Mountain Valley Orthopedics Privacy Practices

MOUNTAIN VALLEY ORTHOPEDICS, P.C.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DECRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW CAREFULLY.

Uses and Disclosures
Treatment. 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.

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

Health care operations. Your health information may be used as necessary to support the day-to-day activities
and management of Mountain Valley Orthopedics, P.C. For example, information on the services you received
may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Law 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.

Public health reporting. Your health information may be disclosed to public health agencies as required by
law. 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 its use for
any purpose other than those listed above requires your specific written authorization. If you change your
mind after 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 affect or undo any use or disclosure
of information that occurred before you notified us of your decision.

Additional Uses of Information

Appointment reminders. Your health information will be used by our staff to send you appointment
reminders. Messages will be left on answering machines for the purpose of reminding you of your appointment.

Information about treatments. Your health information may be used to send you information on the treatment
and management of your medical condition that you may find to be of interest. We may also send you
information describing other health-related goods and service that we believe may interest you.

Individual Rights

You have certain rights under the federal privacy standards. These include:
t 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
t the right to receive an accounting of how and to whom your protected health information has been disclosed
t the right to receive a printed copy of this notice

MOUNTAIN VALLEY ORTHOPEDICS, P.C. Duties
We 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
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes
in our policies and practices may be required by changes in federal and state laws and 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
As 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 the receptionist.
Appropriate fee will be charged to copy medical records.

Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a
letter outlining your concerns to:

Practice Administrator
Mountain Valley Orthopedics, P.C.
447 Office Plaza
600 Plaza Court, Suite C
East Stroudsburg, PA 18301

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending
a letter describing the cause of your concern to the same address. You may also contact the Secretary of Health
and Human Services if you feel your rights have been violated.
You will not be penalized or otherwise retaliated against for tiling a complaint.

Contact Person
The name and address of the person you can contact for further information concerning our privacy practice is:
Practice Administrator
Mountain Valley Orthopedics, P.C.
447 Office Plaza
600 Plaza Court, Suite C
East Stroudsburg. PA 18301

Effective Date
This Notice is effective on or after April 13, 2003.