NOTICE OF PRIVACY  PRACTICES

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.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect 4/14/03. It will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes.

You may request a copy of our notice (or any subsequent revised notice) at any time. 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 HEALTH INFORMATION 

 We will use and disclose health information about you only for the purposes of treatment, payment, and health care operations.
For example:
TREATMENT: We will use your health information within our office to provide you with the best health care possible. We may use or disclose your health information to a physician or other health care provider providing treatment to you.

PAYMENT: Your health information will be used, as needed, to obtain payment for services we provide to you. Examples of this would be confirming coverage with your health plan or sending a claim to your insurance company for payment.

HEALTH CARE OPERATIONS: We may use or disclose, as needed, your health information during business activities of running our practice such as quality assessment and improvement, employee training and reviews, accreditation, certification, licensing or credentialing activities.

YOUR AUTHORIZATION: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Without your written authorization, we will not disclose your health care information except as described in this notice.

OTHERS INVOLVED IN YOUR HEALTH CARE: Unless you object, we may disclose to a family member, friend, caregiver or any other person you identify, your health information that directly relates to that person's involvement in your health care or payment of your health care. In the event of your incapacity, emergency circumstances, or you object, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgement. We may use or disclose health information to notify or assist in notifying a family member, personal representative or another person responsible for your care, of your location, your general condition, or death. We will also use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up medication, medical supplies and appliances, x-rays, or other similar forms of health information.

COMMUNICATION: We may contact you (by phone, voicemail messages, by mail) to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

ABUSE OR NEGLECT: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

PUBLIC HEALTH AND NATIONAL SECURITY: We may disclose to Federal officials or military authorities health information necessary to complete an investigation related to public health or national security.

REQUIRED BY LAW AND FOR LAW ENFORCEMENT: We may use or disclose your health information when we are required to do so by law. We may disclose limited health information to a law enforcement official or correctional institution for law enforcement purposes, under certain circumstances, if you are a victim of a crime, in order to report a crime, or assist law enforcement authorities to apprehend an individual.

FEDERAL AND STATE AGENCIES: We may disclose health information to government agencies that oversee the health care system and government benefit programs for activities authorized by law such as audits, investigations and inspections.

PATIENT RIGHTS

ACCESS: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to the contact person listed at the end of this notice to obtain access to your health information. You may also request access by sending us a letter to the address at the end of this notice, If you request copies, we will charge you $0.25 for each page, $10 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.

ACCOUNTING OF DISCLOSURES: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

RESTRICTION REQUESTS: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf.

ALTERNATIVE COMMUNICATION: You have the right to request that we communicate with you about your health information by alternative means or to an alternative location. You must make your request in writing. We must accommodate your request if it is reasonable, specifies the alternative means or location, and continues to permit us to bill and collect payment from you.

AMENDMENT: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if the information was not created by our office, is not part of our records, or if the records containing your health information are determined to be accurate and complete.

ELECTRONIC NOTICE: If you receive this notice on our website, you are entitled to receive this notice in written form Please contact us to obtain a copy.

QUESTIONS AND COMPLAINTS

 If you want more information about our privacy practices or have questions or concerns, please contact us using the information below.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made, you may complain to us using the contact information below. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to protect the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Name of Contact Person: Susan

Telephone: (920) 921-1669 Fax (920) 921-7950

Address: