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.

This Notice applies to the VIP Medical Services, LLC, referred to as the "Agency".

OUR RESPONSIBILITIES UNDER THE FEDERAL PRIVACY STANDARD
In addition to providing you with your rights, as detailed below, the federal privacy standard requires the Agency to:

Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.
Provide you with this Notice as to our legal duties and privacy practices with respect to the individually identifiable health information we collect and maintain about you.
Mitigate (lessen the harm of) any breach of privacy or confidentiality.

All Agency staff, volunteers and contracted individuals who are involved in providing your care are expected to follow the privacy practices as stated in this Notice.

USE AND DISCLOSURE OF HEALTH INFORMATION
The Agency will not use or disclose your health information without your authorization, except as described in this Notice or otherwise required by law. We reserve the right to change our practices and to make the new provisions effective for all individually identifiable health information we maintain. Should we change our information practices, you may request a copy of the Notice or access it at our website (www.vipmedicalsvcs.com).

The following are examples of how the Agency will use and disclose your health information for treatment, payment and healthcare operations. These examples are not meant to be inclusive, but describe types of uses and disclosures.

To Provide Treatment. A nurse, counselor or other member of your healthcare team will record information in your clinical record to assess and/or diagnose your condition and determine the best course of treatment for you. Your physician may give treatment orders and document what she or he expects other members of the healthcare team to do to provide you with care or service. Those other members will then document the actions they took and their observations.

We will also provide your physician, other healthcare professionals or providers, with copies of portions of your clinical record in order to coordinate your care while you are receiving services from the Agency and/or after you are discharged. If you are receiving Drug & Alcohol (D&A) services, we will only disclose information to others involved in your treatment with your written authorization.

To Obtain Payment. The Agency's business office staff will use your health information and may include your health information on invoices to collect payment from third parties for the care you receive from us.

The information on or accompanying the bill may include information that identifies you, your diagnosis, treatment received and supplies used. If you are receiving D&A services, we will disclose information to others involved in the payment of your treatment with your written authorization and then, only the limited the amount of information permitted by New Jersey D&A regulations.

To Conduct Health Care Operations. Members of the Agency's clinical and support staff, including clerical staff, will use your information to conduct the day-to-day operations that support the care that we provide to you. Agency staff may also use information in your clinical record for other health care operations such as: quality assessment and improvement activities; activities designed to improve health or reduce health care costs; training programs; accreditation, certification, licensing or credentialing activities.

The Agency may use information about you including your name, address, phone number and the dates you received care at the Agency in order to contact you or your family to raise money for the Agency. We may also release this information to a related Agency foundation. We may contact you to provide appointment reminders or provide information about treatment alternatives or other health-related benefits and services that may be of interest to you. If you do not want the Agency to contact you or your family, notify privacy@vipmedicalsvcs.com and indicate that you do not wish to be contacted. If you are receiving D&A services, we will only contact you at the address that you provided to us.

Federal privacy rules allow the Agency to use or disclose your health information without your prior authorization for a number of other reasons, which include: when required by law, public health purposes, abuse or neglect reporting, health oversight activities, research studies, funeral arrangements, when a crime has been committed at the Agency; workers' compensation and emergencies.

Unless you object, our staff, using their best judgment, may disclose to a member of your family, close personal 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. We may also use or disclose your information to any of these people to notify or assist in notifying them of your location and general condition in case of an emergency. If you are receiving D&A services, we will only disclose information to your family or others with your written authorization.

YOUR RIGHTS UNDER THE FEDERAL PRIVACY STANDARD
Although your health records are the physical property of the healthcare provider who completed it, you have certain rights with regard to the information the record contains. You have the right to:

Request restrictions on the uses and disclosures of your health information for treatment, payment, and health care operations. "Healthcare operations" consists of activities that are necessary to carry out the operations of the Agency, such as quality assurance and peer review. The Agency does not, however, have to agree to the restriction. If we do, however, we will adhere to it unless you request otherwise or we give you advance notice. If you wish to make a request for restrictions, please contact the Agency staff providing you with care.

Review and request a copy your health information, including billing records. Again, this right is not absolute. In certain situations, such as if a review would cause harm, the Agency can deny access.

In certain limited situations, we may deny you access to your clinical record. If we do, you may request a review of our decision denying your request. If you request that our denial be reviewed, another licensed healthcare professional must evaluate the decision within 60 days. Reasons for denial may include:

A licensed healthcare professional has determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the life or physical safety of you or another person.
The information in your clinical record makes reference to another person and a licensed healthcare provider has determined, on the exercise of professional judgments, that the access is reasonably likely to cause substantial harm to the other person.
The request is made by your personal representative and a licensed healthcare professional has determined, in the exercise of professional judgment, that providing access to this person is reasonably likely to cause substantial harm to you or another person.
The information was compiled in reasonable anticipation of or for use in a civil, criminal or administrative actions or proceedings.
The information was obtained from someone other than another healthcare provider, under a promise of confidentiality and the request would be reasonably likely to reveal the source of the information.

If we deny you access, we will explain why and inform you of your rights, including how to seek a review.

If we grant access, we will tell you what, if anything, you have to do to get access. The Agency reserves the right to charge a reasonable, cost-based fee for making copies. A request to review or to obtain a copy of your record can be made to any of the Agency staff providing you with care.

Right to amend your health care information. If you believe that the information in your clinical record is incorrect or incomplete, you may request that the Agency amend the record. That request may be made as long as the information is maintained by the Agency. A request for an amendment of records must be made to privacy@vipmedicalsvcs.com.

We may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your clinical record was not created by the Agency, if the records you are requesting are not part of our records, if the health information you wish to amend is not part of the health information you are permitted to inspect and copy, or if, in the opinion of the Agency, the records containing your health information are accurate and complete. If we deny your request for amendment, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we grant your request, we will make the correction and distribute the correction to those who need it and those you identify to us that you want to receive the corrected information.

Right to receive confidential communication. You have the right to request that health information about you be communicated to you in a confidential manner. For example, you may ask that we send you mail to an address other than your home address. We will not request that you provide any reasons for your request and will attempt to honor your reasonable requests. Unless you make a request, we will use the information you have given us to contact you by sending mail to your home address, by calling at your home telephone number, and by leaving a very limited message on your answering machine (if you have one). If you wish to receive confidential communications, please discuss this with the staff providing you with service.

Right to an accounting. You have the right to request an accounting of disclosures of your health information made by the Agency for any reasons other than for treatment, payment, or health operations, or when you signed an authorization for us to disclose the information. The request for an accounting must be made to privacy@vipmedicalsvcs.com. The request should specify the time period for the accounting no earlier than April 14, 2003. Accounting requests may not be made for periods of time more than six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests in the 12-month period may be subject to a reasonable cost-based fee.

COMPLAINTS
You may complain to us (privacy@vipmedicalsvcs.com) and to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.

To file a complaint with the United States Secretary of Health and Human Services, send your complaint to him or her in care of: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201.

You will not be retaliated against for filing a complaint.

EFFECTIVE DATE

This Notice is effective January 1, 2005.