SUMMARY NOTICE OF PRIVACY PRACTICES
Drs. Psomas, Bourekis, and Warnica
Effective date: April 14, 2003

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

Our Pledge regarding your Healthcare Information:

We understand that health information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us.

We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by this office, whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

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

How we may use and disclose health information about you:

• For treatment
• For payment
• For health care operations
• For appointment reminders
• As required by law
• To family or friends involved in your care
• To avert a serious threat to health and safety
• To allow Worker’s Compensation claims
• To allow health oversight activities for quality of care
• As required for lawsuits and disputes (when subpoenaed) & law enforcement
• Coroners, health examiners, and funeral directors

Your rights regarding health information about you:

• Right to inspect and copy your health records
• Right to amend or ask us to correct a mistake in your health records
• Right to an accounting of disclosures
• Right to request restrictions
• Right to request confidential communications
• Right to a paper copy of this Notice

Changes to this notice:

We reserve the right to change this Notice. We will post a copy of the current notice with the current effective date in our facility.

Complaints:

If you believe that your privacy rights have been violated, you may file a complaint with us. All complaints must be in writing. To file a complaint, please contact our Office Manager.

Acknowledgment of Receipt of this Notice:

We request that you sign our form acknowledging you have received a copy of this notice. This acknowledgment will become part or your records.