Notice of Privacy Practices for Protected Health Information
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!

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your
health information for purposes of treatment, payment and care operations. Protected health information
is the information we create and obtain in providing our services to you. Such information may include
documenting your symptoms examination and test results, treatment, and applying for future care or
treatment. It also includes billing documents for those services.

An example of use of your health care information:
We submit a request for payment to your health insurance company. The health insurance company
requests information from us regarding medical care given. We will provide to them
information about you and the care given.

Your Health Information Rights
The health record we maintain and billing records are the physical property of the practice. The
information in it, however, belongs to you. You have a right to:
-request a restriction on certain uses and disclosures of your health information by delivering the
request in writing to your office. We are not required to grant the request but will comply with any request
granted.
-request that you be allowed to inspect and copy your health record and billing record- you may
exercise this right by delivering the request in writing to our office
-appeal a denial of access to your protected health information
-request that your health care record be amended to correct incomplete or incorrect information by
delivering a written request to our office
-file a statement of disagreement if your amendment is denied, and require that the request for
amendment and any denial be attached in all future disclosures or your protected health information
-obtain an accounting of disclosures of your health information as required to be maintained by law by
delivering a written request to our office. An accounting will not include internal uses of information for
treatment, payment, or operations, disclosures made to your or made at your request, or disclosures
made to family members or friends in the course of providing care
-request that communication of your health information be made by alternative means or at an
alternative location by delivering the request in writing to our office; and,
-revoke authorizations that you made previously to use or disclose information except to the extent
information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights, please contact Peter Scarpelli, in person or in writing,
during normal hours. He will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities
The practice is required to:
-maintain the privacy of your health information as required by law
-provide you with a notice for our duties and privacy practices as to the information we collect
and maintain about you.
-abide by the terms of this Notice
-notify you if we cannot accommodate a requested restriction or request
-accommodate your reasonable requests regarding methods to communicate health information
with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access
practices and to enact new provisions in our privacy practices and access practices and to enact new
provisions regarding the protected health information we maintain. If our information practices change, we
will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a
copy of our “Notice” or by visiting our office and picking up a copy.

To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling
of your information, you may contact Peter Scarpelli. Additionally, if you believe your privacy rights have
been violated, you may file a written complaint at our office by delivering the written complaint to Peter
Scarpelli. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human
Services . We cannot, and will not, require you to waive the right to file a complaint with the Secretary of
Health and Human Services as a condition for receiving treatment from the practice. We cannot, and will
not retaliate against you for filing a complaint with the Secretary.

Other Disclosures and Uses
Notification:
Unless you object, we may use or disclose your protected health information to notify, or
assist in notifying, a family member, personal representative,or other person responsible for your care,
about your location, about your general condition.

Communication with Family: Using our best judgment, we may disclose to a family member, other
relative, close personal friend, or any other person you identify, health information relevant to that person's
involvement in your care or in payment for such care if you do not object or in an emergency.
Food and Drug Administration: We may disclose to the FDA your protected health information relating
to adverse events with respect to products and product defects, or post-marketing surveilllance
information to enable product recalls, repairs, or replacements.

Workers Compensation: If you are seeking compensation through Workers Compensation, we may
disclose your protected health information to the extent necessary to comply with laws relating to Workers
Compensation.

Abuse & Neglect: We may disclose your protected health information to public authorities as allowed by
law to report abuse or neglect.

Correctional Institutions: If you are an inmate of a correctional institution, we may disclose to the
institution, or its agents, your protected health information necessary for your health and the health and
safety of other individuals.

Law Enforcement: We may disclose your protected health information for law enforcement purposes as
required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the
custody or law enforcement.

Health Oversight: Federal law allows us to release your protected health information to appropriate
health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings: We may disclose your protected health information in the course
of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed
by a proper court order.

Other Uses: Other uses and disclosures besides those identified in this Notice will be made only as
otherwise authorized by law or with your written authorization and you may revoke the authorization as
previously provided.

Effective 4/1/2003 Revised 6/25/3014