CEDM abides by Federal Regulations requiring us to insure that your health information is protected. The following notice explains our privacy practices. Clients are required to read and sign this notice on admission to our practice. The CEDM Staff is committed to respecting your confidentiality. 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.

1. Introduction. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
2. Your Health Information Rights. While actual records that we maintain about you belong to us, the information contained in our records belongs to you. Under the federal Privacy Rules (42 CFR Part 160 and Part 164) you have the right to:
   • Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522. Note, however, that we are not required to agree to a restriction that you may request. If we believe it is in your best interest to permit use and disclosure of your health information, we will notify you that your request for restriction will not be honored. If we agree to the requested restriction, we may not use or disclose your health information in violation of that restriction unless it is needed to provide emergency treatment.
   • Obtain a paper copy of this Notice of Privacy Practices upon request
   • Inspect and obtain a copy of your health record
   • Amend your health record
   • Obtain an accounting of certain disclosures of your health information
   • Receive confidential communications of your health information by alternative means or at alternative locations
   • Revoke your authorization to use or disclose health information except to the extent that action has already been taken
3. Our Responsibilities. This Practice is required to:
   • Maintain the privacy of your health information
   • Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
   • Abide by the terms of this notice
   • Notify you if we are unable to agree to a requested restriction
   • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to us.

We will not use or disclose your health information without authorization, except as described in this notice.

IV. Examples of How We Will Use or Disclose Your Protected Health Information. Your protected health information may be used and disclosed by members of our staff and others outside of our office that are involved in your care and treatment for the purposes of providing services to you. Your protected health information may also be used and disclosed to enable us to be paid for the services we render to you.

Following are examples of the types of uses and disclosure of your protected health care information that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our Practice.

• Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

• Payment: Your protected health information will be used, as needed, to obtain payment for services that we provide to you. This may include certain activities that your health plan may undertake before it approves or pays for the services we recommend for you. For example, some health plans must make a determination that you are eligible for reimbursement for particular services before we can provide them to you and we must provide them with protected health information to enable them to make such a determination.

• Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support our own business activities. These activities include, but are not limited to, quality assessment activities, training and supervision of staff members, licensing, certification and conducting or arranging for other business activities.

We will share your protected health information with third party various activities that are essential to the operations of our organization. Whenever we have an arrangement between our organization and a business associate, we will limit the amount of protected health information that we provide to the minimum necessary to accomplish the particular task and we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. We may also contact you as part of our fundraising efforts

Uses and Disclosures That We May Make Unless You Object. In the following situation, we may disclose your protected health information if we inform you about the disclosure in advance and you do not object.

• Notification. Upon request, we may use or disclose information to notify or assist in notifying a family member, personal representative or another person responsible for your care, of your location and general condition.
• Communication with family or other caregiver. Staff members may disclose to a family member, other relative, close personal friend or any other person you authorize in writing, health information relevant to that person’s involvement in your care or payment related to your care. If you are present for, or otherwise available prior to, a notification or communication with family or another caregiver, and you have the capacity to make health care decisions, we may make the disclosure if you agree; or if we provide you with the opportunity to object and you do not object; or we reasonably infer from circumstances that you do not object. If you are not present for the notification or disclosure, or the opportunity to agree or object cannot be provided because of your incapacity or an emergency circumstance, we may determine whether the disclosure is in your best interest and, if so, we may disclose to the designated person only that information that is directly care.

Uses and Disclosures Not Requiring Your Authorization. The federal privacy rules provide that we may use or disclose your protected health information without your authorization in the following circumstances:

• Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
• We may disclose health information to the extent authorized by other similar programs established by law.
• Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
• Correctional Institution: Should you be an inmate of a correctional institution we may disclose to the institution or agents thereof, health information necessary for your health and the health and safety of other individuals.
• Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid search warrant or court order.
• Criminal Activity: We may disclose your protected health information if we believe that it constitutes evidence of criminal conduct that occurred on our premises. We may also disclose your protected health information if we are required by applicable state law to report suspected child abuse or neglect or abuse of incapacitated adults or an injury that we believe may have been the result of an illegal act. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
• Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and, in certain situations, in response to a subpoena, discovery request or other lawful process.
• Relating to Decedents: We may disclose protected health information regarding an miners or funeral directors consistent with applicable law.
• As Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by state or federal law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. For example, we must make disclosures when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the federal Privacy Rules.

VII. Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization. Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described in the Notice. You may revoke this authorization at any time in writing, except to the extent that we have already relied upon your authorization in making disclosure.

VIII. For More Information or to Report Complaints. If you wish to exercise any of the rights listed in Section II of this Notice, or if you have questions and would like additional information you may contact our Privacy Officer either in writing or by phone at (603)472-2846.

If you believe that your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the Secretary of the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint.

This notice was published on December 2, 2002, and became effective on April 14, 2003

Acknowledgement

I hereby acknowledge that I received this Notice on _______________________ 20______.

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Signature of Patient or Responsible Party Print Name of Patient

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Print Name of Responsible Party (if applicable)