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 Commitment to Your Privacy

Englewood Spine Associates, LLC, including services provided under the alternate name Englewood Spine & Aesthetics Institute (collectively, "we," "us," or "our practice"), is committed to protecting the privacy of your health information. We create a record of the care and services you receive at our practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by our practice.

We are required by law to maintain the privacy of your health information, to provide you with this notice of our legal duties and privacy practices with respect to your health information, and to notify you following a breach of your unsecured health information. We are required to abide by the terms of the notice currently in effect.

How We May Use and Disclose Your Health Information

The following describes the ways we may use and disclose your health information.

Treatment

We may use your health information to provide you with medical treatment or services. We may disclose your health information to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We may also share health information about you with other providers who are treating you.

Payment

We may use and disclose your health information so that the treatment and services you receive at our practice may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about a service you received so your health plan will pay us or reimburse you for the service.

Health Care Operations

We may use and disclose your health information for health care operations. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you.

Appointment Reminders

We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care at our practice.

Treatment Alternatives

We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services

We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you.

Special Situations

As Required by Law

We will disclose health information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety

We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Business Associates

We may disclose health information about you to our business associates who perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation

If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans

If you are a member of the armed forces, we may release health information about you as required by military command authorities.

Workers' Compensation

We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks

We may disclose health information about you for public health activities. These activities generally include:

• Preventing or controlling disease, injury, or disability
• Reporting births and deaths
• Reporting child abuse or neglect
• Reporting reactions to medications or problems with products
• Notifying people of recalls of products they may be using
• Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
• Notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence

Health Oversight Activities

We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement

We may release health information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons, or similar process
• To identify or locate a suspect, fugitive, material witness, or missing person
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement
• About a death we believe may be the result of criminal conduct
• About criminal conduct at our practice
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime

Coroners, Medical Examiners, and Funeral Directors

We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients of our practice to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities

We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others

We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or conduct special investigations.

Inmates

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution.

Research

Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. Before we use or disclose health information for research, the project will go through a special approval process. We may, however, disclose information to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the health information they review does not leave our practice.

Fundraising

We may use health information about you to contact you in an effort to raise money for our practice and its operations. We may disclose health information to a foundation related to our practice so that the foundation may contact you in raising money for our practice. You have the right to opt out of receiving fundraising communications. If you do not want us to contact you for fundraising efforts, you must notify our Privacy Contact in writing.

If we maintain substance use disorder records protected by 42 CFR Part 2, we will provide clear advance notice and an opportunity to decline fundraising communications that use those records.

Your Rights Regarding Health Information About You

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy

You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to our Privacy Contact. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed.

Right to Amend

If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to our Privacy Contact. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the information kept by or for our practice; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete.

Right to an Accounting of Disclosures

You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of health information about you. To request this list or accounting of disclosures, you must submit your request in writing to our Privacy Contact. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to our Privacy Contact. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

We must agree to a request to restrict disclosure of your health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the health information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid us in full.

Right to Request Confidential Communications

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to our Privacy Contact. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, contact our Privacy Contact listed below.

Right to Be Notified of a Breach

You have the right to be notified in the event that we (or a Business Associate) discover a breach of unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements.

Uses and Disclosures That Require Your Authorization

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

Psychotherapy Notes

We will not use or disclose your psychotherapy notes without your written authorization, except as permitted by law.

Marketing

We will not use or disclose your health information for marketing purposes without your written authorization, except as permitted by law.

Sale of Health Information

We will not sell your health information without your written authorization.

Respond to Lawsuits and Legal Actions

We may disclose your health information in response to a court or administrative order, or in response to a subpoena, discovery request, or other lawful process, subject to applicable legal requirements and protections.

Substance Use Disorder Records

If we maintain substance use disorder treatment records protected by 42 CFR Part 2, we will not use or disclose those records in civil, criminal, administrative, or legislative investigations or proceedings against you without your written consent or a qualifying court order accompanied by a subpoena or other legal requirement compelling disclosure.

Changes to This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our office. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to our practice for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our Privacy Contact listed below. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Privacy Contact

Janine Sapunarich
Englewood Spine Associates, LLC
d/b/a Englewood Spine & Aesthetics Institute
300 Grand Avenue, Suite 201
Englewood, NJ 07631
(201) 608-5656