NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION

Effective Date: April 14, 2003

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.


If you have any questions or wish to receive additional information about the matters covered by this Notice of Privacy Practices, please contact our Practice Manager at (585) 225-0950.


Long Pond Pediatrics, LLP is required to abide by the terms of this Notice of Privacy Practices (this 'Notice'). The Practice reserves the right to change the terms of this Notice at any time. The revised Notice will apply to all protected health information the Practice received or created in the past as well as all protected health information the Practice receives or creates in the future. A current copy of the Notice will be posted in the waiting room. The effective date of this Notice of Privacy Procedures is set forth on the first page of this Notice. If this Notice of Privacy Procedures has been changed since your last appointment, the Practice will provide a copy of the current Notice of Privacy Practices to you when you sign in for your appointment. Additionally, you may obtain a copy of the current Notice by calling your physician and requesting that one be sent to you in the mail or by asking for one when you are in the office.

Your 'protected health information' consists of all individually identifiable information which is created or received by the Practice and which relates to your past, present or future physical or mental health or condition, the provision of health care to you or the past, present or future payment for health care provided to you.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR WHICH YOUR CONSENT OR AUTHORIZATION IS NOT REQUIRED

1. Treatment: The Practice will use and disclose your protected health information to provide, coordinate or manage your health care and related services by the Practice and other health care providers, including consulting with other health care providers about your health care or referring you to another health care provider for treatment. For example, the Practice will disclose your protected health care information to a specialist to whom you have been referred to ensure that the specialist has the necessary information he or she needs to diagnose and/or treat you.

2. Payment: The Practice will use and disclose your protected health information, as needed, to obtain payment for the health care the Practice provides to you. For example, prior to providing services, the Practice may disclose to your insurance carrier the treatment you are going to receive to ensure that your insurance carrier will cover that treatment. Additionally, the Practice may disclose to your insurance carrier, as necessary, the treatment you received to ensure that the Practice is paid or you are reimbursed for the cost of your treatment.

3. Health Care Operations: The Practice may use or disclose your protected health information in order to support the business activities of the Practice. These activities include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualification of health care professionals, conducting training programs in which students provide treatment under the supervision of one of the Practiceís physicians, business planning and development and business management and general administrative activities. For example, the Practice may disclose your protected health information to medical school students that see patients of the Practice. Additionally, the Practice may use your protected health information to ensure that all of the physicians at the Practice provide the highest quality health care.

4. Appointment Reminders: The Practice may use or disclose your protected health information in order to contact you and remind you of a scheduled appointment.

5. Treatment Alternatives: The Practice may use or disclose your protected health information to inform you about treatment alternatives.

6. Health Related Benefits and Services: The Practice may use and disclose your protected health information to inform you about health-related benefits and services that may be of interest to you.

7. Others Involved in Your Health Care and Disaster Relief: Unless you object, the Practice may disclose to a family member, other relative, close personal friend, daycare provider or any other person identified by you protected health information related to that personís involvement in your health care or payment related to your health care. The Practice may also use or disclose to a person responsible for your care your protected health information that relates to your location, general condition or death. If the opportunity for you to agree or object to any such disclosure cannot be provided due to emergency circumstances, the Practice will make these disclosures if they are in your best interests. Additionally, the Practice may disclose protected health information relating to your location, general condition or death to any public or private entity authorized to assist in disaster relief efforts.

8. Public Health: The Practice may disclose your protected health information to a public health authority authorized to collect such information for the purpose of:


9. Food and Drug Administration: The Practice may disclose your protected health information to a person subject to the jurisdiction of the Food and Drug Administration ('FDA') for the purpose of activities related to the quality, safety or effectiveness of FDA regulated products.

10. Communicable Diseases: The Practice may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of spreading a disease or condition.


11. Employer: The Practice may disclose your protected health information to your employer if the Practice is providing health care to you at the request of your employer to conduct an evaluation relating to medical surveillance relating to your workplace or to evaluate whether you have a work-related illness or injury. The Practice will notify you before your protected health information relating to the medical surveillance of the workplace and work-related illnesses and injuries is disclosed to your employer by providing you with written notice at the time the Practice renders health care to you.

12. Abuse, Neglect or Domestic Violence: The Practice may disclose your protected health information to a government authority authorized to receive reports of abuse, neglect or domestic violence if the Practice reasonably believes that you are a victim of abuse, neglect or domestic violence. Any such disclosure will be made (1) to the extent it is required by law, (2) to the extent that the disclosure is authorized by statute or regulation and the Practice believes the disclosure is necessary to prevent serious harm to you or other potential victims, or (3) if you agree to the disclosure.

13. Health Oversight Activities: The Practice may disclose your protected health information to a health oversight agency for any oversight activities authorized by law, including audits; investigations; inspections; licensure or disciplinary actions; civil, criminal or administrative actions or proceedings; or other activities necessary for the oversight of the health care system, government benefit programs, compliance with government regulatory program standards or compliance with applicable civil rights laws.

14. Judicial and Administrative Proceedings: The Practice may, upon certain conditions, disclose your protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal, a subpoena, discovery request, or other lawful process.

15. Law Enforcement Purposes: The Practice may disclose your protected health information for law enforcement purposes to a law enforcement official:


16. Coroners, Medical Examiners and Funeral Directors: The Practice may disclose your protected health information to a coroner or medical examiner for the purpose of identifying you, determining a cause of death or other duties authorized by law. The Practice may disclose your protected health information to a funeral director, consistent with all applicable laws, in order to allow the funeral director to carry out his or her duties.

17. Organ and Tissue Donation: The Practice may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating organ, eye and tissue donation and transplantation.

18. Medical Research: The Practice may disclose your protected health information for research purposes, provided that an institutional review board authorized by law or a privacy board waives the authorization requirement and provided that the researcher makes certain representations regarding the use and protection of the protected health information to be disclosed.

19. Serious Threat to Health or Safety: The Practice may disclose your protected health information, in a manner which is consistent with applicable laws, if the disclosure is necessary to prevent or lessen a serious threat to health or safety or the information is necessary to apprehend an individual.

20. Military and Veterans Activities: The Practice may, if you are a member of the United States or foreign Armed Forces, disclose your protected health information for activities that are deemed necessary by appropriate military command authorities to assure the proper execution of a military mission.

21. National Security and Protection of the President and Others: The Practice may disclose your protected health information to authorized federal officials for the conduct of lawful intelligence, counter-intelligence and other national security activities authorized by law. Additionally, the Practice may disclose your protected health information to authorized federal officials for the provision of protective services to the President, foreign heads of state, or other people authorized by law and to conduct investigations authorized by law.

22. Inmates: The Practice may disclose your protected health information to a correctional institution or a law enforcement official having lawful custody of you if the correctional institution or law enforcement official represents that the information is necessary to (1) provide health care to you; (2) the health and safety of other inmates; (3) the health and safety of the officers and employees of the correctional institution or the people responsible for transporting the inmates; (4) law enforcement on the premises of the correctional institution; or (5) the administration and maintenance of the safety, security and good order at the correctional institution.

23. Workers' Compensation: The Practice may disclose your protected health information as authorized by, and in compliance with, laws relating to workersí compensation and other similar programs established by law that provide benefits for work-related illnesses and injuries without regard to fault.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Any use or disclosure of your protected health information that is not listed above will be made only with your written authorization. You have the right to revoke your authorization at any time, except to the extent that the Practice has already used or disclosed your protected health information in reliance on the authorization.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

1. Restriction of Use and Disclosure: You have the right to request that the Practice restrict the protected health information the Practice uses and discloses in carrying out treatment, payment and health care operations. You also have the right to restrict the protected health information the Practice discloses to a family member, other relative or any other person identified by you, which is relevant to such person's involvement in your treatment or payment for your treatment. THE PRACTICE IS NOT OBLIGATED TO AGREE TO ANY RESTRICTION THAT YOU REQUEST. If the Practice agrees to a restriction, however, the Practice may only disclose your protected health information in accordance with that restriction, unless the information is needed to provide emergency health care to you.

If you wish to request a restriction on the use and disclosure of your protected health information, please send a written request to the Privacy Officer which specifically sets forth (1) whether you are restricting the use or the disclosure of your protected health information, (2) what protected health information you wish to limit, and (3) to whom you wish the limits to apply (i.e., your spouse). The Practice will not ask why you are requesting the restriction. The Privacy Officer will review your request and notify you whether or not the Practice will agree to your requested restriction.

2. Confidential Communications: You have the right to request that you receive communications of your protected health information form the Practice in alternative means or at alternative locations. The Practice will accommodate all reasonable requests.

To request that the Practice make communications of your protected health information by alternative means or at alternative locations, please send a written request to the Privacy Officer setting forth the alternative means by which you wish to receive communications or the alternative location at which you wish to receive such communications. The Practice will not ask why you are making such a request. When appropriate, the Practice may condition the provision of a reasonable accommodation upon receiving information relating to how payment, if any, will be handled.

3. Access to Protected Health Information: You have the right to inspect and obtain a copy of your protected health information that the Practice maintains in a designated record set, for so long as that protected health information is maintained in a designated record set. A 'designated record set' is a group of records maintained by or for the Practice, which includes billing, records and records used in whole or in part to make decisions about you. You do not have the right to inspect or copy psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding, or information that the Practice is otherwise prohibited by law from disclosing.

If you wish to inspect or obtain a copy of your protected health information, please send a written request to the Privacy Officer. If you request a copy of your protected health information, the Practice may charge a fee for the cost of copying and mailing the information.

The Practice may, for certain limited reasons, deny your request to inspect or obtain a copy of your protected health information. If the Practice denies your request, you may be entitled to a review of that denial. If you are entitled to a review and you wish to have the Practice's decision reviewed, please contact the Privacy Officer. The Privacy Officer will designate a licensed health care professional to review your request. This reviewing health care professional will not have participated in the original decision to deny your request. The Practice will comply with the decision of the reviewing health care professional.

4. Amending Protected Health Information: You have the right to request that the Practice amend your protected health information in a designated record set for so long as that information exists in a designated record set. To request that an amendment be made to your protected health information, please send a written request to the Privacy Officer. Your written request must provide a reason that supports the requested amendment.

The Practice may deny your request if it does not contain a reason that supports the requested amendment. Additionally, the Practice may deny your request to have your protected health information amended if the Practice determines that (1) the information was not created by the Practice, unless the person or entity that created the information is no longer available to make the amendment; (2) the information is not part of a designated record set; (3) the information is not available for your inspection; or (4) the information is accurate and complete.


5. Accounting of Disclosures of Your Protected Health Information: You have the right to request a listing of certain disclosures of your protected health information made by the Practice during the period of up to six (6) years prior to the date on which you make your request. Any accounting you request will not include (1) disclosures made to carry out treatment, payment or health care operations; (2) disclosures made to you; (3) disclosures made pursuant to an authorization given by you; (4) disclosureís made to other people involved in your care or made for notification purposes; (5) disclosures made for national security or intelligence purposes; (6) disclosures made to correctional institutions or law enforcement officials; or (7) disclosures made prior to April 14, 2003. The right to receive an accounting is subject to certain other exceptions, restrictions and limitations set forth in applicable statutes and regulations.

To request an accounting of the disclosures of your protected health information made by the Practice, please send a written request to the Privacy Officer. Your written request must set forth the format in which you want the accounting (i.e., hard copy, electronically) and the period for which you wish to receive an accounting. The Practice will provide one free accounting during each twelve (12) month period. If you request additional accountings during the same twelve (12) month period, you will be charged for all costs the Practice incurs in preparing and providing that accounting. The Practice will inform you of the fee for each accounting in advance and will allow you to modify or withdraw your request in order to reduce or avoid the fee.

6. Obtaining a Copy of this Notice: You have the right to request and receive a paper copy of this Notice of Privacy Practices from the Practice at any time.

COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of Health and Human Services. To file a complaint with the Practice, please contact our Practice Manager at (585) 225-0950. All complaints must be submitted in writing. THE PRACTICE WILL NOT RETALIATE AGAINST YOU FOR FILING A COMPLAINT.