THERAPY ASSOCIATES, LLC NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. Therapy Associates, LLC is dedicated to protecting your medical information. The medical record is the physical property of Therapy Associates, LLC, and the health information contained in the medical record is yours. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. Who Will Follow This Notice? Therapy Associates, LLC health care to our patients and clients in partnership with physicians and other professionals and organizations. The information privacy practices in this Notice will be followed by: Any health care professional who treats you on behalf of Therapy Associates, LLC Any business associate or partner of Therapy Associates, LLC with whom we share health information All employed staff, including independent contractors Our Pledge To You: We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive and to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care that we maintain, whether created by staff, your personal physician or records disclosed to us per your authorization from other providers. We Are Required By Law To: Keep medical information about you private Give you this Notice of our legal duties and privacy practices with respect to medical information about you Follow the terms of the Notice that is currently in effect. Changes To The Notice: We reserve the right to change the terms of this Notice, making any revision applicable to all of the health information that we maintain. If Therapy Associates, LLC revises the terms of this Notice, we will post a revised Notice at all locations of Therapy Associates, LLC and on our web site: www.therapyassociatesllc.com. We will also provide paper copies of the Notice upon request. You also will be asked to acknowledge in writing your receipt of this Notice. How Your Medical Information Will Be Used and Disclosed: We may use and disclose medical information about you for treatment (such as sending medical information about you to a specialist as part of a referral); to obtain payment for treatment (such as sending billing information to your insurance company or Medicare); and for health care operations (such as review for quality assessment and the appropriateness of the care you receive). Subject to several requirements, we may use or disclose medical information about you without prior authorization including but not limited to public health purposes, abuse and neglect reporting, health oversight audits or inspections, research studies, worker's compensation or other similar programs. We may disclose medical information in specific circumstances when required by law (such as a request from law enforcement for a blood alcohol level) or in response to valid judicial or administrative orders. We may contact you for appointment reminders or to tell you about our recommended possible treatment options, alternatives, health-related benefits or services that may be of interest to you or to support fund-raising efforts. You may be asked for your comments on the care that you received from Therapy Associates, LLC. Unless you object, Therapy Associates, LLC may disclose your medical information to family members, other relatives or close personal friends involved in your medical care. Therapy Associates, LLC may disclose your medical information to a public or private entity for the purpose of coordinating with that entity to assist in disaster relief efforts. Therapy Associates, LLC may disclose your medical information to prevent or lessen a serious threat to the health or safety of another person or the public. Other Uses Of Medical Information: In any other situation not covered by this Notice, we will ask for your written authorization before using or disclosing medical information about you. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision. Patient Rights: Your rights regarding your medical information include: The right to request restrictions on certain uses and disclosures of your medical information. Therapy Associates, LLC is not required to agree to your requested restriction. The right to receive communications from Therapy Associates, LLC in a confidential manner (such as sending mail to an address other than your home). The right to inspect and obtain a copy of your medical information. You may be charged a reasonable fee for any copies of your records. The right to request an amendment of your medical information. Your request must be in writing and may be denied if the information was not created by Therapy Associates, LLC; it is not part of the medical information maintained by Therapy Associates, LLC; or if it is determined that the information in the record is accurate. You may appeal the denial in writing. The right to receive an accounting of the disclosures of your official information made by Therapy Associates, LLC except for the disclosure made for treatment, payment of healthcare operations and for those specifically authorized by you. The right to receive a paper copy of the Notice. Complaints: If you are concerned that your privacy rights may have been violated or you disagree with a decision Therapy Associates, LLC has made, you may register your complaint with the Privacy Officer by leaving a message directly on the Privacy Officer's voicemail, or submitting your complaint in writing and addressed to the Privacy Officer at Therapy Associates, LLC. Finally, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Under no circumstances will you be penalized or retaliated against for filing a complaint.