MOWERY CLINIC, L.L.C.

  Administrator                                                                                   Privacy Officer

If you have any questions about this notice, please contact

OUR PLEDGE REGARDING YOUR HEALTH INFORMATION.

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for your future care or treatment, and billing-related information. Such records are necessary for the healthcare provider to provide you with quality care and to comply with certain legal requirements.

We are committed to protecting the confidentiality of our records containing information about you. This notice applies to all records of your care created or received by Mowery Clinic. Other healthcare providers from whom you obtain care and treatment may have different policies or notices regarding the use and disclosure of your health information created or received by that provider. Also, health plans in which you participate may have different policies or notices concerning information they receive about you.

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

We are required by law to maintain the privacy of your health information; give you this notice of our legal duties and privacy practices and make a good faith effort to obtain your acknowledgement of receipt of this notice; and follow the terms of the notice that is currently in effect.

Right To Inspect and Copy. You have the right to inspect and copy health 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 copy your health information, you must complete a specific form providing information we need to process your request. To obtain this form or to obtain more information concerning this process, please contact the person identified on the first page of this Notice. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services associated with your request. We may require that you pay such fee prior to receiving the requested copies.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by Mowery Clinic will review your request and the denial. The person conducting the review will not be the person who denied your original request. We will comply with the outcome of the review.

Right To Request Amendment. If you believe that our records contain information that is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Mowery Clinic.

To request an amendment, you must complete a specific form providing information we need to process your request, including the reason that supports your request. To obtain this form or to obtain more information concerning this process, please contact the person identified on the first page of this Notice.

We may deny your request for an amendment if you fail to complete the required form in its entirety. 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 health information kept by or for Mowery Clinic;

• Is not part of the information that you would be permitted to inspect and copy; or

• Is accurate and complete.

If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of health information about you, with certain exceptions specifically defined by law.

To request this list or accounting of disclosures, you must complete a specific form providing information we need to process your request. To obtain this form or to obtain more information concerning this process, please contact the person identified on the first page of this Notice.

Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). 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 cost 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 health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must complete a specific form providing information we need to process your request. To obtain this form or to obtain more information concerning this process, please contact the person identified on the first page of this notice.

Right to Request Alternative Methods of Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request an alternative method of communications, you must complete a specific form providing information we need to process your request. To obtain this form or to obtain more information concerning this process, please contact the person identified on the first page of this Notice. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

You may obtain a copy of this notice at our website, www.moweryclinic.com.

To obtain a paper copy of this notice, contact the person identified on the first page of this Notice.

If you believe your rights with respect to health information about you have been violated by Mowery Clinic, you may file a complaint with Mowery Clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with Mowery Clinic, contact the person identified on the first page of this Notice. All complaints must be submitted in writing.

You may be assured that you will not be penalized for filing a legitimate complaint.

The following categories describe different ways that we are permitted to use and disclose health information without a specific authorization from you. If you desire to restrict our use of your health information for any of these purposes, you need to submit a request for restrictions in the manner described above.

For Treatment. We may use information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at Mowery Clinic. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Different departments of Mowery Clinic also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays.

We also may disclose health information about you to people outside Mowery Clinic who may be involved in your medical care after you leave Mowery Clinic, such as family members, friends, or others that either we or you use to provide services that are part of your care. We will give you an opportunity, however, to restrict such communications.

We may disclose health information about you to other health care providers who request such information for purposes of providing medical treatment to you.

For Payment. We may use and disclose health information about you so that the treatment and services you receive at Mowery Clinic may be billed to and payment may be collected from you, an insurance company, or other third party. For example, we may need to give your health plan information about surgery you received so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

We also may provide information about you to other health care providers to assist them in obtaining payment for treatment and service provided to you by that provider. We may also provide information to a health plan for purposes of arranging payment for treatment and services provided to you.

For Health Care Operations. We may use and disclose health information about you for our internal operations. These uses and disclosures are necessary to operate Mowery Clinic and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may also combine the health information we have with health information from other health care providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific patients are.

We may disclose health information about you to another health care provider or health plan with which you also have had a relationship for purposes of that provider’s or plan’s internal operations.

Appointment Reminders. We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care at Mowery Clinic. Unless you direct us to do otherwise, we may leave messages on your telephone answering machine identifying Mowery Clinic or a particular physician and asking for you to return our call. Unless we are specifically instructed by you otherwise, we will not disclose any health information to any person other than you who answers your phone except to leave a message for you to return the call.

Surveys. We may use and disclose health information to contact you to assess your satisfaction with our services.

Treatment Alternatives. We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you, or to provide you with promotional gifts of nominal value.

Business Associates. There are some services provided in our organization through contracts or arrangements with business associates. For example, we may contract with a copy service to make copies of your health record. When these services are contracted, we may disclose your health information to our business associate so they can perform the job we’ve asked them to do. To protect your health information, however, we require our business associates to appropriately safeguard your information.

Individuals Involved In Your Care or Payment For Your Care. We may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. In addition, we may disclose health information about you to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patients' need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process, but we may, however, disclose health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs. We will ask for your specific permission if a researcher will have access to your name, address, or other information that reveals who you are.

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

To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and

safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Organ and Tissue Donation. If you are an organ donor, we may use or disclose health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Employers. We may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.

Workers' Compensation. We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

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

• to prevent or control disease, injury or disability;

• to report births and deaths;

• to report child abuse or neglect;

• to report reactions to medications or problems with products;

• to notify people of recalls of products they may be using;

• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

• to notify the appropriate government 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 health 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 laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health 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 an order protecting the information requested.

Law Enforcement. We may release health information to a law enforcement official if requested to do so:

• 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;

• About criminal conduct at Mowery Clinic; and

• 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 health 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 health information about patients of Mowery Clinic to funeral directors as necessary for them to carry out their duties.

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

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

Inmates/Persons In Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

OTHER USES OF HEALTH INFORMATION.

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. Of course, we are unable to take back any disclosures we have already made with your permission.

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at our facility and on our website. The notice will contain on the first page the effective date. ACKNOWLEDGEMENT. You will be asked to provide a written acknowledgement of your receipt of this Notice. We are required by law to make a good faith effort to provide you with our Notice and obtain such acknowledgement from you. However, your receipt of care and treatment from Mowery Clinic is not conditioned upon you providing the written acknowledgement.

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