PLEASE REVIEW IT CAREFULLY.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose medical information.

• For Payment. We may use and disclose medical information about you so that the treatment and services you receive from us may be billed to and payment may be collected from you, an insurance company or a third party. For example, it may be essential that you provide us with your health plan information, so that your health plan will pay us or reimburse you for medical care we provide to you. In addition, we may tell your health plan about a treatment you are going to receive in order to obtain necessary approval or to determine whether your plan will cover the treatment.
• For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to acupuncturists, practitioners, students, or other personnel who are involved in taking care of you at our office. We also may disclose medical information about you to people outside the clinic who may be involved in your medical care, such as family members, clergy or other persons that are part of your care.
• For Health Care Operations. We may use and disclose medical information about you for clinic operations. These uses and disclosures are necessary to run the clinic and ensure that all of our patients receive quality care.

POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION:
We understand that medical information pertaining to you and your health is personal. We are committed toprotecting your medical information. We create a record of the care and services you receive at our office. We needthis record in order to provide you with quality care and to comply with certain legal requirements.

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

The law requires us to:

• Make sure that medical information that identifies you is kept private;
• Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the notice that is currently in effect.

OTHER CATEGORIES OF OUR INFORMATION USE AND DISCLOSURE

• Appointment Notices. We may use and disclose medical information to contact you about an appointment for treatment or medical care.
• As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.
• Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
• Individual Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care, unless you request that we not do so. We may also give information to someone who helps pay for your care. We may also inform your family or friends about your condition. In addition, we may disclose medical information about you to an entity 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 medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received treatment 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 medical information in order to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, as long as the medical information they review does not leave our office. We will almost always ask for your specific permission if the researcher obtains access to your name, address or other information that reveals who you are, or will be involved in your care.
• To Avert a Serious Threat to Health or Safety. We may use and disclose medical 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.
• Treatment Alternatives. We may use and disclose medical information to inform you about or recommend possible treatment options or alternatives that may be of interest to you.
• Worker’s Compensation. We may release medical information about you for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness.

LESS FREQUENT USES AND DISCLOSURES OF YOUR PERSONAL INFORMATION INVOLVING THOSE NOT DIRECTLY INVOLVED IN YOUR CARE COULD INCLUDE:

• Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner, in order to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their services.
• Health Oversight Activities. We may disclose medical 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.
• Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical 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.
• Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
1. o In response to a court order, subpoena, warrant, summons or similar process;
2. o To identify or locate a suspect, fugitive, material witness, or missing person;
3. o About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
4. o About a death we believe may be the result of criminal conduct;
5. o About criminal conduct at the facility; and
6. o In emergency circumstances to report a crime; the location of the crime or victims; or to identify, description or location of the person who committed the crime.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical 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.
• Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
• National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
• Organ and Tissue Donation. If you are an organ donor, we may release medical 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.
• Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, and foreign heads of state or conduct special investigations.
• Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following, but are not limited to:
1. o Preventing or controlling disease, injury or disability;
2. o Reporting births and deaths;
3. o Reporting child abuse or neglect;
4. o Reporting reactions to medications or problems with products;
5. o Notifying people of recalls of products they may be using;
6. o Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
7. o Notifying the appropriate government authority if we believe a patient has been a victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you:

• 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 medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to AVOMC’s Privacy Officer. 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 cost 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 Amend. If you feel that medical information we have about you 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 our office. To request an amendment, your request must be made in writing and submitted to AVOMC’s Privacy Officer. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
1. o Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
2. o Is not part of the medical information kept by or for the practice;
3. o Is not part of information which you would be permitted to inspect and copy; or
4. o Is accurate and complete.
• Right to Inspect and Copy. You have the right to inspect and copy medical 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 medical information that may be used to make decisions about you, you must submit your request in writing to AVOMC’s Privacy Officer. If you request a copy of the information, we are entitled to charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the clinic will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
• 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.acupuncturevermont.com. To obtain a paper copy of this notice contact AVOMC’s Privacy Officer.
• Right to Request Confidential 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 confidential communications, you must make your request in writing. We will not ask you the reason for the request and will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the medical 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 medical 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 make your request in writing to AVOMC’s Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
• Office Visits: Some of our treatment rooms have outdoor windows. At your request, we will close the blinds to protect your privacy.

CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical 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 in the office. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, copies of our current notice are available at our reception desk.

COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Bldg., 200 Independence Ave, Washington, DC 20201. To file a complaint with the clinic, contact the Privacy Officer, Acupuncture Vermont Oriental Medical Clinic, PLC, 39 Timber Lane, South Burlington, Vermont 05403. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the laws that apply to use will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provide to you.

If you have any questions about this notice, please contact this organization’s Privacy Officer. Effective Date: June 29, 2005.