HIPAA NOTICE OF PRIVACY PRACTICES

This Notice of Privacy practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling our office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1) Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent

You will be asked by your physician to sign a consent form. Once you have consented to use and disclosure of your protected health information for treatment, payment and health care operations by signing the consent form your physician will use or disclose your protected health information as described in this Section 1. Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice.

Following are examples of the types of uses and disclosures of your protected health care information that the physician’s office is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you when we have the necessary permission from you to disclose your protected health information. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (such as a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities.

For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Officer to request that these materials not be sent to you.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only
with your written authorization, unless otherwise permitted or required by law as
described below. You may revoke this authorization, at any time, in writing,
except to the extent that your physician or the physician’s practice has taken an
action in reliance on the use or disclosure indicated in the authorization.

Other Permitted and Required Uses and Disclosures That May Be Made
With Your Consent, Authorization or Opportunity to Object

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Other Involved in Your Healthcare: Unless you object, we may disclose to a
member of your family, a relative, a close friend or any other person you identify,
your protected health information that directly relates to that person’s
involvement in your health care. If you are unable to agree or object to such a
disclosure, we may disclose such information as necessary if we determine that it
is in your best interest based on our professional judgment. We may use or
disclose protected health information to notify or assist in notifying a family
member, personal representative or any other person that is responsible for your
care of your location, general condition or death. Finally, we may use or disclose
your protected health information to an authorized public or private entity to assist
in disaster relief efforts and to coordinate uses and disclosures to family or other
individuals involved in your health care.

Emergencies: We may use or disclose your protected health information in an
emergency treatment situation. If this happens, your physician shall try to
obtain your consent as soon as reasonably practicable after the delivery of
treatment. If your physician or another physician in the practice is required by
law to treat you and the physician has attempted to obtain your consent, but is
unable to obtain your consent, he or she may still use or disclose your protected
health information to treat you.

Communication Barriers: We may use an disclose your protected health
information if your physician or another physician in the practice attempts to
obtain consent from you but is unable to do so due to substantial communication
barriers and the physician determines, using professional judgment, that you
intend to consent to use or disclosure under the circumstances

Other Permitted and Required uses and disclosures That May Be Made Without Your Consent, authorization or Opportunity to Object

We may use or disclose your protected health information in the following
situations without your consent or authorization. These situations include:

Required By Law: We may use or disclose your protected health information
to the extent that the use or disclosure is required by law. The use or disclosure
will be made in compliance with the law and will be limited to the relevant
requirements of the law. You will be notified, as required by law, of any such
uses or disclosures.

Public Health: We may disclose your protected health information for public
health activities and purposes to a public health authority that is permitted by
law to collect or receive the information. The disclosure will be made for the
purpose of controlling disease, injury or disability. We may also disclose your
protected health information, if directed by the public health authority, to a
foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We 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 contracting or spreading the disease or
condition.

Health Oversight: We may disclose protected health information to a health
oversight agency for activities authorized by law, such as audits, investigations,
and inspections. Oversight agencies seeking this information include
government benefit programs, other government regulatory programs and civil
rights laws.

Abuse or Neglect: We may disclose your protected health information to a
public health authority that is authorized by law to receive reports of child abuse,
neglect, or domestic violence to the governmental entity or agency authorized to
receive such information. In this case, the disclosure will be made consistent
with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health
information to a person or company required by the Food and Drug
administration to report adverse events, product defects or problems,
biologic product deviations, track products; to enable product recalls; to make
repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course
of any judicial or administrative proceeding, in response to an order of a court or
administrative tribunal (to the extent such disclosure is expressly authorized), in
certain conditions in response to a subpoena, discovery request or other lawful
process.

Law Enforcement: We may also disclose protected health information, so long
as applicable legal requirements are met, for law enforcement purpose. These
law enforcement purposes include (1) legal processes and otherwise required
by law, (2) limited information requests for identification and location purposes,
(3) pertaining to victims of a crime, (4) suspicion that death has occurred as
a result of criminal conduct, (5) in the event that a crime occurs on the premises
of the practice, and (6) medical emergency (not on the Practice’s premises) and it
is likely that a crime has occurred.

Coroners, funeral Directors, and Organ Donation: We may disclose protected
health information to a coroner or medical examiner for identification purposes,
determining cause of death or for the coroner or medical examiner to perform
other duties authorized by law, in order to permit the funeral director to carry out
their duties. We may disclose such information in reasonable anticipation of
death. Protected health information may be used and disclosed for cadaveric
organ, eye or tissue donation purposes.

Research: We may disclose your protected health 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 protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may
use or disclose your protected health information, if we believe that the use or
disclosure is necessary to prevent or lessen a serious and imminent threat to the
health or safety of a person or the public. We may also disclose protected health
information if it is necessary for law enforcement authorities to identify or
apprehend an individual.

Military Activity and National Security: When the appropriate conditions
apply, we may use or disclose protected health information of individuals who
are armed forces personnel (1) for activities deemed necessary by appropriate
military command authorities; (2) for the purpose of a determination by the
Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign
military authority if you are a member of that foreign military services. We may
also disclose your protected health information to authorized federal officials for
conducting national security and intelligence activities, including for the
provision of protective services to the President or others legally authorized.

Workers’ Compensation: Your protected health information may be disclosed
by us as authorized to comply with workers’ compensation laws and other similar
legally-established programs.

Inmates: We may use or disclose your protected health information if you are
an inmate of a correctional facility and your physician created or received your
protected health information in the course of providing care to you.

Required Uses and Disclosures: Under the law, we must make disclosures to
you and when required by the Secretary of the Department of Health and Human
services to investigate or determine our compliance with the requirement of
Section 164.500 et. seq.

2) Your Rights

Following is a statement of your rights with respect to your protect health
information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information
this means you may inspect and obtain a copy of protected health information
about you that is contained in a designated record set for as long as we maintain
the protected health information. A “designated record set” contains medical
and billing records and any other records that your physician and the practice
uses for making decisions about you.

Under federal law, however, you may not inspect or copy the following records;
psychotherapy notes; information compiled in reasonable anticipation of, or use
in, a civil, criminal, or administrative action or proceeding, and protected health
information that is subject to law that prohibits access to protected health
information. Depending on the circumstances, a decision to deny access may be
reviewable. In some circumstances, you may have a right to have the decision
reviewed. Please contact our Privacy Officer if you have questions about access
to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your
protected health information for the purpose of treatment, payment or healthcare
operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If
physician believes it is in your best interest to permit use and disclosure of your
protected health information, this information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to requires with your physician. You may request a restriction by requesting this from our office’s Privacy Officer.

You have the right to have your physician amend your protected health
information. This right applies to disclosures for purposes other than
treatment, payment or healthcare operations as described in this Notice of
Privacy Practices. It excludes disclosures we may have made to you, to family
members or friends involved in your care, or for notification purposes. You have
the right to receive specific information regarding these disclosures that occurred
after April 14, 2003. You may request a shorter timeframe. The right to receive
this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notice from us, upon request.

3) Complaints

You may complain to us or to the Secretary of Health and Human Services if you
believe your privacy rights have been violated by us. You may file a complaint
with us by notifying our Privacy Officer of your complaint. We will not retaliate
against you for filing a complaint.

You may contact our Privacy Officer, Sandy Loughman, at (904) 241-7865 for
further information about the complaint process.

This notice was published and becomes effective on April 14, 2003.

4/14/03

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Jacksonville Cosmetic
Surgery Center
A.H. Nezami, M.D.
904-399-5061

Baptist Medical Center
820 Prudential Drive
Suite 702
Jacksonville, FL 32207

Harbor Village, Salon La Vie
13475 Atlantic Blvd, suite 39
Next to Queens Harbor,
Atlantic Beach 32225