HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INORMATION ABOUT MAY BE USED AND DISCLOSED

AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The above-named agency (the “Clinic”) is committed to protecting the confidentiality of its patients’ health information.

This Notice of Privacy Practices describes how we may use and disclose your health information and the rights that you

have regarding your health information.

HOW WILL WE USE AND DISCLOSE YOUR HEATH INFORMATION

Your authorization is not required for us to use or disclose your health information for the following purposes:

Treatment: We will use and disclose your 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

may disclose your health information, as necessary, to another health care provider that provides care to you or to a

physician to whom you have been referred to ensure that the physician has the necessary information to diagnose and treat

you.

Payment: Your health information will be used or disclosed, as needed, to obtain payment for your health care services.

For example, obtaining approval for a therapy session may require that your relevant medical information be disclosed to

your health plan to obtain approval for such therapy.

Healthcare Operations: We may use or disclose, as needed, your health information in order to support the business

activities of the Clinic or other involved providers. These activities include, but are not limited to, training and education;

quality assessment/improvement activities; risk management; claims management; legal consultation; physician and

employee review activities; licensing; regulatory surveys; and other business planning activities. For example, we may

disclose your medical information to medical students that see patients at our office.

Appointments and Health-Related Services: We may use your health information to contact your to remind you of an

upcoming appointment, to inform you about possible treatment options or alternatives, or to tell you about health-related

services available to you. Text messages may be utilized for upcoming appointment reminders.

Family and Friends: We may disclose your health information to a family member or friend who is involved in your

medical care of to someone who helps pay for your care. If you do not want us to disclose your medical information to

family members or other involved in your care, please contact the manager of the Clinic and your referring physician’s

office.

Business Associates: We enter into contracts with third-party entities known as business associates. These business

associates provide services to or perform functions on our behalf, e.g., accountants, consultants and attorneys. We may

disclose your relevant health information to business associates once they have agreed in writhing to safeguard your

medical information. Business associates are also required by law to protect the privacy of your health information.

Research: Under certain circumstances, we may also use and disclose information about you for research purposes.

Before we use or disclose your medical information for research (without your authorization), the research project will

have been approved through a special approval process which balances the research needs with patients’ need for privacy

of their medical information. We may also use or disclose your medical information (i) to researchers who are preparing

to conduct a research project, so long as the medical information they review is not removed from us: or (ii) to contact you

or, under certain circumstances, to allow a research entity with whom we contract, to you about the possibility of

enrolling in a research study.

Required by Law: Federal, state and local laws sometimes require us to disclose patients’ health information. For

example, we are required to report child abuse or neglect and must provide certain information to law enforcement

officials in domestic violence cases.

Special Situations: We are also permitted to use or disclose your health information without your written authorization in

connection with: Public Health Activities (e.g., to report births, deaths, communicable diseases, injuries or disabilities);

Health Oversight Activities (e.g., to report certain information to state and federal agencies that monitor our compliance

with state and federal laws); Food and Drug Administration (relative to adverse events or post-marketing surveillance);

Law Enforcement (in limited circumstances, such as to identify or locate suspects, fugitives, witnesses or victims of

crime, to report deaths from crimes or crimes on premises or to prevent or lessen a serious and imminent threat to the

health or safety of the community or an individual); Legal Proceedings (if ordered to do so by a court or if we receive an

appropriate subpoena); Worker’s Compensation (in connection with work-related injuries and pursuant to applicable

law); Coroners, Medical Examiners and Funeral Directors (consistent with applicable law); Organ and Tissue

Donation (consistent with applicable law); Military, Veterans, National Security and Other Government Purposes

(e.g., if you are a member of the armed forces, we may release your medical information as required by military command

authorities); and Correctional Institutions (if you are and inmate, we may disclose medical information necessary for your

health and the health and safety of other individuals in the institution or its agents).

Other Uses and Disclosures: If we wish to use or disclose your health information for a purpose not discussed in this

Notice, we will seek your authorization. Specific examples of uses and disclosures of health information requiring your

authorization include: (i) most uses and disclosures of your health information for marketing purposes; and (ii)

disclosures of your health information that constitute the sale of your health information. You may revoke your

authorization at any time in writing, except to the extent that your physician or his/her practice has taken an action in

reliance on the use or disclosure indicated in the authorization.

YOUR HEALTH INFORMATION RIGHTS

Although your health information is our property, you have the right to:

Request access to your health information. You may request to inspect and/or obtain a copy of your health information.

If we maintain your health information electronically, you may obtain and electronic copy of the information or ask us to

send it to a person or organization that you identify. If you request a copy (paper or electronic), we may charge you a

reasonable, cost-based fee.

Request a restriction on the use or disclosure of your health information. You may ask us not to use or disclose any part

of your health information for a particular reason related to treatment, payment or health care operations. We will

consider your request, but we are not legally obligated to agree to a requested restriction except for in the following

situation: If you have paid for services out-of-pocket in full, you may request that we not disclose information related

solely to those services to your health plan. We are required to abide by such a request, except where we are required by

law to make the disclosure. Any request for a restriction must in writing and submitted to the manager of the Clinic. We

will notify you if we cannot accommodate a requested restriction.

Request to receive confidential communications. You have the right to receive confidential communication from us by

alternative means or at an alternative location. Such a request must be made in writing and submitted to the manager of

the Clinic. We will notify you if we cannot accommodate your request.

Request an amendment to your medical information. If you believe that any information in your medical record is

incorrect, or if you believe important information is missing, you may request that we correct the existing information or

add the missing information. Such a request must be in writing and submitted to the manager of the Clinic. You will be

notified if your request cannot be granted.

Request an accounting of certain disclosures. You have the right to request a list of many of the disclosures we make of

your health information. Any request for an accounting must be in writing and submitted to the manager of the Clinic.

The first list will be provided to your for free, but you may be charged for any additional lists requested during the same

year.

Receive a paper copy of the Notice. You have the right to receive a paper copy of this Notice upon request, even if you

agreed to accept this Notice electronically.

OUR RESPONSIBILITIES:

We are required to (i) maintain the privacy of your health information as required by law; (ii) provide you with notice of

our legal duties and privacy practices with respect to your health information, and to abide by the terms of such notice;

and (iii) notify you following a breach of your health information that is not secured in accordance with security

standards.

We reserve the right to change the terms of his Notice and to make the provisions of the new Notice effective for all

health information that we maintain. If we change the terms of this Notice, the revised Notice will be made available

upon request and posted in our practice locations. Copies of the current Notice may be obtained by contacting the

manager of the Clinic.

QUESTIONS, COCERNS OR COMPLAINTS

If you have any questions or want more information about this Notice or how to exercise your privacy rights, please

contact the Clinic.

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the

Department of Health and Human Services (HHS). To file a complaint with us, you may contact the Privacy Officer of

the Clinic by mail to: DHM Privacy Officer, 1523 Texas Ave., Bastrop, LA 71220.

To file a complaint with HHS, you may contact the Office for Civil Rights, U.S.

Department of Health and Human Services, 200 Independence Ave. S.W., Room 509F HHH Bldg., Washington DC

20201 (OCRComplaing@hhs.gov).

We will not retaliate against you for filing a complaint.