Statement of Rights and Responsibilities

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

Following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.

You have the right to inspect and copy your PHI. This means you may inspect and obtain a copy of your PHI contained in your medical and billing records and any other records that your (Orthotist or Prosthetist) uses for making decisions about you, for as long as we maintain the PHI.

To inspect and copy your medical information, you must submit a written request to the Privacy Contact listed on the first and last pages of this Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other cost incurred by us in complying with your request.

We may deny your request in limited situations specified in the law. For example, you may not inspect or copy psychotherapy notes; or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and certain other specified PHI defined by law. In some circumstances, you may have a right to have this decision reviewed. The person conducting the review will not be the person who initially denied your request. We will comply with the decision in any review. Please contact our Privacy Contact if you have questions about access to your medical record.

You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your (Orthotist or Prosthetist) is not required to agree to a restriction that you may request. If the (Orthotist or Prosthetist) believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. If your (Orthotist or Prosthetist) does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your (Orthotist or Prosthetist). You may request a restriction by submitting a request in writing to Privacy Contact, Dothan Brace Shop, 1240 East Main Street, Dothan, Alabama 36301.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method on contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.

You may have the right to have your (Orthotist or Prosthetist) amend your PHI. This means you may request an amendment of your PHI contained in your medical and billing records and any other records that your (Orthotist or Prosthetist) uses for making decisions about you, for as long as we maintain the PHI. You must make your request for amendment in writing to our Privacy Contact, and provide the reason or reasons that support your request.

We may deny any request that is not in writing or does not state a reason supporting the request. We may deny your request or an amendment of any information that:

1. Was not created by us, unless the person that created the information is not longer available to amend the information;

2. Is not part of the PHI kept by or for us;

3. Is not part of the information you would be permitted to inspect or copy or

4. Is accurate and complete.

If we deny your request for amendment, we will do so in writing and explain the basis for the denial. You have the right to file a written statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact to determine if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. This right only applies to disclosures for purposes other than treatment payment or healthcare operations as described in the Notice of Privacy Practices. It also excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations. You must submit a written request for disclosures in writing to the Privacy Contact. You must specify a time period, which may not be longer than six years and cannot include any date before April 14, 2003. You may request a shorter timeframe. Your request should indicate the form in which you want the list (i.e. .on paper, etc.). You have the right to one free request within any 12-month period, but we may charge you for any additional requests in the same 12-month period. We will notify you about the charges you will be required to pay, and you are free to withdraw or modify your request in writing before any charges are incurred.

You have the right to obtain a paper copy of this notice from us, upon request to our Privacy Contact, or in person at our office, at any time, even if you have agreed to accept this notice electronically. (You may obtain a copy of this notice at our website, ( www.dothanbraceshop.com .)

3. COMPLAINTS

You may complain to us or to the Secretary of Health and Human Services if your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Contact of your complaint. We will not retaliate against your in any way for filing a complaint, either with us or with the Secretary.

You may contact our Privacy Contact, Cari Piper at 334-792-4330 or cari@dothanbraceshop.com about the complaint process.

4. CHANGES TO THIS NOTICE

We reserve the right to change the privacy practices that are described in this Notice of Privacy Practices. We also reserve the right to apply these changes retroactively to PHI received before the change in privacy practices. You may obtain a revised Notice of Privacy Practices by calling the office a requesting a revised copy be sent in the mail, asking for one at the time of your next appointment, or accessing our website.

This notice was published and became effect on April 14, 2003.