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HIPAA 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. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT

This notice describes Wellington Retreats privacy practices and that of:
• Any health care professionals authorized to enter information into your medical record.
• All departments and units of our facilities.
• All employees, staff and other office personnel.
• All these individuals, sites and locations follow the terms of this notice. In addition these individuals, sites and locations may share medical information with each other or with third party specialists for treatment, payment or office operations purposes described in this notice.

We create a record of the care and services you receive at our facilities which we need to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our facilities. The terms “information”, “health information” or “medical information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to you or physical or mental health condition, the provision of health care to you, or the payment for such health care.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
• Maintain the privacy of your Protected Heath Information.
• Provide you this notice of our legal duties and privacy practices with respect to your Protected Heath I information;
• Follow the terms of this notice;
• Notify you if we are unable to agree to a requested restriction; and
• Accommodate reasonable requests.

The main reasons for which Wellington Retreat may use and disclose your Protected Health Information are for treatment, payment, and health care operations. The following describes these and other use and disclosures, together with some examples:

• For Treatment. We may use and disclose medical information and test results about you with other health care providers for confirmation of a diagnosis. We may disclose medical
Information about you to our office personnel who are involved in taking care of you at one of our facilities or elsewhere. We also may disclose medical information about you to people
outside our facilities who may be involved in your care after you leave one of our facilities, such as family members or others we use to provide services that are part of your care. Provided you have consented to such disclosure. These entities include physicians. Hospitals, pharmacies or clinical labs with whom the office consults or makes referrals.
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• For Payment. We may use and disclose medical information about you so that the treatment and services you receive at our office 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 procedures you receive at one of our facilities so your health plan will pay us or reimburse you for the services. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether you r plan will cover the treatment.

• For Health Care Operations. We may use and disclose medical information about you for your internal operations. These uses and disclosures are necessary to run our facilities and make sure that all of our patients receive quality care. For example, we may use medical information about you to review our treatment and services and to evaluate the performance of our staff in a caring for you. We may also combine medical information about many patients to decide what additional services one of our facilities should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to our physicians, staff and other office personnel for review and learning purposes.

• Individuals Involved in your Care or Payment for your Care. We may release medical information about you to a friend or family member who is involved in you r medical care, provided you have consented to such disclosure. We may also give information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about you r condition, status and location.

• Where Required by Law or for Public Health Activities: We’d disclose Protected Health Information when required by federal, state or local law. Examples of such mandatory disclosures include notifying state or local health authorities regarding particular communicable diseases, or providing Protected Health Information to a governmental agency or regulator with health care oversight responsibilities. We may also release Protected Health Information to a coroner or medical examiner to assist in identifying a deceased individual or to determine the cause of death.

• To Avert a Serious Threat to Health or Safety: We may disclose Protected Health Information to avert a serious threat to someone’s health or safety. We may also disclose Protected Health Information to federal, state or local agencies engaged in disaster relief as well as to private disaster relief or disaster assistance agencies to allow such entities to carry out their responsibilities in specific disaster situations.

• For Health-Related Benefits or Services: We may use Protected Heath Information to provide you with information about benefits available to you under your current coverage or pol icy and in limited situations, about health-related products or services that may be of interest to you.

• For Law Enforcement or Specific Government Functions. We may disclose Protected Health Information in n response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose Protected Health Information about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

• When Requested as Part of a Regulatory or Legal Proceeding. If you or your estate is involved in a lawsuit or a dispute, we may disclose Protected Health Information about you in response to a court or administrative order. We may also disclose Protected 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 Protected Health Information requested. We may disclose Protected Health information to any govern mental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination.

• Disclosures of Workers’ Compensation. We may, without you r authorization. disclose
Information in your Medical Record to the extent that disclosure is authorized by, and necessary to comply with, laws relating to workers’ compensation.

• Privacy and Security of Health Information. We will not use or disclose your health
Information for marketing purposes, sell your health information, or, in most cases, use or
Disclose any psychotherapy notes without you r authorization. We are required by law to notify you following a breach of your unsecured Protected Health Information.

• Other Uses of Protected Health Information: Other uses and disclosures of Protected Health Information not covered by this notice and permitted by the laws that apply to us will be made only with your written authorization or that of your legal representative. If we are authorized to use or disclose Protected Health information about you, you or your legally authorized representative may revoke that authorization in writing, at any time, except to the extent that we have taken action relying on the authorization or if the authorization was obtained as a condition of obtaining your Health Insurance coverage. You should understand that we will not be able to take back any disclosures we have already made with authorization.

You r Rights Regarding Protected Health Information we Maintain About you:

The following are your various rights as a consumer under H I PAA concerning your Protected Health Information:
• Right to Inspect and Copy Your Protected Health Information. In most cases. You have the right to in inspect and obtain a copy of the Protected Health I information that we maintain about you. To inspect and copy Protected Health Information, you must submit you r request in writing to the applicable administrator listed above. We will normally respond to your request within 30 days of receipt unless the information to which you request access is located off site, in which case, it may take us up to 60 days to respond. If for some reason we are unable to respond within the time frames just stated, we will, prior to the expiration of the 30-day or 60-day period, notify you in writing why we are unable to respond and the date by which we will respond. I n no case will our response be given later than 30 days after the expiration of the date that it would have been due had we not given notice.
To receive a copy of you r Protected Health l nforn1ation, you may be charged a fee for the costs of copying, mailing or other supplies associated with you r request. However, certain types of Protected Health Information will not be made available for inspection and copying. This includes Protected Health Information collected by us in connection with, or in reasonable anticipation of any claim or legal proceeding. In very limited circumstances we may deny you r request to inspect and obtain a copy of you r Protected Health Information or we may deny your request with respect to only some of the information i n your Medical Record. If you r request is denied, you will be notified in writing why we denied the request. That same notice will also explain to you your rights to request a review of that denial and how to exercise those rights.

o The following use and disclosures of PHI will only be made pursuant to us receiving a written authorization from you:

• Most uses and disclosure of psychotherapy notes;
• Uses and disclosure of your PHI for marketing purposes, including subsidized treatment and health care operations;
• Disclosures that constitute a sale of PHI under HI PAA; and
• Other uses and disclosures not described in this notice.

You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have a l ready taken actions relying on your authorization.
Finally, we will also advise you how you may make a complaint to us or to the Secretary of the Department of Health and Human Services. If your request is denied only in part we will provide you with access to the remaining information in your Medical Record. If we do, you may request that the denial be reviewed. The review will be conducted by an individual chosen by us who was not involved in the original decision to deny you r request. We will comply with the outcome of the review.

• Right to Amend Your Protected Health Information: If you believe that you r Protected Health Information is incorrect or that an important part of it is missing, you have the right to ask us to amend you r Protected Health Information while it is kept by or for us. You must provide your request and your reason for the request in writing, and submit it to the applicable administrator listed above. We may deny your request if it is not in writing or does not include a reason that supports the request. In addition, we may deny you r request if you ask us to amend Person Information that: is accurate and complete; was not created by us unless the person or entity that created the Protected Heath Information is no longer available to make the amendment; is not part of the Protected Health Information kept by or for us; or is not part of the Protected Health Information which you would be permitted to inspect and copy. Our response regarding such request will follow the same procedures set forth above for accessing your records. The same complaint procedures should also be following in n the event you r request to amend you r records is denied.

• Right to an Accounting of Disclosures: You have the right to request a list of the disclosures we have made of Protected Health Information about you. This list will not include disclosures made for treatment, payment, health care operations, for purposes of national security, made to law enforcement or to corrections personnel, or made pursuant to your authorization or made directly to you. To request this list you must submit your request in writing to the applicable administrator listed above. Your request must state the time period from which you want to receive a list of disclosures. The time period may not be longer than six years and may not include dates before April 1 4, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). We will respond to your request for an accounting within 60 days after receipt un less we notify you in writing prior to the expiration of the 60-day period why we are unable to respond within that time frame and specify the date on which we will respond, which will not be later than 90 days after receipt of your request. The first list you request within a 12-month period will be free. We may charge you for responding to any additional requests. 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 Protected Health Information we use of disclose about you for treatment, payment or health care operations, or that we disclose to someone who may be involved in your care or payment for your

Care, like a family member or friend. While we will consider you r request, we are not required to agree to it in all circumstances, except in the case of a disclosure restricted 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 Protected Health Information pertains solely to a health care item or service for which you, or the person other than the health plan on you r behalf, has paid the covered entity in full. If we do agree to it, we will comply with your request. To request a restriction, you must make your request in writing to the applicable administrator listed above. I n 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 or parent). We will not agree to restrictions on Protected Health Information uses or disclosures that are legally required, or which are necessary to administer our business.

• Right to Request Confidential Communication: You have the right to request that we communicate with you about Protected Health Information 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 you r request in writing to the applicable administrator listed above and specify how or where you wish to be contacted . We will accommodate all reasonable requests.

• Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact Stacey Hodges at 561-296-5288 or the Secretary for the Department of Health and H u man Services. You will not be penalized for filing a complaint.

ADDITIONAL INFORMATION:

Changes to This Notice: We reserve the right to change the terms of this notice at any time. We reserve the right to make the revised or changed notice effective for Protected Health Information we already have about you as well as any Protected Health Information we receive in the future. If we do make such changes, we will post a copy of the revised notice in the reception area of all our facilities and in other areas of our facilities where we provide health care services. You may obtain a copy of the current notice by calling Stacey Hodges at 561-296-5288 and requesting a copy, or by requesting a copy from any of our health care professionals with whom you have contact.

Other Uses of Medical Information: Other uses and disclosures of medical information not covered by this notice that apply to use will be made only with your written permission. I f you provide us permission to use or disclose medical 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 medical 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.

The U.S.Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll Free: 1-877-696-6775
Please be aware that mail sent to the Washington D.C area offices takes an additional 3-4 days to process due to changes in mail handling resulting from the Anthrax crisis of October 2001.

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