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 IS EFFECTIVE 12/12/02 UNTIL FURTHER NOTICE.

Right to Notice
As a patient, you have the right to adequate notice of the uses and disclosures of your protected health information. Under
the Health Insurance Portability and Accessibility Act (HIPAA), [Practice Name here] can use your protected health information
for treatment, payment and health care operations.
a) Treatment - We may use or disclose your health information to a physician or other healthcare provider providing treatment
to you.
b) Payment - We may use and disclose your health information to obtain payment for services we provide you.
c) Health care operations - We may use and disclose your health information in connection with our healthcare operations.
Healthcare operations include quality assessment and improvement activities, reviewing the competency or qualifications of
healthcare professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing
or credentialing activities.

Your Authorization
Most uses and disclosures that do not fall under treatment, payment, health care operations will require your written
authorization. Upon signing, you may revoke your authorization (in writing) through our practice at any time.

Emergency Situations
In the event of your incapacity or an emergency situation, we will disclose health information to a family member, or another
person responsible for your care, using our professional judgment. We will only disclose health information that is directly
relevant to the person's involvement in your healthcare.
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