NOTICE IS EFFECTIVE ON APRIL 14, 2003
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.

Protected Health Information (referred to in this Notice as PHI) is information, including demographic information, that may identify you and that relates to health care services provided to you. Washington Plastic Surgery Group is required by law to maintain the privacy of your PHI. We are required by law to provide you with this Notice of Privacy Practices explaining our legal duties and privacy practices with respect to medical information. We are required to abide by the terms of this Notice – in other words, we are only allowed to use and disclose medical information in the manner that we have described in this Notice.

We may change the terms of the Notice in future. We reserve the right to make changes and to make the new Notice effective for all medical information that we maintain. If we make changes
to the Notice, we will:

• Post the new Notice in our waiting area
• Have copies of the new Notice available upon request
• Post the new Notice on our website (www.washingtonplastics.com)

If, at any time, you have questions about information in this Notice or about our privacy policies, procedures or practices, you can contact our Privacy Officer at (301) 656 –6398.

The rest of this Notice will discuss how we may use and disclose medical information about you, explain your rights with respect to medical information about you and describe how and where you may file a privacy-related complaint.

USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION:
Your protected health information may be used and disclosed by our physicians, our office staff and others outside of our office that are involved in your care and for the purpose of providing health care services to you. Following are examples of the types of uses and disclosures of your protected health information that our office is permitted to make. They are not meant to be exhaustive, but to describe the types of uses and disclosures that may be used by our office.

1. Treatment: We may use and disclose medical information about you to provide health care treatment to you. For example, we may communicate with other health care providers regarding your treatment to coordinate or manage your health care.

2. Payment: We may use and disclose medical information about you to obtain payment for care services that you received. This means that we may use medical information about you to arrange for payment (such as preparing bills and managing accounts). We may also disclose medical information about you to others (such as insurers, collections agencies, consumer reporting agencies). We may also disclose medical information to an insurance plan before you receive certain health care services because, for example, we may need to determine what or if the insurance company will cover a particular service.

3. Health care operations: We may use or disclose, as needed, your protected health information to support the business activities of our practice. For example, we may use a sign-in sheet at the registration desk. We may also call you by name when the physician is ready to see you. We use or disclose your protected health information to contact you with a reminder of your appointment with our office.

4. Business Associates: We will share your protected health information with third party business associates such as transcription or billing services for the practice. We will have a written contract that protects the privacy of your protected health information for each business associate relationship that involves using or disclosing your protected health information.

5. Persons involved in your care Unless you object, we may disclose your protected health information about you to a relative, close personal friend or any other person you identify if that person is involved in your care and the information is relevant to your care. If the patient is a minor, we may disclose protected health information about the minor to a parent, guardian or other responsible person. You may ask us at any time not to disclose protected health information about you to persons involved in your care. We will agree to your request and not disclose the information except in certain limited circumstances.

6. Required by law: We will use and disclose protected health information about you whenever we are required to do so by applicable state and federal law.

7. National priority uses and disclosures: When permitted by law, we may use or disclose protected health information about you without your permission for various activities that are recognized as “national priorities.” We will only disclose protected health information about you in the following circumstances when we are permitted to do so by law. Below is a list of those activities – for more information on these types of disclosures, contact our Privacy Officer:

1. Threat to health or safety
2. Public health activities
3. Abuse, neglect, domestic violence
4. Health oversight activities
5. Court proceedings
6. Food and Drug Administration
7. Law enforcement
8. Worker’s compensation
9. Research organizations
10. Certain government functions

8. Treatment alternatives: We may use and/or disclose protected health information about you in order to inform you of or recommend new treatment or different methods for treating a medical condition that you have or to inform you of other health related benefits and services that may be of interest to you.

9. Marketing: We may use and disclose protected health information about you to contact you in person or by other means to encourage you to purchase or use a product or service. For instance, we may use protected health information about you to send you a small promotional gift or to send you information about a health-related product or service.

10. Authorization: other than the uses and disclosures described above we will not use or disclose your protected health information about you with your or your personal representative’s authorization – written permission – to do so. If you sign such an authorization, you may later revoke or cancel your authorization in writing (except in very limited circumstances). If you would like to revoke your authorization please contact our Privacy Officer for the necessary form. We will follow your instructions except to the extent that we have already relied upon your authorization and have taken some action.

II. YOUR RIGHTS WITH RESPECT TO YOUR MEDICAL INFORMATION
The following is a statement of your rights with respect to your protected health information and a description of how you may exercise these rights.

1. Right to a copy of this Notice: You have a right to have a paper copy of this Notice. Please ask the receptionists for a copy or contact our Privacy Officer. You may also obtain a copy of the notice from our website: www.washingtonplastics.com. If you wish to receive a copy of this notice via email please contact our Privacy Officer.

2. Right of access to inspect and copy: You have the right to inspect and receive a copy of medical information about you that we maintain in certain groups of records. If you wish to inspect or receive a copy of your medical information you must provide us a request in writing. Please contact our Privacy Officer for the necessary form. If we deny your request we will explain our reason for doing so in writing. We will also inform you in writing if you have the right to have our decision reviewed by another person. If you would like a copy of the information, we will charge you a fee to cover the costs of the copy. The fee is $.60 (cents) per page plus postage (if mailed) and supply costs and must be paid prior to receipt of the requested information.

3. Right to have medical information amended: You have the right to have us amend (which means correct or supplement) medical information about you. If you believe that we have information that is either inaccurate or incomplete, we may amend the information to indicate the problem and notify others who have copies of the information. You must request any amendment in writing. Please contact our Privacy Officer for the necessary form. We may deny your request in certain circumstances. We will explain any denial in writing. You will have the opportunity to send us a statement explaining why you disagree with our denial and we will share your statement whenever we disclose the information in the future. We will respond to your request within 60 days. One 30-day extension is permitted with a notification of the reason for the delay.

4. Right to an accounting of disclosures we have made: You have the right to receive a detailed listing of disclosures that we have made for the previous six (6) years. We must have your request for an accounting in writing. Please contact the Privacy Officer for the necessary form. The accounting will not include several types of disclosures, including, but not limited to, disclosures for treatment, payment or health care operations. It will also not include disclosures made to family members or friends involved in your care for notification purposes or for disclosures made prior to April 14, 2003. If you request an accounting more than once every twelve (12) months, we may charge you a fee of $10.00 (ten dollars) to cover the costs of preparing the accounting. You have a right to withdraw/modify your request for a subsequent accounting to avoid or reduce this fee.

5. Right to request restrictions on uses and disclosures: You have the right to request that we limit the use and disclosure of medical information about you treatment, payment and health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care for notification purposes as described in this Notice. We are not required to agree with your request. If your physician believes it is in your best interest to permit use and disclosure of your PHI, it will not be restricted. If we do agree, we must follow your restrictions except if the information is needed for emergency treatment. You may cancel the restrictions at any time and we may cancel a restriction as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation. The restriction must be in writing – please contact the Privacy Officer for the necessary form.

6. Right to request an alternative method of contact: You have the right to request to be contacted at a different location or by a different method. We require that this request be in writing. Please contact the Privacy Officer for the necessary form. We will agree to any reasonable request for alternative methods of contact and/or may require additional conditions to be met.

III FILING COMPLAINTS
If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. We will not take any action against you or change our treatment of you in any way if you file a complaint.
To file a written complaint to us, you may bring it to the office or mail it to our office.
To file a complaint with the Department of Health and Human Services, you may send your complaint to:

Department of Health and Human Services
Office for Civil Rights
Region III
150 S. Independence Mall West, Suite 372
Public Ledger Building
Philadelphia, Pa. 19106-9111
Phone: Main Line: 215-861-4441
Hotline: 800-368-1019
Fax: 215-861-4431
TDD: 215-861-4440

Timely Filing: Please note: You must file your complaint to the Department of Health and Human Services within 180 days of knowing, or perceived knowing, that the violation occurred unless the time limit is waived by the Secretary of DHHS for good cause shown. Please contact the Department of Health and Human Services if you have questions or need other guidance in filing your complaint.