NOTICE OF PRIVACY PRACTICES 

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 about this notice, please contact our office at 954-447-5206 

PURPOSE OF THIS NOTICE 

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

OUR LEGAL REQUIREMENTS 

We are required by law 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. 
• • Follow the terms of the notice that currently is in effect. 
• • Provide our internal complaint process for privacy issues to you. 

WHO WILL FOLLOW OUR PRIVACY PRACTICES 

This notice describes the practices of Blue Water Pain Solutions and that of: 

• • All Blue Water Pain Solutions employees, staff and other Blue Water Pain Solutions personnel. 
• • Blue Water Pain Solutions subsidiaries, affiliates and managed entities. 

All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or health care operations purposes described in this notice. 

OUR PLEDGE REGARDING MEDICAL INFORMATION: 

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services that we provide to you. We need this record to provide you with medical care and to comply with certain legal requirements. This notice applies to other health information about you, such as information we collect with your authorization during research studies that do not involve treatment. Your personal doctor and other entities providing products or services to you may have different policies or notices regarding their use and disclosure of your medical information. 

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU 

You have the following rights regarding medical information we maintain about you: 

Right to Inspect and copy: You have the right to inspect and copay, medical information about your or year care. Usually, this includes medical and billing records. 

Please submit your request in writing, with your signature and specific items needed and fax to 954-447-5259 

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 us 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 Amend: If you feel 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 us. 

We may deny your request for amendment if it does not include a reason sufficient to support the request. 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 medical information kept by or for us. 
• • If it is not part of the information which you would be permitted to inspect and copy or is accurate and complete. 

Right to an Accounting of Disclosures: You have the right to request an “Accounting of disclosures”. This accounting is a list of the disclosures we made of medical information about you, except disclosures made for treatment payment, and Blue Water Pain Solutions operations (“TPO” Accounting”). 

Right to Request Restrictions: You have the right to request or limitation on the medical information we use or disclose about you for the 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 or your care, like a family member or friend. We are not required to agree to your request, except as stated at the end of this paragraph. If we do agree, we will comply with your request unless the information is needed to provide your emergency treatment. If you pay out of pocket for the entire cost of a service, you have the right to request that we not disclose this service to your health plan for payment or health care operations purposes. We must comply with that request unless the disclosure of your health plan is required by law. 

To request restrictions; you can include below on our intake paperwork what information you want to limit, whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply, for example, disclosures to your spouse. 

Right 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 restrictions; you can include the below on our intake paperwork. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wisht 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. 

HOW WE MAY USE AND DSCLOSE MEDICAL INFORMATION ABOUT YOU 

The following categories describe different ways that we are permitted to use and disclose medical information as health care provider, although certain of these categories may not apply to our business and we may not actually use or disclose your medical information for such purposes for each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted or required to use and disclose information will fall within one of the general categories 

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 the physicians, nurses and their office personnel, medical technicians, residents, medical students, labs, hospitals, and other facilities and their staff. For example, your health care provider may disclose your medical information for treatment purposes when referring you to another 

health care provider. We also may disclose medical information about you to people who may be involved in your medical care after you have received our products and services, such as social workers or home health agencies. 

For payment: We may use and disclose medical information about you so that the treatment and services we provide you may be billed to, and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about products and services we provided to you so your health plan will pay us or reimburse you for the products and services. 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. 

For health care operations: We may use and disclose medical information about you for our health care operations. These uses and disclosures are necessary to run our company and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical 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 our compliance department, attorneys, auditors business planners and managers, health re educators and trainers, peer review committees and general information for review and learning purposes and to assist in the defense of any claim, lawsuit, proceeding or investigation. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. 

Appointments reminders: We may use and disclose medical information to contact you as reminder that you have an appointment for treatment or services. 

Treatment Alternatives: We may use and disclose medical 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 medical information to tell you about health-related benefits or services that may be of interest to you. 

Individual Involved in your care or payments for your care: We may release medical 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. We may also tell your family or friend your location and conditions and that you are receiving products and services from us. In addition, we may disclose medical information about you to any entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. 

As Required by law: We will disclose medical 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 disclosed 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. 

SPECIAL SITUATIONS 

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. 

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. 

Public Health Activities: We may disclose medical 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 of 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 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 healthcare system, government programs, and compliance with civil rights laws. 

Lawsuits and Disputes: If you are involved in a lawsuit or 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 and order protecting the information requested. 

Law Enforcement: We may release medical information if asked to do so by a law enforcement official: 

• • 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 occurring on our premises. 
• • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person which committed the crime. 

Coroners Medical Examiners arid funeral directors: We may release medical 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 medical information about our patients to funeral directors as necessary to carry out their duties. 

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. 

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 person or foreign heads of state or conduct special investigations. 

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 for the institution to provide you with health care; to protect your health and safety or the health and safety of others or for the safety and security of the correctional institution. 

Organ and Tissue Donation: If you are an organ donor, we ay release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to go an organ donation bank, as necessary to facilitate organ tissue donation and transplantation. 

Sale of Business Assets: We reserve the right to transfer medical information about you to a third party in conjunction with the sale of our company or certain assets belonging to our company. 

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 already have about you as well as any information we receive in the future. We will post a copy of the current notice in your physician’s office (or at the facility where you are being treated). 

COMPLAINTS: 

If you believe your privacy rights have been violated, you may file a complaint with us or with the secretary of the department of Health and Human Services. To file a complaint in our office please ask to speak to the office manager. You will not be penalized for filing a complaint. 

OTHER USES OF MEDICAL INFORMATION: 

Other uses and disclosures of medical information not generally covered by the examples given in this notice or the laws that apply to us will be made only with your written authorization. If you authorize us to use or disclose medical 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 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 authorization, and that we are required to retain our records of the care that we provided for you.