THE ALLERGY

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 GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions or need any additional information about this Notice of Privacy Practices (Notice”), please contact The Allergy & Asthma Center, P.C.’s (“AAC”) Contact Person at (260) 432-5005.

AAC is required by the final Standards for Privacy of Individually Identifiable Health Information (the “Privacy Standards”) to maintain the privacy of your protected health information. In addition, AAC is required by law to provide you with adequate notice of AAC’s uses and disclosures of your protected health information, notice of your rights with respect to your protected health information, and notice of AAC’s legal duties with respect to your protected health information. This Notice is given to you to satisfy AAC’s legal obligations to provide adequate notice to you. AAC agrees to abide by the terms of its Notice then in effect.

AAC is required to give this Notice to you no later than its first delivery of services to you on or after April 14, 2003 (if the first service delivery to you is delivered electronically, AAC will provide electronic notice of its privacy practices automatically and contemporaneously in response to your first request for service). In addition, AAC is required to make its Notice available to you at any time upon your request, and to post the Notice in a clear and conspicuous location in the waiting room of each of AAC’s offices. AAC has a website at: www.allergyasthmacenter.com. A copy of this Notice will be posted on that website and a copy of the Notice will be available electronically through the website.

For purposes of the Privacy Standards and this Notice, the term “protected health information” means “individually identifiable health information”. The term “individually identifiable health information” means health information (whether oral or recorded in any form or medium), including demographic information collected from you, that identifies you, or could reasonably be used to identify you and which: is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and, relates to your past, present, or future physical or mental health or condition, the provision of health care to you, or the past, present, or future payment for the provision of health care to you.

As a general rule, AAC may not use, disclose or request protected health information about you except as required or permitted by the Privacy Standards. Furthermore, except in limited circumstances, AAC must use, disclose or request only the minimum necessary protected health information to accomplish the purpose of the use, disclosure or request.

1. Required Disclosures. The following categories describe the instances in which AAC is required to disclose your protected health information:

● To You. AAC is required to disclose protected health information about you to you when requested by you in certain circumstances. Pursuant to the Privacy Standards, you have the right to request access to your protected health information for inspection and copying purposes and to request an accounting of disclosures. Each of those rights in discussed in more detail in the “Your Rights Regarding Protected Health Information About You” section of this Notice.

● To the Secretary. AAC is required to disclose protected health information to the Secretary of the Department of Health and Human Services when the information is required in order for the Secretary to investigate or determine whether AAC is in compliance with the Privacy Standards.

2. Permitted Uses and Disclosures. The following categories describe the instances in which AAC is permitted to use and disclose protected health information about you without obtaining your written authorization. For each category, AAC has attempted to explain what it means and has given examples. Not every use or disclosure in a category will be listed. However, all of the ways AAC may use and disclose information without authorization will fall within one of the following:

● Treatment. AAC may use your protected health information to provide you with medical treatment or services. AAC may disclose protected health information about you to doctors, nurses, or other health care professionals who are involved in taking care of you. For example, AAC may be treating you for certain allergies. Those allergies may be relevant to care you may receive from another physician. As such, AAC may share your information with the other physician

● Payment. AAC may use or disclose your protected health information for purposes of receiving payment for treatment and services you receive. For example, AAC may give your insurance company information about your treatment so the insurance company will pay AAC or reimburse you. AAC may also tell your insurance company about treatment you are going to receive to determine whether your insurance company will pay for it.

● Health Care Operations. AAC may use and disclose protected health information about you for operational purposes. For example, your protected health information may be disclosed to AAC’s health care professionals to evaluate the performance of the health care professionals, to assess the quality of care and outcomes in your cases and similar cases, to learn how to improve AAC’s facilities and services, and, to determine how to continually improve the quality and effectiveness of the health care AAC provides.

● Incidental Uses and Disclosures. AAC may use and disclose protected health information about you incident to a use or disclosure permitted or required by the Privacy Standards so long as AAC has complied with the minimum necessary and safeguards requirements imposed under the Privacy Standards. For example, AAC’s nurses may discuss information about your care at the nursing station, and if someone overhears that discussion, the disclosure to that person will be permitted so long as the nurses discussed only the minimum necessary and AAC took appropriate steps to put safeguards in place.

● Appointment Reminders. AAC may use and disclose protected health information about you to contact you as a reminder that you have an appointment for treatment or medical care.

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

● Health-Related Benefits and Services. AAC may use and disclose your protected health information to tell you about health-related benefits or services that may be of interest to you.

● Fundraising Activities. AAC may use protected health information about you to contact you in an effort to conduct fundraising activities.

● Business Associates. AAC contracts with others outside of AAC’s organization to perform or assist AAC in performing functions that involve the use and disclosure of protected health information. For example, AAC may contract with a billing company to do billing for AAC. The billing company will need protected health information in order to perform its job. As such, AAC may disclose protected health information about you to business associates of AAC so that the business associates can perform the job AAC has asked them to do. In order to protect your protected health information, AAC will require all of its business associates to make assurances to AAC they will each appropriately safeguard your protected health information.

● Individuals Involved in Your Care. In certain circumstances, AAC may use or disclose protected health information about you to a family member, relative or close personal friend who is involved in your medical care. In addition, AAC may disclose protected health information about you to notify or assist in the notification of a family member, relative or close personal friend who is involved in your medical care of your condition, location and status.

● Disaster Relief Efforts. In certain circumstances, AAC may use or disclose protected health information about you to a public or private entity authorized by law to assist in disaster relief efforts for the purpose of coordinating with such entities.

● Personal Representatives. Except in limited circumstances, AAC must treat a personal representative of a decedent as the individual about who the protected health information relates. As such, AAC may disclose protected health information to your personal representative.

● Adults and Emancipated Minors. If a person has authority to act on behalf of an adult or an emancipated minor in making decisions related to health care, AAC must treat that person as a personal representative. As such, except in limited circumstances, AAC may disclose protected health information to your personal representative as if the disclosure was being made to you.

● Unemancipated Minors. If, under applicable law, a parent, guardian or other person acting in loco parentis has authority to obtain access to protected health information about an unemancipated minor, then AAC may disclose protected health information to the person acting in loco parentis as if the disclosure was being made to the unemancipated minor.

● Required by Law. AAC will disclose protected health information about you when it is required to do so by federal, state or local law, rule or regulation. For example, AAC may disclose information for the following purposes: for judicial and administrative proceedings pursuant to legal authority; to report information related to victims of abuse, neglect or domestic violence; and, to assist law enforcement officials in their law enforcement duties.

● Public Health/Health Oversight. AAC may use or disclose protected health information about you for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.

● Deceased Individuals. AAC may disclose protected health Information to funeral directors, medical examiners and/or coroners to enable them to carry out their lawful duties.

● Organ/Tissue Donation. AAC may use or disclose protected health information about you for cadaveric organ, eye or tissue donation purposes.

● Research. AAC may use or disclose protected health information about you for research purposes. For example, a research project may involve comparing the health and recover of patients who received one medication to those who received another medication. All research projects are subject to a special approval process. Before AAC will use or disclose protected health information about you, the project will be approved through the special approval process.

● Health and Safety. AAC may use or disclose your protected health information to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

● Specialized Government Functions. AAC may use and disclose your protected health information for military and veterans activities, for national security and intelligence activities, for protective services of the President and others, and to correctional institutions and other law enforcement custodial situations.

● Workers’ Compensation. AAC may use and disclose protected health information about you for workers’ compensation or similar programs to the extent authorized by and to the extent necessary to comply with laws regarding said programs.

● FDA Reporting. In the event AAC is subject to the jurisdiction of the federal Food and Drug Administration with respect to a product or activity for which AAC has a duty to make reports of quality, safety or effectiveness, AAC may use and disclose protected health information about you to make any fulfill any requirements imposed by the FDA.

3. Uses and Disclosures For Which Authorization is Required. The following categories describe the instances in which AAC may only use and disclose protected health information about you after first obtaining your written authorization:

a. All Instances Except as Required or Permitted. Except as required or permitted by the Privacy Standards, AAC may not use or disclose protected health information about you without your written authorization. When AAC receives your authorization to use or disclose your protected health information, AAC must make its use and disclosure consistent with such authorization. If you provide AAC authorization to use or disclose your protected health information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, AAC will no longer use or disclose your protected health information for the reasons covered by your authorization. However, your revocation will not be applicable to disclosures that AAC already made prior to its receipt of your written revocation.

b. Psychotherapy Notes. AAC may not use and disclose psychotherapy notes without your authorization except: to carry out certain treatment, payment and health care operation activities; as required by law; for health oversight activities; to coroners and medical examiners; and, to prevent or lessen a serious and imminent threat to the health and safety of a person or the public.

c. Marketing. AAC may not use and disclose protected health information about you for marketing without your authorization, except if the communication is in the form of: face to face communication made by AAC to you; or, a promotional gift of nominal value provided by AAC.

You have the following rights regarding protected health information AAC maintains about you:

1. Request Restrictions. You have the right to request that AAC restrict or limit how it uses or discloses your protected health information for treatment, payment or health care operations. AAC will consider your request, but AAC is not required to agree to your request. AAC cannot agree to limit uses and disclosures that are required by the Privacy Standards. If AAC agrees to your request, AAC will comply with your request unless the information is needed to provide you emergency treatment or in other limited circumstances. To request a restriction, you must make your request in writing to the Privacy Officer of AAC. In your request, you must provide AAC with your name, address, a specific description of the requested restriction, and the requested duration of the restriction. The request must also be signed and dated. Please refer to 45 C.F.R §164.522 for a more detailed description of your rights.

2. Request Confidential Communications. You have the right to request that AAC communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that AAC only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Privacy Officer of AAC. In your request, your must provide AAC with your name, address, a specific description of the request, an identification of the alternate method of communication and/or alternate address, and the duration of the request. The request must also be signed and dated. AAC will not ask you the reason for your request and AAC will accommodate all reasonable requests. Please refer to 45 C.F.R §164.522 for a more detailed description of your rights.

3. Request Access to Inspect and Copy. You have the right to request access for purposes of inspecting and copying your protected health information. To request access, you must make your request in writing to the Privacy Officer of AAC. In your request, you must provide AAC with your name, address, a description of the requested access (i.e., inspection, copying, both) and a statement as to the requested form or format of the information. The request must also be signed and dated. AAC will respond to your request within 30 days (unless the information is stored off-site, in which event AAC will respond within 60 days). If AAC is unable to respond within that time, AAC may have an additional 30 days if it notifies you in writing as to the reason for the delay and gives you the date on which it will respond. In some instances, AAC may deny your request to inspect and copy. If you are denied access to your protected health information, you may request that the denial be reviewed in certain circumstances. If you are entitled to a review, another licensed health care professional chosen by AAC will review your request and the denial. The person conducting the review will not be the person who denied your request. AAC will comply with the outcome of the review. If you request a copy of the information, AAC may charge a fee for the cost of copying, mailing and other supplies associated with your request. Please refer to 45 C.F.R §164.524 for a more detailed description of your rights.

3. Request Amendments. If you feel that protected health information AAC has about you is incorrect or incomplete, you have the right to request that AAC to amend the information. You have the right to request an amendment for as long as the information is kept by or for AAC. To request an amendment, you must make your request in writing to the Privacy Officer of AAC. In your request, you must provide AAC with your name, address, a specific description of the requested amendment and a description of the reason or basis for the amendment. The request must also be signed and dated. AAC will respond to your request within 60 days. If AAC is unable to respond within that time, AAC may have an additional 30 days if it notifies you in writing as to the reason for the delay and gives you the date on which it will respond. In some instances, AAC may deny your request for an amendment. If AAC denies your request, you will be given the opportunity to submit a written statement of disagreement and/or request in writing that AAC include your request with any future disclosures of the affected information. In the event you file a written statement of disagreement, AAC will be allowed to prepare a written rebuttal. In some instances, the future disclosures of the affected information will include your request, the denial, your written statement and the rebuttal. Please refer to 45 C.F.R §164.526 for a more detailed description of your rights.

4. Request an Accounting of Disclosures. You have the right to request an accounting of disclosures describing certain of the disclosures AAC has made of protected health information about you. To request an accounting, you must make your request in writing to the Privacy Officer of AAC. In your request, you must provide AAC with your name, address, and a statement of the period of time for the accounting (which may not be longer than six (6) years and may not include dates before April 14, 2003). Your request should indicate in what form you want the accounting (for example, on paper, electronically, etc.) The request must also be signed and dated. AAC will respond to your request within 60 days. If AAC is unable to respond within that time, AAC may have an additional 30 days if it notifies you in writing as to the reason for the delay and gives you the date on which it will respond. The first accounting you request within a twelve (12) month period will be free of charge. For additional accountings during a twelve (12) month period, AAC may charge you for the cost of providing the accounting. AAC will notify you of the cost involved in advance and you may choose to withdraw or modify your request at that time before any costs are incurred. Please refer to 45 C.F.R §164.528 for a more detailed description of your rights.

5. Request Paper Copy of this Notice. You have the right to a paper copy of this Notice. You may ask AAC 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. To obtain a paper copy of this Notice, contact the Contact Person of AAC.

If you believe your privacy rights have been violated, you may file a complaint. To file a complaint with AAC, contact the Contact Person of AAC at (260) 432-5005. The Contact Person will inform you as to the formal procedure for filing a complaint with AAC and the Contact Person can assist you with respect to making a complaint. You will not be retaliated against for filing a complaint.

You may also file a complaint with the Secretary of the Department of Health and Human Services. To file a compliant with the Secretary of the Department of Health and Human Services, you should contact the Department of Health and Human Services at: The U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201; (877)-696-6775 within one hundred eighty (180) days of when you knew or should have known that the act or omission complained of occurred (this time limit can be waived by the Secretary for good cause shown)). You will not be retaliated against for filing a complaint.

AAC reserves the right to change its privacy practices and this Notice at any time. AAC will promptly revise and distribute a revised Notice whenever required by law or when there is a material change to: the uses or disclosures that may be made by AAC; your rights with respect to your protected health information; AAC’s legal duties; and/or AAC’s other privacy practices described in this Notice. AAC reserves the right to make the revised or changed privacy practices and Notice effective for protected health information AAC already has about you as well as any information AAC receives in the future.

AAC will post a copy of the current Notice in the waiting room of each of AAC’s offices. The Notice will contain on the first page, in the top center section, the effective date. In addition, each time you register at AAC’s office for treatment or health care services, AAC will make available to you a copy of the current Notice then in effect. AAC will also post a copy of its current Notice on its website.

AAC is required to make a good faith effort to obtain your written acknowledgement of your receipt of this Notice. As such, please complete the attached form acknowledging your receipt of this Notice and give the completed form to a member of AAC.