PRIVACY NOTICE

PF-100 Notice of Privacy Practices
This notice is effective on or after April 15, 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.

Uses and Disclosures
MMTreatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

MMPayment: Your health information may be used to seek payment from your health plan, from other sources of coverage such as automobile insurer, or from credit card companies that you may use to pay for service. For example, your health plan may request and receive information on dates
of service, the service provided, and the medical condition being treated.

MMHealth Care Operations: Your health information may be used as necessary to support the dayto day activities and management of Riverside Plastic Surgery and Sinus Center. For example informationon the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

MMLaw Enforcement: Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

MMPublic health reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization: Disclosure of your health information or it’s use for any other purpose other then those listed above requires your specific written authorization. If you change your mind after the authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not effect or undo any use or disclosure of information that occurred before you notified us of your decision.

Individual Rights
You have certain rights under the federal privacy standards. These include:
* The right to request restrictions on the use and disclosure of your protected health information
* The right to receive confidential communications concerning your medical condition and treatment.
* The right to inspect and copy your protected health information
* The right to amend or submit corrections to your protected health information
* The right to receive an accounting of how and to whom your protected health information has been disclosed.
* The right to receive a printed copy of this notice.

Riverside Plastic Surgery and Sinus Center’s Duties:
MMWe are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices:
MMAs permitted by law, we reserve the right to amend or modify our policies practices. These changes in our policies and practices may be required by changes in federal and state laws regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain

Requests to Inspect Protected Health Information:
MMAs permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting Denise Crowley or Dawn Calefato. Complaints:
MMIf you would like to submit a complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

Dawn Calefato
Riverside Plastic Surgery and Sinus Center
70 East Front Street
Red Bank, New Jersey 07701

MMIf you believe that our privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.

Contact Person:

Dawn Calefato
Riverside Plastic Surgery and Sinus Center
70 East Front Stret 3rd floor
Red Bank, New Jersey 07701
(732) 747-5300