HIPAA POLICY

NOTICE OF PRIVACY PRACTICES

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your individually identifiable health information.

Our Commitment to Your Privacy

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

• How we may use and disclose your PHI

• Your privacy rights in your PHI

• Our obligations concerning the use and disclosure of your PHI

The terms of this notice applies to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. The following categories describe the different ways in which we may use and disclose your PHI:

Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

Payment: Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. You may flag procedures you do not want submitted to your insurance company, if you pay for the procedures yourself.

Health Care Operation: We may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, we may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations.

Appointment Reminders: We may use and disclose your PHI to contact you and remind you of an appointment.

Treatment Options: We may use and disclose your PHI to inform you of potential treatment options or alternatives.

Health-Related Benefits and Services: We may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.

Anesthesia Services: We may contact you regarding financial matters involving anesthesia, and we may provide your information to the anesthesiologist, if applicable.

Release of Information to Family/Friends: We may release your PHI to a friend or family member who is involved in your care, or who assists in taking care of you that you have elected to receive this information.

Deceased Patients: Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

Disclosures Required By Law: We will use and disclose your PHI when we are required to do so by federal, state or local law.

Use and Disclosure of Your PHI in Certain Circumstances

Public Health Risks: We may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

• Maintaining vital records, such as births and deaths

• Reporting child abuse or neglect

• Preventing or controlling disease, injury or disability

• Notifying a person regarding potential exposure to a communicable disease

• Notifying a person regarding a potential risk for spreading or contracting a disease or condition

• Reporting reactions to drugs or problems with products or devices

• Notifying individuals if a product or device they may be using has been recalled

• Notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult patient, including domestic violence; however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information.

• Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

Health Oversight Activities: We may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

Lawsuits and Similar Proceedings: We may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding.

Law Enforcement: Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Research: We may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Institutional Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (a) an adequate plan to protect the identifiers from improper use and disclosure; (b) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (c) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.

Serious Threats to Health or Safety: We may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Military: We may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

National Security: We may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

Inmates: We may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

Right to Provide an Authorization for Other Uses and Disclosures: We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.

Please note: we are required to retain records of your care.

Individual Rights: You have certain rights under the federal privacy standards including:

• The right to request restrictions on the use and disclosure of your protected health information

• The right to receive confidential communications concerning your medical condition and treatment

• The right to file a complaint – We will provide you with the address.

• The right to inspect and receive a copy of your protected health information – Contact the front office receptionist for the form.

• The right to amend or submit corrections to your protected health information

• The right to receive an accounting of how and to whom your protected health information has been disclosed

• The right to receive a printed copy of this notice.