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.

The privacy of your medical information is important to us. You may be aware that U.S. government regulations established under HIPAA (Health Information Portability and Accountability Act) govern the protection of health information. This notice describes how it may be used, as well as certain rights you have as a patient.

- Use And Disclosure Of Protected Information -
All information regarding patients, their treatments, diagnosis and appointments is kept strictly confidential. Patient chart and financial data will be seen only by the practitioner. There is no electronic transfer of your medical data. For treatment
purposes, private information will be provided to another practitioner only after your written consent is given. Your medical information may be used, without further notice to you, or specific authorization by you, where required by law:

• for public health purposes; • to report child abuse; • in judicial or administrative proceedings;
• by a health oversight agency for oversight activities authorized by law; • under law enforcement purposes;
• by a coroner or medical examiner; • to avert serious threat to health or safety;
• under military authorities if you are a member of the armed forces of the United States.

New York State law provides additional protection for information regarding HIV/AIDS. We will continue to follow New
York State law with respect to such information.

We may contact you by mail or telephone, at your residence, to remind you of appointment(s). No reference to medical
service will be made. Occasionally, we may call to give instructions. If you wish for us to make use of alternative methods of communicating with you, please provide that information on the signature sheet.

- Rights That You Have -
You have the right to inspect and obtain copies of your medical information. A reasonable fee will be charged for copying. You have the right to request amendments to your medical information. Such requests must be in writing and must state the reason for the requested amendment. If we disagree with requested amendment, we will notify you of such disagreement, and we will further notify you of your rights. You have the right of request an accounting of any disclosures we make of your medical information, except for: disclosures we make directly to you, or to carry out treatment, payment or health care operations, or as requested by your written authorization, or for emergency or notification purposes.

- Obligations That We Have -
We are required by law to maintain the privacy of protected health information and to provide individuals with
notice of our legal duties and privacy practices. We are required to abide by the terms of this notice as long as it currently is in effect. Please sign the attached acknowledgement of receipt as we are required under law to show that we gave you this information.

- Acknowledgement of Receipt of Notice of Privacy Practices -
By signing below, I acknowledge that I have read and understand the Notice of Privacy Practices and have
therefore been advised of how medical information may be used and disclosed in the office, and have also been informed of how I may gain access to and control this medical information.