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.

Understanding Your Health Record/Information
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit it made.  Typically,
this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care
or treatment.  This information, often referred to as your health or medical record, serves as a:

Understanding what is in your record and how your health information is used helps you to:

Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the
information belongs to you.  You have the right to:

Our Responsibilities
This organization is required to:

We reserve the right to change our practices and to make the new provisions effective for all protected health
information we maintain.  Should our information practices change, we will mail a revised notice to the address
you’ve supplied us.  

We will not use or disclose health information without your authorization, except as described in this notice.

For More Information or to Report a Problem  
If have questions and would like additional information, you may contact the practice administrator at our main
office phone:  610-376-8671.

If you believe your privacy rights have been violated, you can file a complaint with the director of health
information management or with the Secretary of Health and Human Services.  There will be no retaliation for
filing a complaint.

Examples of Disclosures for Treatment, Payment and Health Operations
We will use your health information for treatment.

For example: Information obtained by a nurse, physician, or other member of your healthcare team will be
recorded in your record and used to determine the course of treatment that should work best for you.  Your
physician will document in your record his or her expectations of the members of your healthcare team. 
Members of your healthcare team will then record the actions they took and their observations.  In that way,
the physician will know how you are responding to treatment.

We will use your health information for payment.
For example: A bill may be sent to you or a third-party payer.  The information on or accompanying the bill may
include information that identifies you, as well as your diagnosis, procedures, and supplies used.

We will use your health information for regular health operations.
For example: Members of the medical staff may use information in your health record to assess the care and
outcomes in your case and others like it.  This information will then be used in an effort to continually improve
the quality and effectiveness of the healthcare and service we provide.

Business associates: There are some services provided in our organization through contacts with business
associates.  Examples include certain radiology and laboratory tests, scheduling information for surgery with the
hospital and a transcription service.  When these services are contracted, we may disclose your health information
to our business associate so that they can perform the job we’ve asked them to do.  To protect your health
information, however, we require the business associate to appropriately safeguard your information.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal
representative, or another person responsible for your care, your location, and general condition.

Communication with family: Health professionals, using their best judgment, may disclose to a family member,
other relative, close personal friend, or any other person you identify, health information relevant to that person’s
involvement in your care or payment related to your care.

Research: We may disclose information to researchers when their research has been approved by an institutional
review board that has reviewed the research proposal and established protocols to ensure the privacy of your
health information.  This would occur only after specific approval on your part.

Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry
out their duties.

Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or
other health-related benefits and services that may be of interest to you.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events
with respect to food, supplements, product and product defects, or post marketing surveillance information to
enable product recalls, repairs, or replacement.

Workers compensation: We may disclose health information to the extent authorized by and to the extent
necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public health: As required by law, we may disclose your health information to public health or legal authorities
charged with preventing or controlling disease, injury, or disability.

Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution
or agents thereof health information necessary for your health and safety of other individuals.

Law enforcement: We may disclose health information for law enforcement purposes as required by law or in
response to a valid subpoena.

Federal law makes provision for your health information to be released to an appropriate health oversight agency,
public health authority or attorney, provided that a work force member or business associated believes in good
faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and
are potentially endangering one or more patients, workers or the public.

Effective date: [July 1, 2002]