Franklin Urological Associates, P..C.
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.

The Health Insurance Portability & Accountability Act of 1996 (“HlPAA") is a federal program that requires that all medical records and
other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept
properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is
used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and
how we may use and disclose your health information.
We may use and disclose your medial records only for each of the following purposes: Treatment, payment and health care operations.
° Treatment means providing, coordination, or managing health care and related services by one or more health care providers.
An example of this would include a physical examination.
¢ Payment means such activities as obtaining reimbursement for service, confirming coverage, billing or collection activities,
and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
o Health care operations include the business aspects of running our practice, such as conducting quality assessment and
improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal
quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
We may contract you to provide appointment reminders or information about treatment alternatives or other health-related benefits and
services that may be of interest you.

Any other uses and disclosures will be made only with you written authorization. You may revoke such authorization in writing and we
are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your
authorization. .

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request
to the Privacy Officer:

The right to request restrictions on certain uses and disclosures of protected health information, including those related to
disclosures to family members, other relatives, close personal friends, or any other person identified by you we are, however,
not required to agree to a requested restriction. lf we do agree to a restriction, we must abide by it unless you agree in writing
to remove it.

The right to reasonable requests to receive confidential communications of protected health information from us by alternative
means or at alternative locations.
The right to inspect and copy your protected health information.
The right to amend your protected health information.
he right to receive an accounting of disclosures of protected health information.
The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties
and privacy practices with respect to protected health information.
This notice is effective as of June 10, 2002, and we are required to abide by the terms of the Notice of Privacy Practices currently in
effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for
all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy
Practice from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint
with our office or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice
or the policies and procedures of our office. We will not retaliate against you for Filing a complaint.
Please contact us for more information, by For more information about HIPAA
Asking to speak to our Privacy Officer or for or to tile a complaint:
Written inquiries, note “Attention Privacy
Officer”. The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257
Toll Free: 1-877-696-6775
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