Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES                                                                                  Effective April 14, 2003

This notice describes the Privacy Practices of our organization. It also describes the Privacy Practices of any Business Associates with which a patient's Protected Health Information (PHI) may be utilized, shared, or protected. For more information, please refer to http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html.

We understand medical and health information should be protected. We have taken steps to ensure your PHI will be strictly maintained and existing rules and regulations will be followed.

PERMITTED USES OF PHI

TREATMENT – We must keep record of the services provided to you and, in some cases, share that information with doctors, hospitals, and other related healthcare providers for the purpose of diagnosing and treating your healthcare needs. Some disclosures of your PHI may have additional restrictions as dictated by State and Federal Laws.

PAYMENT – The PHI we obtain from you as well as any financial information may be used to obtain payment from you, your insurers, or other applicable third parties. Insurance verification, treatments, and payments are permissible uses of your PHI.

OPERATIONS – Your information may be used to evaluate internal policies, procedures, cost management, quality control, customer service, training, and other related operational activities.

OTHER SERVICES

Some of the other possible uses of your PHI include:

• Utilizing your information with other agencies that may assist us in treatment, payment, or operations such as hospitals, collection agencies, and billing companies.
• Your information may be shared with family or friends for the purpose of treatment and payment decisions.
• Business Associates must adhere to the same privacy practices with respect to PHI as regulated by State and Federal Law.

YOUR RIGHTS – You may…

• Request copies of your PHI for inspection and corrections. Access may be denied under certain circumstances; a review may be requested. (Must be in writing)
• Ask for restrictions on usage of your PHI, which may or may not be considered.
• Request certain communication processes such as addresses and phone numbers.
• Ask for a copy of this notice.
• Receive an electronic notice and restrict disclosures to a health plan for which the patient has paid in full, out of pocket.
• Request an accounting in writing of certain disclosures that do not fall within the uses allowed under the provisions of treatment, payment, and operations as well as some disclosures as required by law. Any such requests must include the time period (limited to the last 6 years, and exclude any disclosures prior to April 14, 2003). Fees may apply.
• File a written complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services.

PERMITTED DISCLOSURES

• Organ and tissue donation;
• Prevent and protect against abuse, neglect, or domestic violence;
• Legal proceedings;
• Investigations, inspections, and audits;
• Medical examiners, coroners, funeral directors;
• Government intelligence and matters of security;
• Workers compensation;
• Public health issues relating to drug reactions, problems with medical devices, and communicable diseases.

All other uses and disclosures not described in this notice such as marketing purposes, sale of your information, and sharing of psychotherapy notes require your signed signature of authorization. This authorization may be revoked at any time in writing.

You can find out more about your rights by contacting our Billing Office. Please refer to the agency indicated on this form.

First Professional Services

8841 South Redwood Road, Suite B

West Jordan, Utah 84088

(801) 255-0400