NOTICE OF PRIVACY PRACTICES

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.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health
information used or disclosed to us in any form, whether on paper, orally, or electronically to be kept confidential. This federal law gives you, the
patient, new rights to understand and control how your personal health information is used. As required by law, we have prepared this explanation of
how we are required to maintain the privacy of your personal health information and how we may use and disclose this information.

Without specific written authorization, we are permitted to use and disclose your health care records for the purpose of
treatment, payment for services and health care operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care
providers.
Example: We may need to share information with other health care providers involved in the continuation of your care.
Payment means activities to obtain reimbursement for services, confirming benefits and coverage, billing or collection
activities, and utilization review.
Example: We may disclose treatment information to an insurance company when obtaining an authorization or referral.
Health Care Operations include the business aspects of running our practice.
Example: Patient information may be used for training purposes, or quality assessment.

Unless you request otherwise, we may use or disclose your health information to a family member, friend, personal representative or other individual
to the extent necessary to help with your health care or with payment for your health care. In the event of an emergency or your incapacity, we will
use our professional judgment in disclosing the minimum protected health information necessary to provide needed care. Your protected health
information may be disclosed for public health oversight activities, judicial or administrative proceedings, in response to a subpoena or court order, to
military authorities of Armed Forces personnel, to federal officials, correctional institutions or law enforcement officials. We will report suspected
abuse, neglect and/or domestic violence to proper agencies and/or authorities. Any other uses and disclosures will be made only with your written
authorization. Such authorization expires 90 days from date of consent unless noted an original authorization. You may revoke such authorization at
any time in writing.

You have certain rights in regards to your protected health information, which you may exercise by presenting a written request
to our Privacy Officer at the practice address listed below.

You have the right to request restrictions on specific uses and disclosures of your personal health information, including
those related to disclosures to family members, other relatives, close friends or any other persons identified by you. If we do
agree to such restrictions, we must abide by it unless you agree in writing to remove it. We, however, are not required to
agree to a requested restriction.
You have the right to access, inspect, and copy your personal health information, with limited exceptions. This request must
be submitted in writing with 10 day notice. A reasonable fee may be assessed.
You have the right to request amendment to your personal health information. We may deny your request in certain
situations.
You have the right to obtain a copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected personal health information.

This notice is effective March 3, 2003. We are required by law to abide by the terms of this Notice of Privacy Practices currently in effect. We
reserve the right to change the terms of our Privacy Practices and to make the new notice provisions effective for all protected health information we
maintain. Revisions will be posted on the effective date and you may request a copy from this office.

You have the right to file a formal, written complaint to the address listed below, in the event you feel your privacy rights have
been violated.

For more information about our Privacy Practices: For more information about HIPAA:
Privacy Officer: Stephanie McZegle The U.S. Dept. Of Health & Human Services
Office Name: Penny Tanner, PhD, A.R.N.P. Office of Civil Rights
7424 Bridgeport Way W., #302 200 Independence Avenue, SW
Lakewood, WA 98499 Washington, D.C. 20201
(253) 581-6106 (877) 696-6775 (toll-free)

Signature: Date: