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.
Dear Patient: The Federal laws, HIPPA-Health Insurance Portability and Accountability Act,
have been written to protect the confidentiality of your health information. Your personal
health history is NEVER unnecessarily made available to others outside of our office.
Protecting your Confidential Health Information is always important to us.

SO WHAT HAS CHANGED? WHY A PRIVACY POLICY NOW?
The most significant variable that has motivated the Federal government to legally enforce the
importance of the privacy of health information is the rapid evolution of computer technology
and its use in healthcare. The government has appropriately sought to standardize and protect
the privacy of the electronic exchange of your health information. We have reviewed how your
health information is used with the Internet, phone, faxes, copy machines and files. We have
put in writing the policies and procedures we use to ensure the protection of your health
information everywhere it is used.

We want you to know about these policies and procedures that we developed to make sure
your health information will not be shared with anyone who does not require it. Our office is
subject to State and Federal laws regarding the confidentiality of your health information and
in keeping with these laws, we want you to understand procedures and your rights as our
valuable client. We will use and communicate your health information only for the purposes of
We will use and communicate your health information only for the purposes of providing your
treatment, obtaining payment, and conducting health care operations. Your health information
will not be used for other purposes unless we have asked for and been voluntarily given your
written permission.

HOW YOUR HEALTH INFORMATION MAY BE USED.

To Provide Treatment
We will use your health information within our office to provide you with the best care
possible. This may include administrative and clinical office procedures. We may share your
health information with referring physicians/pediatricians/therapists or other health care
personnel providing your treatment.

To Obtain Payment
We may include your health information with an invoice used to collect payment for treatment
you receive in our office. At this time we do not file insurance, but if this changes, we may do
this with insurance forms filed for you in the mail or sent electronically. We will be sure to

only work with companies with a similar commitment to the security of your health
information.

To Conduct Health Care Operations
It is possible that health information will be disclosed during audits by insurance companies or
government appointed agencies as part of their quality assurance and compliance reviews.
Your health information may be reviewed during the routine processed of certification,
licensing, or credentialing activities.

Patient Communication
We may contact you to follow up on your care and inform you of treatment options or services
that may be of interest to you or your family. These communications may include postcards,
letters, telephone calls, voice mail, bulletins or email.

Abuse or Neglect
We will notify government authorities if we believe a patient is the victim of abuse, neglect, or
domestic violence. We will make this disclosure only when we are compelled by our ethical
judgment, when we believe we are specifically required or authorized by law or with the
patient’s agreement.

Public Health and National Security
We may be required to disclose to Federal officials or military authorities health information
necessary to complete an investigation related to public health or national security. Health
information could be important when the government believes that the public safety could
benefit when the information could lead to the control or the prevention of an epidemic or the
understanding of a new medical device.

For Law Enforcement
As permitted or required by State or Federal Law, we may disclose your health information to a
law enforcement official for certain law enforcement purposes, included (under certain limited
circumstances) if you are a victim of a crime or in order to report a crime.

Family, Friends, and Caregivers
We may share your health information with those you tell us will be assisting you with your
treatment or payment. We will be sure to ask your permission first. In the case of emergency,
we will use our best judgment when sharing your health information.

Medical Research
Advancing medical knowledge often involved learning from the careful study of the medical
histories of prior patients. Formal review and study of health histories as a part of research
study will happen only under the ethical guidance, requirements and approval of an
Institutional Review Board.

Authorization to Use or Disclose Health Information

Other than what is stated about or where Federal, State, or Local law requires us, we will not
disclose your health information without your written authorization. You may revoke that
authorization in writing at any time.

PATIENTS’ RIGHTS
This law is careful to describe that you have the following rights related to your health
information.

Restrictions
You have the right to request restrictions on certain uses and disclosures of your health
information. We will make every effort to honor reasonable restriction preferences from our
clients.

Confidential Communications
You have the right to request that we communicate with you in a certain way. You may request
that we only communicate your health information privately with your other family members
present or through mailed communications that are sealed. We will make every effort to honor
reasonable requests for confidential communications.

Inspect and Copy Your Health Information
You have the right to read, review, and copy your health information, including your complete
file, and billing records. If you would like a copy of your health information, please let us
know. You will be charged, according to the State regulations, for duplication costs.

Amend your Health Information
You have the right to ask us to update or modify your records if you believe your health
insurance records are incorrect or incomplete. We will be happy to accommodate you as long
as our office maintains this information. In order to standardize the process, requests must be
made in writing along with a description of the reason for the change. Your request may be
denied if the health information record in question was not created by our office, is not part of
our records, or if the records containing your health information are determined to be
complete and accurate.

Documentation of Health Information
You have the right to ask for a description of how and where your health information was used
by us for any reason other than for treatment, payment or health care operations. Please let us
know in writing the time period for which you are interested. Thank you for limiting your
request to no more than six years at a time. We will charge you a reasonable fee for your
request.

Request a Paper Copy of this Notice
You have the right to obtain a copy of this Notice of Privacy Practices directly from us at any
time. We are required by law to maintain the privacy of your health information and to provide

you and your representative this Notice of Privacy Practice. We are required to practice the
policies and procedure described in this notice but do reserve the right to change the terms of
this Notice. If we change our privacy practices, all patients will receive a copy of the revised
Notice.

You have the right to express complaints to us, or the Secretary of Health and Human Services
if you believe your privacy rights have been compromised. We encourage you to express any
concerns you may have regarding the privacy of you information. Please let us know of your
concerns or complaints in writing so that we may undertake the proper procedures to remedy
the situation as quickly as possible.

Thank you very much for taking the time to review how we are carefully using your health
information. If you have any questions, please ask.