PRIVACY NOTICE

PHI-PROTECTED HEALTH INFORMATION

In this notice, we will tell you about:

• How we use your PHI
• When we may disclose your PHI to others
• Our privacy duties
• Who to contact for more information or with a complaint

1. SOME OF THE WAYS WE USE OR DISCLOSE YOUR PHI
   • We will use your PHI to treat you
   • We will use your PHI and disclose it to get paid for your care
   • We are allowed to use or disclose you PHI for certain activities that we call “health care operations.” Health care operations involve a lot of the administration, education and quality assurance activities in our practice.
2. * Treatment-For example, if you are receiving therapy services from our practice, we may take your initial vital signs.
   * Payment-After we treat you, we will ask your insurer to pay us. We may type some of your PHI into our computers and send claims to your Insurer.
   * Health care operations- For example, our therapists may meet periodically to study therapy records to monitor the quality of care in our practice. Your medical record and PHI could be used in these quality assessments.
   * Special uses
   • Remind you that you have an appointment with us for treatment.
   • Tell you about treatment alternatives and options.
   • Tell you about our other health benefits and services.
   • Ask you to contribute funds to our charitable activities unless you tell us not to ask you.
3. * Your authorization may be required-In many cases summarized. We may use or disclose your PHI either with your consent or as required or permitted by law. In all other cases, we must ask for, and you must agree to give, a written authorization that has specific instructions and limits to our use or disclosure of your PHI. If you later change your mind, you may revoke your authorization.CERTAIN USES AND DISCLOSURES OF YOUR PHI THAT ARE REQUIRED OR PERMITTED BY LAW
4. Many laws and regulations apply to us that affect your PHI. Here is a list, from the federal health information privacy regulations, describing required or permitted uses and disclosures.
   • If you do not verbally object, we may include information identifying you in a visitor’s directory of patients in our office when you are receiving therapy services by our practice. This may include your name, general condition, and religious affiliation, if any.
   • If you do not verbally object, we may share some of your PHI with a family member or friend involved in your care.
     We may use your PHI in an emergency when you are not able to express yourself.
   • If we receive certain assurances that protect your privacy, we may use or disclose your PHI for research.
5. We may also use or disclose your PHI:
   • When required by law, for example when, ordered by a Court to turn over certain types of your PHI, we must do so.
     For public health activities, such as reporting a communicable disease or reporting an adverse drug reaction to the Food and Drug Administration.
   • To report neglect, abuse or domestic violence.
   • To the government regulators or its agents to determine whether we comply with applicable rules and regulations.
     In judicial or administrative proceedings such as in response to a valid subpoena.
   • When properly requested by law enforcement officials (such as reporting gunshot wounds), or for other legal requirements.
   • If we reasonably believe that to do so will avert a health hazard or to response to public safety such as an imminent crime against another person
   • If you are Armed Forces personnel and it is deemed necessary by the appropriate military command authorities.
   • In connection with certain types of organ donor programs
6. CERTAIN STRICTER REQUIREMENTS THAT WE FOLLOW
7. Several state laws may apply to your PHI that set a stricter standard that the protections required by the federal health privacy regulations. Stricter state law in Pennsylvania will, for example, limit us from using or disclosing:
   • PHI regarding individuals who are the subject of HIV-related information. We may not use or disclose such HIV information except to you, your doctor, your insurer and a small number of additional persons without your express written consent.
   • Your medical information outside of our practice except as provided by your written permission that is maintained by us in your original record.
   • Your PHI to pursue a grievance against certain managed care organizations unless we have your written consent.
   • Records that contain drug and alcohol abuse information without your consent or a court order if state or local government funds the treatment program.
   • Your records without your consent or a court order if they contain information relating to inpatient mental health treatment or involuntary outpatient mental health treatment. There may be exceptions for certain government officials.
8. YOUR PRIVACY RIGHTS AND HOW TO EXERCISE THEM
9. You have specific rights under our federally required privacy program. Each of them is summarized here.
   Your right to request limited use or disclosure. You have the right to request that we do not use or disclose your PHI in a particular way. However, we are not required to abide by your request. If we do agree to your request, we must abide by the agreement.
   Your right to confidential communication. You have the right to receive confidential communications from us at a location that you provide. We require that you make your request in writing, to provide us with the other address, and explain to us if the request will interfere with your method of payment for your care.
   Your right to revoke your consent or authorization. If you have granted us your consent or authorization to use or disclose you PHI, you may revoke the consent or authorization in writing. However, if we have relied on your consent or authorization, we may use or disclose you PHI to that extent.
   Your right to inspect and copy. You have the right to inspect and copy your PHI. We may refuse to give you access to your PHI if we think it may cause you harm, but we have to explain why and give you someone to contact about our decision who will know how and when to get a review of our refusal.
   Your right to amend your PHI. If you disagree with what your PHI in our records says about you, you have the right to request in writing that we amend your PHI when it is in a record that we create or have maintained for us. We are not required to respond to your request if the records you are asking about are not ours. Then, you will have a right to submit a written statement about why you disagree. If we still disagree, we may prepare a counter-statement. Your statement and our counter-statement must be made a part of our record about you.
   Your right to know who else sees your PHI. You have the right to request an accounting of certain disclosures that we have made of your PHI since the start of services. You cannot ask for disclosures prior to April 1, 2016. We do not have to account for all disclosures, including those involving treatment, payment and health care operations as described above. There is no charge for an annual accounting, but there may be for additional accountings. We will tell you if there is a charge for your accounting and you will have the right to withdraw your request, or to pay to proceed.
   Your right to complain. If you believe that your privacy rights have been violated, you have the right to make a complaint to us, or to the Secretary of Health and Human Services. We will not retaliate against you if you file a complaint about us. To file a complaint, you should submit it in writing to the contact person identified in the Notice (6 below). Your complaint should provide a reasonable amount of specific detail to enable us to investigate a potential problem.SOME OF OUR PRIVACY OBLIGATIONS AND HOW WE PERFORM THEM
10. We are required to comply with the federal health information privacy regulations. Those rules require us to protect your PHI. Those rules also require us to give you notice of our privacy practices. This document is our notice. If you did not get a paper copy of this notice, you may have one. We will abide by the privacy practices set forth in this notice and our privacy practices when permitted or as required by law. If we change our notice of privacy practices, we will provide our revised notice to you when you next seek treatment from us. You may also obtain our most recent notice from our website at:
    www.speechspa.comCONTACT INFORMATION
11. If you have any questions about this notice, or if you have a complaint, please contact:
    Name: Amy Coleman-Perryman
    Title: Privacy Officer
    Address: Speech Spa, LLC
    2260 Northlake Pkwy, Ste. 210
    Tucker, GA 30084
    Phone: 678-825-5750EFFECTIVE DATE:

This notice takes effect on April 1, 2016