Adam Strassberg, M.D.

Notice of Privacy Practices for Protected Health Information

Effective Date: September 1, 2011

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!

My office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of Uses of Your Health Information for Treatment Purposes are:

· During the course of treatment, I determines that I will need to consult with another specialist in the area. I will share the information with such specialist and obtain his/her input.

Example of Use of Your Health Information for Payment Purposes:

· I submit requests for payment to your health insurance company. The health insurance company requests information from me regarding medical care given. I will provide information to them about you and the care given (typically a diagnosis, the day of the visit, and the type of visit).

Example of Use of Your Information for Health Care Operations:

· I obtain services from insurers such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. I will share information about you with such insurers or other business associates as necessary to obtain these services.

· Your insurance company may request a prior authorization form in order to cover the cost of certain medications. I will provide information to them about you and your treatment history in order for them to authorize payment of a specific medication.

Your Health Information Rights

The health and billing records I maintain are the physical property of my office. The information in it, however, belongs to you. You have a right to:

· Request a restriction on certain uses and disclosures of your health information by delivering the request to my office

· Request a restriction on disclosures of medical information to a health plan for purposes of carrying out payment or health care operations

· Obtain a paper copy of this current Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at my office

· Request that you be allowed to inspect and copy your health record and billing record

· Appeal a denial of access to your protected health information, except in certain circumstances;

· Request that your health care record be amended to correct incomplete or incorrect information by delivering a request to my office. I may deny your request if you ask me to amend information that:

· Was not created by me, unless the person or entity that created the information is no longer available to make the amendment;

· Is not part of the health information kept by or for my office;

· Is not part of the information that you would be permitted to inspect and copy; or,

· Is accurate and complete.

If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records;

· Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to my office

· Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a request to my office. An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person's involvement in your care or in payment for such care; or, uses or disclosures to notify family or others responsible for your care of your location, condition, or your death.

· Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to my office, except to the extent information or action has already been taken.

If you want to exercise any of the above rights, please contact Dr. Strassberg in person or in writing, during regular, business hours. He will inform you of the steps that need to be taken to exercise your rights.

Our Responsibilities

My office is required to:

· Maintain the privacy of your health information as required by law;

· Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;

· Abide by the terms of this Notice;

· Notify you if we cannot accommodate a requested restriction or request; and,

· Accommodate your reasonable requests regarding methods to communicate health information with you.

I reserve the right to amend, change, or eliminate provisions in my privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If my information practices change, I will amend my Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of my "Notice" or by visiting my office and picking up a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, please contact Dr. Strassberg.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at my office. You may also file a complaint by mailing it to the Secretary of Health and Human Services, whose street address is: 200 Independence Avenue, S.W., Washington, D.C. 20201

I cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from my office.

I cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Other Disclosures and Uses

Communication with Family

· Using my best judgment, I may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

Notification

· Unless you object, I may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Disaster Relief

· I may use and disclose your protected health information to assist in disaster relief efforts.

Food and Drug Administration (FDA)

· I may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Public Health

· As authorized by law, I may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.

Abuse & Neglect

· I may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Health Oversight

· Federal law allows me to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings

· I may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.

Serious Threat

· To avert a serious threat to health or safety, I may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions

· I may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Other Uses

· Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under "Your Health Information Rights."

Website

· This Notice will be posted on my website.