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 Practices describes how we may use and disclose your protected health information to carry out treatment,
payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access
and controls your protected health information. “Protected health information” is information about you, including demographic
information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related
health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The
new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you
with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office, and
requesting that a revised copy be sent to you in the mail, or asking for one at the time of your next appointment.
1. Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office who
are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information
may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.
Following are examples of the types of uses and disclosures of your protected health information that your physician’s office is
permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made
by our office.
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 another provider. For example, we would
disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose
protected health information to other physicians who may be treating you. For example, your protected health 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. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider
(e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with
your health care diagnosis or treatment to your physician.
Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services
provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it
approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for
insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. 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.
Health Care Operations: We may use or disclose, as needed, your protected health information in order 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, fundraising activities, and conducting or arranging for other business activities.
We will share your protected health information with third-party “business associates” that perform various activities (for example,
billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the
use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy
of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives
or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these
materials not be sent to you.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or
Object.
We may use or disclose your protected health information in the following situations without your authorization or providing you the
opportunity to agree or object. These situations include:
Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by
law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You
will be notified, if required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health
authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of
preventing or controlling disease, injury, or disability.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been
exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as
audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the
health care system, government benefit programs, other government regulatory programs, and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive
reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a
victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case,
the disclosure will be made consistent with the requirements of applicable
federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food
and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to
report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make
repairs or replacements, or to conduct post-marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in
response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions
in response to a subpoena, discovery request, or other lawful processes.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law
enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited
information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred
as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on
our practice’s premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical
examiner for identification purposes, determining the cause of death, or for the coroner or medical examiner to perform other duties
authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the
funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health
information may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.
Research: We may disclose your protected health information to researchers when their research has been approved by an
an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected
health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we
believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or
the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or
apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health
information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command
authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to
foreign military authority if you are a member of that foreign military service. We may also disclose your protected health
information to authorized federal officials for conducting national security and intelligence activities, including for the provision of
protective services to the President or others legally authorized.
Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation
laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician
created or received your protected health information in the course of providing care to you.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization:
Other uses and disclosures of your protected health information will be made only with your written authorization unless otherwise
permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your
authorization, we will no longer use or disclose your protected health information for the reasons covered by your written
authorization. Please understand that we are unable to take back any disclosures already made with your authorization.
Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object:
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to
the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or
disclosure of the protected health information, then your physician may, using professional judgment, determine whether the
disclosure is in your best interest.
Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are
receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious
affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy,
such as a priest or rabbi.

Others Involved in Your Health Care or Payment for Your Care: Unless you object, we may disclose to a member of your family,
a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person’s
involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as
necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health
information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for the
care of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized
public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved
in your health care.
2. Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may
exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected
health information about you for so long as we maintain the protected health information. You may obtain your medical record that
contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.
As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in
reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to
law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be
reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you
have questions about access to your medical record.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any
part of your protected health information for the purposes of treatment, payment, or health care operations. You may also request that
any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for
notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to
whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction,
we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency
treatment. With this in mind, please discuss any restriction you wish to request with your physician.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We
will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment
will be handled or specification of an alternative address or other methods of contact. We will not request an explanation from you as to
the basis for the request. Please make this request in writing to our Privacy Officer.
You may have the right to have your physician amend your protected health information. This means you may request an amendment
of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we
may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of
disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please
contact our Privacy Officer if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This
right applies to disclosures for purposes other than treatment, payment, or health care operations as described in this Notice of Privacy
Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to
family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement
(as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific
information regarding these disclosures that occur after April 14, 2003. The right to receive this information
is subject to certain exceptions, restrictions, and limitations.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice
electronically.
3. Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.
You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a
complaint.
You may contact your doctor if you have any other questions about privacy practices.