HIPAA 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 of Privacy describes how we may use and disclose your protected health information (PHI) to
carry our treatment, payment or health care operations (TPO) for other purposes that are permitted or
required by law. “Protected Health Information” is information about you, including demographic
information that may identify you and that related to your past, present, or future physical or mental health or
condition and related care services.

Use and Disclosures of Protected Health Information:

Your protected health information may be used and disclosed by your physician, our staff and others outside
of our office that are involved in your care and treatment for the purpose of providing health care services to
you, pay your health care bills, to support the operations of the physician’s practice, and any other use
required by law.

Treatment:

We will use and disclose your protected health information to provide, coordinate, or manage your health
care and any related services. This includes the coordination or management of your health care with a third
party. For example, we would disclose your protected health information, as necessary, to a home health
agency that provides care for you. For example, your health care information may be provided to a physician
to whom you have been referred to ensure that the physician has the necessary information to diagnose or
treat you.

Payment:

Your protected health information will be used, as needed, to obtain payment for your health care services.
For example, obtaining approval for a hospital stay may require that your relevant protected health
information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations:

We may disclose, as needed, your protected health information to support the business activities of your
physician’s practice. These activities include, but are not limited to, quality assessment activities, employee
review activities, training of medical students, licensing, marketing, and fundraising activities, and
conduction or arranging for other business activities. For example, we may disclose your protected health
information to medical school students that see patients at our office. In addition, we may use a sign-in sheet
at the registration desk where you will be asked to sign your name and indicate your physician. We may also
call you by name in the waiting room when your physician is ready to see you. We may use or disclose your
protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your
authorization. These situations included as required by law, public health issues, communicable diseases,
health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law
enforcement, coroners, funeral directors, and organ donation. Required uses and disclosures under the law,
we must make disclosures to you when required by the Secretary of the Department of Health and Human
Services to investigate or determine our compliance with the requirements of Section 164.500.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES WILL BE MADE ONLY WITH
YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT UNLESS REQUIRED BY
LAW.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the
physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.