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.

Our General Policy and Duties

Although we are not subject to the privacy rules of the Health Insurance Portability and Accountability Act (“HIPAA”), we nevertheless safeguard information about your health and generally keep it private. This Notice of Privacy Practices explains our practices with your health information. We will abide by the terms of this Notice of Privacy Practices until we choose to change it; we reserve the right to change this notice at any time.

If we change this Notice of Privacy Practices, we will post the new notice in a visible location in our office and on our website (if we have one), and will have copies available in our office. The new privacy practices will apply to your health information that we already have received or created, as well as to such information we may receive or create in the future. If you have questions or concerns regarding our privacy practices, contact our Privacy Official listed below.

Uses and Disclosures of Your Health Information

Permissive Uses and Disclosures

We will routinely use and disclose your health information in our office for purposes of your treatment , payment for that treatment, and for our health care operations , without special permission from you. If we need to disclose your health information outside our office for treatment, payment , and health care operations , we will usually not seek special permission from you for that disclosure. We may also use your health information to contact you regarding your premiums for coverage and other reminders.

Disclosures Pursuant to Your Authorization

If you authorize disclosure of your health information, we may comply with your authorization. You may revoke your authori­zation at any time, except to the extent any disclosure has already been made in reliance on it. Authorizations and requests for revocation must be submitted in writing to our Privacy Official. Any other disclosure of your health information may only be made pursuant to laws requiring or allowing disclosure. Sometimes we may request an authorization from you, but you are not required to sign it. Without it we cannot disclose your health information. Other times you may ask us to disclose your health information by submitting a properly-completed authorization form or by completing our form (available from our Privacy Official).

Uses and Disclosures Required or Allowed by Law Without Your Specific Authorization

In certain circumstances, the law requires or allows us to receive, use and disclose your health information, regardless of whether we have your permission to do so. (Some of the listed situations do not apply to our office; some may never occur.) Examples of these circumstances include, but are not limited to:

• In administrative and judicial proceedings, including responses to subpoenas and orders of an administrative agency or court.
• To our business associates who perform health care operations and agree to keep your health information private and protected.
• To your family member, friend or other person, unless you disagree, to the extent necessary to help with your health care and the payment for it.
• As incidental to, and unavoidable in, uses and disclosures to provide your treatment, secure payment, and in the health care operations of our office.

Your Rights Regarding Your Health Information

You may be entitled to protection of your health information under provisions of HIPAA

In receiving and maintaining personal information about you, including health information, we may be acting on behalf, or as the “business associate,” of a “covered entity,” such as a health insurance plan, that is subject to the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), and the related regulations. In those situations, we may be subject to a “business associate agreement,” whereby we agree to protect and safeguard your protected health information on behalf of the “covered entity” with which both you and we have a working relationship. In the event that our relationship with you is governed by such a “business associate agreement,” we will adhere to the terms and conditions of that agreement regarding receiving, disclosing, protecting, reporting, amending, and otherwise handling your protected health information.

You may request and receive additional copies of our Notice of Privacy Practices

You may request and receive a copy of our most current Notice of Privacy Practices at any time, regardless of whether you previously received one on paper or electronically. Requests for additional paper copies must be submitted in writing to our Privacy Official at the address and/or fax number on this form.

Questions and Complaints

If you have any questions about how we handle your health information, our policies and procedures for that information, or believe your health information has been handled inappropriately, please notify our Privacy Official immediately. Our Privacy Official may be contacted at:

EBenefits, Inc.
ATTN: Privacy Official
1919 Central Ave. Cheyenne , WY 82001
307-635-4604
Fax: 307-635-5022
E-mail: privacy@ebenefits.com
Effective Date of this Notice: October 1, 2003

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