

2. OUR LEGAL DUTY

   Law Requires Us to:

   • Keep your medical information private.
   • Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
   • Follow the terms of the notice that is now in effect.

   We Reserve the Right to:

   • Change our privacy practices and the terms of this notice at any time, provided that the, changes are permitted by law.
   • Make the revised or changed notice effective for medical information that we already have about you, as well as any information we receive in the future. We will post a copy of the current notice in the office. The notice will contain, on the front page, bottom center, the effective date, and we will make a revised notice available upon request.

3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION

   The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us.

   FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other healthcare providers to assist them in treating you.

   FOR PAYMENT: We may use and disclose your medical information for payment purposes.

   FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you. In some instances, we have contracted separate entities to provide services for us. These "associates" require your health information in order to accomplish the tasks that we ask them to provide. Some examples of these "business associates" might be a billing service, collection agency, answering service, and computer software/hardware provider.

   ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment and health care operations, we may use and disclose medical information for the following purposes.

   Business Associates: In some instances, we have contracted separate entities to provide services for us. These "associates" require your health information in order to accomplish the tasks that we ask them to provide. Some examples of these "business associates" might be a billing service, collection agency, answering service, and computer software/hardware provider.

   Notification: Medical information to notify or help notify: a family member, your personal representative or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information about you. We may use or disclose medical information to contact you by mail or by phone as a reminder that you have an appointment for treatment in our office of for procedure at the hospital of the surgery center.

   Disaster Relief: Medical information with a public or private organization or person who can legally assist in disaster relief efforts.

   Research in Limited Circumstances: Medical information for research circumstances where the research proposal and established protocols to ensure the privacy of medical information.

   Funeral Director, Coroner, Medical Examiner: To help them carry out their duties, we may share the medical information of a person who has died with the coroner, medical examiner, funeral director, or an organ procurement organization.

   Specialized Government Function: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.

4. YOUR INDIVIDUAL RIGHTS

   You Have a Right to:

   1. Look at or get copies of your medical information. You may request that we provide copies in a format other than photocopies. We will use the format you request unless it is not practical for us to do so. You must make your request in writing. You may get the form to request access by using the contact person listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice. If you request copies, we will charge you $1.00 for each page, a $10.00 search charge, and postage if you want the copies mailed to you. Contact us using the information listed at the end of the notice for a full explanation of our fee structure.
   2. Receive a list of all the times we shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions.
   3. Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).
   4. Request that we communicate with you about your medical information by different means or to different locations. Your request that we communicate your medical information to you by different means or at different locations must be made in writing to the contact person listed at the end of this notice.
   5. Request that we change your medical information. We may deny your request if we did not create the information you want changed, and for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you want changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of the information.

   If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing.

   QUESTIONS AND COMPLAINTS: If you have questions about this notice or if you think that we may have violated your privacy rights, please contact us. You may also submit a written complaint to the U.S. Department of Health and Human Services in Washington DC. We will not retaliate in any way if you choose to file a complaint.

   CONTACT PERSON: OFFICE MANAGER