HIPAA NOTICE OF PRIVACY PRACTICES As required by the Privacy Regulations
Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996
describes how we may use and disclose your protected health information (PHI) to carry out
treatment, payment or health care operations (TPO) and for other purposes that are permitted or
required by law. It also describes your rights to access and control 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.

Uses and Disclosures of Protected Health Information: Your protected health information may be
used and disclosed by our organization, our office 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, to
pay your health care bills, to support the operation of the organization, 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 to 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.
Payment: Your protected health information will be used, as needed, to obtain payment for your
health care services. For example, obtaining approval for equipment or supplies coverage may
require that your relevant protected health information be disclosed to the health plan to obtain
approval for coverage.

Healthcare Operations: We may use or disclose, as needed, your protected health information in
order to support the business activities of our organization. These activities include, but are not
limited to, quality assessment activities, employee review activities, accreditation activities, and
conducting or arranging for other business activities. For example, we may disclose your
protected health information to accrediting agencies as part of an accreditation survey. We may
also call you by name while you are at our facility. We may use or disclose your protected health
information, as necessary, to contact you to check the status of your equipment. We may use or
disclose your protected health information in the following situations without your authorization:
as Required By Law, Public Health issues as required by law, Communicable Diseases, Health
Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings,
Law Enforcement, Criminal Activity, Inmates, Military Activity, National Security, and
Workers ’Compensation.

Required Uses and Disclosures: Under the law, we must make disclosures to you and 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 this organization has taken an action in reliance on the use or disclosure indicated in
the authorization.

Your Rights: Following is a statement of your rights with respect to your protected health
information. You have the right to inspect and copy your protected health information. 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 protected health information that is subject to law that prohibits access
to protected health information.

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 healthcare 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. Our organization is not required to agree to a restriction that you may request. If our
organization believes it is in your best interest to permit use and disclosure of your protected
health information, your protected health information will not be restricted. You then have the
right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative
means or at an alternative location. 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 alternatively, e.g., electronically.

You may have the right to have our organization amend your protected health information. 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

You have the right to receive an accounting of certain disclosures we have made, if any, of your
protected health information. We reserve the right to change the terms of this notice and will
inform you by mail of any changes. You then have the right to object or withdraw as provided in
this notice.

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 contact of your complaint. We will not retaliate against you for filing a
complaint. We are required by law to maintain the privacy of, and provide individuals with, this
notice of our legal duties and privacy practices with respect to protected health information, if
you have any questions concerning or objections to this form, please ask to speak with our owner
in person or by phone at 877-381-4115. Associated companies with whom we may do business,
such as an answering service or delivery service, are given only enough information to provide
the necessary service to you. No medical information is provided. We welcome your
comments: Please feel free to call us if you have any questions about how we protect your
privacy. Our goal is always to provide you with the highest quality services.