Notice of Privacy Practices:

This notice describes how medical information concerning you may be used, disclosed and how you may access the information. This Notice of Privacy Practices describes how we may use and disclose your protected health information when providing treatment, health care services, payment, operations, or other purposes that are permitted or required by law. The notice also discusses your rights to access and control your personal health information. “Protected health information” includes your personal information such as demographic information that may identify you and relates to your past, present or future physical or mental health condition and related health care services.

1. Uses and Disclosures of Protected Health Information your physician, our office staff and others outside of our office who are involved in your care and treatment for the purposes of providing you with healthcare services may disclose or use your protected health information. 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. The following provides examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. The examples are not inclusive of all
uses of protected health information, however they provide some description of 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 service. This includes coordination or management of your health care with another provider. For example, we will disclose protected health information to other physicians who may be treating you. Your protected health information may be shared with 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 to another physician or health care provide who, at the request of your physician becomes involved in your care by providing assistance to your physician with your health care diagnosis or treatment.

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. Examples include: 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 an office visit may require your relevant protected health information be disclosed to the health plan. You will however be able to restrict disclosures to your insurance carrier for services for which you wish to pay “out of pocket” under the Omnibus Rules.

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 students/education, licensing fundraising activities, customer service, auditing functions and conducting or arranging for other business activities. In addition, your confidential information may be used to remind you of an appointment (by phone, text, email or mail) or provide you with information about treatment options or other health-related services. We will share your protected health information with third party “business associated” 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 to provide 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. We may use or disclose your demographic information and the dates that you received treatment from your physician in order to contact you for fundraising activities supported by or office. If you
do not want to receive their materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you. Other Permitted and Required Uses and Disclosure 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 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 prevention or control of communicable diseases, injury or disability, reporting information such as adverse reaction to medications or products, suspected abuse, neglect or exploitation of children, disabled adults or the elderly, or domestic violence.

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.

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 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 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 purposes 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 services.

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.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOU 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 judgement.

Psychotherapy Notes: Use and disclosure of psychotherapy notes maintained by your healthcare provider is allowed only with your written authorization. Others involved in your healthcare 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 your 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 is in your best interest based on our professional judgement. 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 your 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 healthcare.

2. YOUR RIGHTS
The following is a description 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 that 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 physicians practice use for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee to copy 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 nay 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 may request a restriction
by providing a written letter to your provider. 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 method of contact. We will not request an explanation from you as to the basis of 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, to family
members of 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 or will receive information of breaches of your unsecured protected health information as required by HIPAA law. 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.

ATTN: Privacy Officer
13090 N 94th Dr., Ste 204
Peoria, AZ 85381