This notice describes how information about you may be used and disclosed and how you can get access to this information.

If you have any questions about this notice, our policies or practices please contact

Privacy Officer
Wendy Sullivan
806 Glover Street, Suite B
Enterprise, AL 36330
or 1-334-347-0991 for the main desk.

OUR COMMITMENT TO PROTECTING HEALTH INFORMATION ABOUT YOU

In this Notice, we describe the ways that we may use and disclose health information about our patients. The HIPAA Privacy Rule requires that we protect the privacy of health information that identifies a patient, or where there is a reasonable basis to believe the information can be used to identify a patient. This information is “protected health information or PHI”. This Notice describes you rights as our patient and our obligations regarding the use and disclosure
or PHI.

We are required by law to:

• Maintain the privacy of PHI about you.
• Give you this Notice of our legal duties and privacy practices
with respect to PHI
• Comply with the terms of our Notice of Privacy Practices that
is currently in effect.

We reserve the right to make changes to this Notice and to make such changes effective for all PHI we may already have about you. If and when this Notice is changed, we will post a copy in our office in a prominent location. We will also provide you with a copy of the revised Notice upon your request made to our Privacy Officer.

OUR PLEDGE REGARDING MEDICAL AND BILLING INFORMATION

We understand that information about you and your health is personal. We are committed to protecting medical and billing information about you. We create a record of the care and services you receive at our facility. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and charges or bills for services related to your care. These records are used to provide you with quality care and to comply with certain legal requirements.

This Notice applies to all of the records of your care generated by your provider of care, David H. Hayes, M.D.

It will tell you about the ways in which we may use and disclose medical and billing information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your medical information.

We are required by law to:

• Make sure that medical and billing information that identifies
you is kept private
• Give you this Notice of our legal duties and privacy practices
with respect to medical and billing information about you
• Follow the terms of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL AND BILLING INFORMATION
The following categories describe different ways we use and disclose medical billing information. We may also disclose information about you to other healthcare providers so they may treat you.

Communication from Our Office
We may contact you to remind you of appointments and to provide you with information about treatment alternatives to other health related benefits such as annual screenings, mammograms and recheck appointments. We will attempt to relay this message on your answering machines or with whomever answers your phone unless we are notified otherwise in writing at the time of this notification.

Right to Request Confidential Communications
You have the right to request that we communicate with you about medical treatment and options in a certain way or at a certain location. For example, you can ask that we contact you at a different phone number or address than that shown in your records.

Payment
Your protected health information will be used, as needed, in activities related to obtaining payment for your healthcare services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to your health insurance or governmental plan to obtain approval for the hospital admission.

Healthcare Operations
We may use or disclose, as needed, your protected health information in order to support our business activities. For example when we review employee performance, we may need to look at what an employee has documented in your medical record.

Treatment Alternatives
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. For example, your protected health information may be provided to a doctor to whom you have been referred to ensure that the doctor has the necessary information to diagnose or treat you.

Individuals Involved in Your Care or Payment for Your Care
Unless you tell us otherwise, we may release medical information about you to a friend or family member who is involved in your medical care. We may also tell your family or friends your condition. In addition, we may disclose medical information about you to an entity assisting us in a disaster relief effort so that your family can be notified about your condition, status and location.

Business Associates
There are some services provided in our organization through contacts with business associates. Examples may include certain laboratory, test, medical transcription services. When these services are contracted we may disclose your health information to our business associates so they can perform the jobs we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to safeguard your information appropriately.

As Required by Law
We will disclose medical information about you when required to do so by federal, state or local laws.

To Avert a Serious Threat to Health or Safety
We may use or disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or other person. Any disclosure, however, would only be to someone able to help prevent the threat.

Military Personnel
If you are a member of the armed forces, active duty or reserve, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Worker’s Compensation
We may release medical information about you as necessary to comply with laws related to the worker’s compensation or similar program that provide benefits to work-related injuries or illnesses.

Public Health Risks
We may disclose medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability
• To report birth and deaths
• To report reactions to medications or problems with products
• To notify a person who may been exposed to a disease, or
who may be at risk for contracting or spreading a disease or
condition
• To notify the appropriate governmental or law enforcement
authority if we believe a patient has been the victim of abuse,
neglect or domestic violence.

We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities
We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights law.

Lawsuit and Disputes
If you are involved in a lawsuit or a dispute, we may disclose information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain and order protecting the information requested.

Law Enforcement
We may release medical information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons, or similar process
• To identify or locate a suspect, fugitive, material witness or missing person
• About the victim of a crime, if under certain limited circumstances, we are unable to obtain the person’s agreement
• About a death we believe may be the result of criminal conduct
• In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of
the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about you as a patient of the facility to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities
We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Protective Services for the President and Others
We may disclose medical information about you to authorize federal officials so they may provide protection to the President, other authorized person and foreign head of state or to conduct special investigations.

Inmates
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others or for the safety and security of the correctional institution.

Other Uses of Medical Information: Authorization and Right to Revoke Authorization
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you authorize us to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required by state law to retain our records of the care that we provide to you.

YOUR RIGHTS REGARDING MEDICAL AND BILLING INFORMATION You have the following rights regarding
your medical and billing information we maintain.

Right to Inspect and Copy Your Medical and Billing Information
You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and obtain a copy of medical and billing information that may be used to make decisions about you, you must submit your request in writing to Wendy Sullivan, 806 Glover Street, Suite B, Enterprise AL 36330.

If you request a copy of the information, we may charge a fee for the cost of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy this information in certain limited circumstances. If you are denied access to medical or billing information, you may make a request in writing to Privacy Officer, Wendy Sullivan, 806 Glover Street, Suite B, Enterprise AL 36330. and the denial will be reviewed.

Right to Amend Your Medical and Billing Information
If you feel that medical and billing information we have about you is incorrect or incomplete, you may ask us to amend the information. You have a right to request an amendment for as long as the information is kept by or for the facility.

To request an amendment your request must be made in writing and submitted to Privacy Officer, Wendy Sullivan, 806 Glover Street, Suite B, Enterprise AL 36330. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
• Is not part of the information that you would be permitted to inspect and copy is not accurate and complete

Right to an Accounting of Disclosures of your Medical and Billing Information
You have the right to request an “accounting of disclosure”. This is a list of certain disclosures we made of medical and billing information about you, except for those disclosure to carry out treatment, payment or health care operation, disclosure made to you, disclosure you have authorized or certain other disclosures. To request an accounting of disclosures, you must submit your request in writing to Privacy Officer, Wendy Sullivan, 806 Glover Street, Suite B, Enterprise AL 36330.

Your request must state a time period, which may not be longer than six (6) years and may not include dates before April14, 2003. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions
You have the right to request a restriction or limitation on the uses and disclosures of your medical or billing information for treatment, payment or health care operations. You also have the right to request a restriction of the medical or billing information we disclose about you to someone who is involved in your care or payment for your care, like a family member or friend. For example you could ask that we not use or disclose information about your particular surgery or other particular treatment. We are not required to agree to your request. If we cannot agree to your requested restriction, we will notify you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. We may terminate our agreement for a restriction if we inform you and you agree.

To request restrictions, you must make your request in writing to Privacy Officer, Wendy Sullivan, 806 Glover Street, Suite B, Enterprise AL 36330.

Right to a Paper Copy of This Notice
You have the right to a paper copy of this Notice, which will be given to you during the registration process.

Changes to this Notice
We reserve the right to change this Notice at any time. We reserve the right to make the revised or changed Notice effective for medical and billing information we already have about you as well as any information we receive in the future.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with the facility or with the Secretary or the Department of Health and Human Services. To file a complaint with the facility, contact:

Privacy Officer
Wendy Sullivan
806 Glover Street, Suite B
Enterprise, AL 36330
or 1-334-347-0991 for the main desk.

You will not be retaliated against or penalized for filing a complaint.

The Secretary of the Department of Health and Human Services may be contacted at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by telephone at 1.877.696.6775.