Thissummaryisprovidedto Assistyouin Understanding Theattachednoticeofprivacypractices

SUMMARY OFNOTICEOF PRIVACYPRACTICES

Thissummaryisprovidedto assistyouin understanding theattachedNoticeofPrivacyPractices

TheattachedNoticeofPrivacy Practices containsadetaileddescriptionof howour office willprotectyourhealthinformation, your rightsasa patientandour common practicesin dealing with patienthealth information. PleaserefertothatNoticefor furtherinformation.

UsesandDisclosuresof Health Information.Wewill use and discloseyour healthinformationinorder totreatyouor to assistother healthcare providersintreating you. We willalsouseanddiscloseyour health information in orderto obtain paymentforourservices orto allow insurancecompanies toprocess insurance claimsforservicesrenderedtoyouby usor otherhealthcare providers. Finally,we may discloseyour healthinformation limited operational activities such as quality assessment, licensing,accreditation and trainingofstudents.

UsesandDisclosuresBasedon Your Authorization. Except as stated in more detailintheNoticeofPrivacy Practices,we willnotuse or discloseyour health informationwithoutyour written authorization.

UsesandDisclosuresNot Requiring Your Authorization.Inthe following circumstances,wemay discloseyourhealth informationwithoutyour written authorization:

•Tofamilymembersorclosefriendswho areinvolved inyourhealth care;

•Forcertain limited research purposes;

•Forpurposes ofpublichealth and safety;

•ToGovernmentagenciesforpurposesof their audits,investigationsandother oversightactivities;

•To governmentauthoritiestopreventchild abuseordomesticviolence;

•TotheFDAtoreportproductdefectsor incidents;

•To law enforcement authorities to protectpublicsafety ortoassistin apprehending criminal offenders;

•Whenrequiredbycourtorders,search warrants, subpoenas and as otherwise required bythelaw.

Patient Rights.As ourpatient, you havethe followingrights:

•Tohaveaccesstoand/oracopyofyour health information;

•To receiveanaccountingofcertain disclosureswe have made ofyour health information;

•Torequestrestrictionsastohow your health information is used ordisclosed;

•To requestthatwecommunicatewithyou in confidence;

•Torequestthatweamend yourhealth information;

•To receive notice of our privacy practices.

Ifyouhave a question,concernor complaintregardingourprivacy practices, please refer to the attached Notice of Privacy Practicesforthepersonorpersons whomyou maycontact.

NOTICE OF PRIVACY PRACTICES

THISNOTICEDESCRIBESHOW MEDICALINFORMATION ABOUTYOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GETACCESS TO THIS INFORMATION.

PLEASEREVIEW ITCAREFULLY. THEPRIVACY OFYOURMEDICAL INFORMATION ISIMPORTANT TO US.

OurLegalDuty

Wearerequiredbyapplicable federalandstate lawstomaintaintheprivacyofyourprotectedhealth information. Wearealsorequired togiveyouthis noticeabout ourprivacypractices,ourlegal duties,and yourrightsconcerning yourprotectedhealth information.Wemustfollowthe privacypracticesthat aredescribedinthisnoticewhileitisineffect. This noticetakeseffectSeptember 23, 2013andwillremain in effectuntilwereplaceit.

We reservetherighttochangeourprivacypractices andthetermsofthisnoticeatanytime, ifsuchchanges arepermittedbyapplicable law. Wereservetherighttomakethechangesinour privacy practicesandthenewtermsofournotice effectiveforallprotectedhealthinformation thatwe maintain, including medical informationwecreatedor receivedbeforewemadethechanges.

Youmay request acopy ofournotice (orany subsequent revisednotice)atanytime. Formore information aboutourprivacy practices,orfor additional copiesofthisnotice,pleasecontactususing theinformationlistedattheendofthis notice.

Usesand Disclosures of Protected

Health Information

Wewilluseanddiscloseyourprotected health information aboutyoufortreatment, payment,and healthcareoperations.

Followingareexamplesofthetypesofusesand disclosures ofyourprotectedhealthcareinformation thatmayoccur.Theseexamples arenotmeanttobe exhaustive, buttodescribethetypesofusesand disclosuresthat maybemadebyouroffice.

Treatment: Wewilluseanddiscloseyour protectedhealthinformationtoprovide,coordinateor manageyourhealthcareandany relatedservices.This includes thecoordinationormanagementofyourhealth carewithathirdparty.Forexample,wewould disclose yourprotectedhealthinformation, asnecessary,toahomehealthagencythatprovidescare toyou.Wewillalsodisclose protected health information tootherphysicianswhomaybetreating you.Forexample,yourprotected health information maybeprovidedtoaphysicianto whomyouhave beenreferredtoensurethatthephysician hasthe necessaryinformationto diagnoseortreat you.

Inaddition,wemay discloseyourprotected health information fromtimetotimetoanotherphysician or healthcareprovider(e.g.,aspecialist orlaboratory) who, attherequestof your physician, becomes involvedin yourcarebyassistingyourphysician.

Payment:Yourprotectedhealthinformation will beused,asneeded,toobtain payment foryourhealth careservices.Thismayincludecertainactivities that yourhealthinsurance planmayundertakebeforeit approves orpaysforthehealthcareserviceswe recommendforyou,suchas:makingadetermination ofeligibility orcoverageforinsurancebenefits, reviewingservicesprovidedtoyouforprotected health necessity,andundertakingutilization reviewactivities. For example,obtainingapprovalfor ahospitalstay mayrequirethatyourrelevant protected health information bedisclosedtothehealthplantoobtain approvalforthe hospitaladmission.

Health Care Operations: We may use or disclose,asneeded,yourprotectedhealthinformation inordertoconduct certainbusiness andoperational activities.Theseactivitiesinclude,butarenotlimited to,quality assessmentactivities, employeereview activities, training of students, licensing, and conductingorarrangingforotherbusinessactivities.

Forexample,wemayuseasign-in sheetatthe registration deskwhereyouwillbeaskedtosignyour name.Wemayalsocallyoubynameinthewaiting roomwhenyourdoctorisreadytoseeyou.Wemay useordiscloseyourprotectedhealthinformation, as necessary, to contactyoubytelephone or mailtoremindyouofyourappointment.

Wewillshareyourprotected healthinformation withthirdparty“businessassociates” thatperform variousactivities(e.g.,billing,transcription services) forthe practice.Wheneveranarrangementbetweenour office andabusiness associateinvolves theuseor disclosure of your protected health information, we willhaveawrittencontractthatcontainstermsthat will protect the privacy of your protected health information.

SaleofHealth Information: Wewillnotsellor exchangeyourhealthinformation foranytypeof financialremuneration withoutyourwritten authorization.

FundraisingCommunications: Wemayuseor discloseyourhealthinformation forfundraising purposes, butyouhavetherighttoopt-outfrom receivingthesecommunications.

UsesandDisclosures BasedonYourWritten Authorization: Otherusesanddisclosures ofyour protectedhealthinformation willbemadeonlywith yourauthorization, unlessotherwisepermittedor requiredbylawasdescribedbelow.

Youmaygiveuswritten authorizationtouseyour protectedhealthinformation ortodiscloseittoanyone foranypurpose. Ifyougiveusanauthorization,you mayrevokeitinwritingatanytime. Yourrevocation willnotaffect any useordisclosurespermittedbyyour authorization whileitwasineffect. Withoutyour written authorization, wewillnotdiscloseyourhealth careinformationexceptasdescribedinthis notice.

OthersInvolved inYourHealthCare:Unless youobject,wemaydisclose toamember ofyour family,arelative,aclosefriendoranyotherperson youidentify,yourprotectedhealthinformation that directly relatestothatperson’s involvement inyour healthcare.Ifyouareunabletoagreeorobject tosuch adisclosure,wemaydisclosesuchinformation as necessaryifwedetermine thatitisinyourbest interest basedonourprofessional judgment. Wemayuseor discloseprotectedhealthinformation tonotify orassist innotifyingafamilymember,personalrepresentative

oranyotherpersonthatisresponsibleforyourcareof yourlocation,generalconditionordeath.

Marketing: Wemayuseyourprotected health information tocontactyouwithinformation about treatmentalternativesthatmaybeofinteresttoyou. We maydisclose yourprotectedhealthinformationto a business associatetoassistusintheseactivities. Ifwe arepaidby athirdparty tomakemarketing communications to you about their products or services,wewillnot makesuchcommunicationsto youwithoutyourwritten authorization. Exceptas statedabove,noothermarketingcommunications will be senttoyouwithoutyourauthorization.

Research;Death;OrganDonation:Wemay use ordiscloseyourprotectedhealthinformation for researchpurposesinlimitedcircumstances. Wemay disclosetheprotectedhealthinformation ofadeceased persontoacoroner,protected healthexaminer,funeral directorororganprocurement organizationforcertain purposes.

PublicHealthandSafety:Wemaydisclose your protectedhealthinformation totheextentnecessary to avertaseriousandimminentthreattoyourhealthor safety,orthehealthorsafety ofothers. Wemay discloseyourprotectedhealthinformation toa government agency authorizedtooverseethehealth caresystem orgovernmentprogramsoritscontractors, andtopublichealth authorities forpublichealth purposes.

HealthOversight: Wemaydiscloseprotected healthinformation toahealthoversightagencyfor activities authorizedbylaw,suchasaudits, investigationsandinspections. Oversight agencies seekingthisinformationincludegovernmentagencies that overseethehealthcaresystem, governmentbenefit programs,othergovernmentregulatoryprogramsand civilrightslaws.

Abuse or Neglect: We may disclose your protected health information to a public health authoritythatisauthorizedbylawtoreceivereports of childabuseorneglect. Inaddition,wemay disclose yourprotectedhealthinformationif webelievethat youhavebeenavictimofabuse,neglectordomestic violencetothegovernmental entityoragency authorizedtoreceive such information.Inthiscase,the disclosure willbemadeconsistent with therequirementsofapplicablefederaland statelaws.

Food and Drug Administration:We may discloseyourprotectedhealthinformationtoaperson orcompany requiredbytheFoodandDrug Administration to report adverse events, product defects orproblems, biologic productdeviations, to track products; to enable product recalls; to make

repairsorreplacements;ortoconductpostmarketing surveillance,asrequired.

CriminalActivity: Consistent withapplicable federal andstatelaws,wemay discloseyourprotected healthinformation, ifwebelievethattheuseor disclosureisnecessarytopreventorlessenaserious andimminentthreattothehealth orsafety ofaperson orthepublic. Wemay alsodisclose protectedhealth information ifitisnecessaryforlawenforcement authoritiesto identifyorapprehendanindividual.

RequiredbyLaw: Wemayuseordiscloseyour protectedhealthinformationwhenwearerequiredto dosoby law.Forexample,wemust discloseyour protectedhealthinformation totheU.S.Departmentof HealthandHuman Servicesuponrequestforpurposes ofdetermining whetherweareincompliancewith federalprivacylaws. Wemaydiscloseyourprotected health informationwhenauthorized byworkers’ compensationor similarlaws.

Process andProceedings: Wemay discloseyour protectedhealthinformationinresponsetoacourtor administrative order,subpoena,discoveryrequestor otherlawfulprocess, undercertain circumstances. Underlimitedcircumstances, suchasacourtorder, warrant orgrandjurysubpoena,wemaydiscloseyour protectedhealthinformation tolawenforcement officials.

LawEnforcement: Wemay discloselimited informationtoalawenforcementofficialconcerning theprotectedhealthinformation ofasuspect,fugitive, materialwitness,crimevictimormissingperson. We maydisclosetheprotectedhealthinformation ofan inmateorotherpersoninlawfulcustody toalaw enforcement officialorcorrectional institutionunder certain circumstances. Wemaydisclose protected healthinformationwherenecessary toassistlaw enforcement officials tocaptureanindividualwhohas admittedto participationin acrimeor hasescapedfromlawfulcustody.

Patient Rights

Access: You have the right to look at or get copies of your protected health information, with limitedexceptions.Youmustmakearequestinwriting tothecontactpersonlistedhereintoobtainaccessto your protectedhealthinformation. You mayalsorequestaccessbysendingusalettertotheaddressat theendofthisnotice. Ifyourequestcopies,wewill chargeyou25¢foreach page,$15.00perhourforstaff timetolocate andcopyyour protected health information,andpostage ifyouwantthecopiesmailed toyou.IfthePracticekeepsyourhealthinformationin electronic form,youmayrequestthatwesendittoyou

oranotherpartyinelectronicform. Ifyouprefer,we willprepareasummary oranexplanation ofyour protected healthinformationforafee.Contact ususing theinformationlistedattheendofthisnoticeforafull explanationofourfee structure.

AccountingofDisclosures:You havethe rightto receivealistofinstances inwhichweorourbusiness associates disclosedyournon-electronicprotected healthinformation forpurposesotherthantreatment, payment,healthcareoperations andcertain other activities during thepastsix(6)years. Fordisclosures ofelectronichealthinformation,ourduty toprovide an accounting onlycoversdisclosuresafterJanuary 1,2014andonlyappliestodisclosures forthethree(3)yearspreceding yourrequest.Wewill provideyouwiththedateonwhichwemade the disclosure,thenameofthepersonorentitytowhomwedisclosedyourprotectedhealthinformation, a description oftheprotectedhealthinformationwe disclosed,the reasonfor thedisclosure,and certainotherinformation. Ifyourequestthislistmorethan onceina12-month period,wemaychargeyoua reasonable, cost-basedfeeforrespondingtothese additionalrequests. Contactususingtheinformation listedattheendofthisnoticeforafullexplanation of our fee structure.

Restriction Requests: Youhavetherightto requestthatweplaceadditionalrestrictions onouruse ordisclosure ofyourprotectedhealth information. Except asnotedherein,wearenotrequired toagreeto theseadditionalrestrictions,but ifwe do,wewill abide byouragreement(exceptinanemergency). Weare requiredtoacceptandfollowrequestsforrestrictions ofhealthinformation toinsurancecompaniesifyou havepaidout-of-pocket andinfullfortheitemor serviceweprovidetoyou. Any agreementwemay maketoarequestforadditional restrictionsmustbein writing signed byaperson authorized tomakesuchan agreementonourbehalf. Wewillnotbeboundunless ouragreementissomemorializedin writing.

Confidential Communication: You havetherighttorequestthatwecommunicate withyouin confidenceaboutyourprotectedhealthinformation by alternativemeansortoanalternativelocation. You mustmakeyourrequestinwriting. Wemust accommodate yourrequestifitisreasonable, specifies thealternativemeansorlocation,andcontinues to permitusto billandcollectpaymentfromyou.

Amendment: Youhavetherighttorequestthat weamendyourprotected health information. Your requestmust beinwriting, anditmustexplainwhythe informationshouldbeamended. Wemaydenyyour requestifwedidnotcreatetheinformation youwant amendedorforcertainotherreasons. Ifwedenyyour

request, wewillprovideyoua writtenexplanation. Youmayrespondwithastatementofdisagreement to beappendedtotheinformationyouwantedamended. Ifweaccept yourrequesttoamendtheinformation,we will makereasonableeffortstoinform others, including peopleorentitiesyouname,ofthe amendment andtoincludethechangesinanyfuture disclosuresofthatinformation.

ElectronicNotice: Ifyoureceivethisnoticeon our websiteor byelectronic mail (e-mail), youare

entitledtoreceivethisnoticeinwrittenform. Please contactususingtheinformationlisted attheend ofthis noticeto obtainthisnoticein writtenform.

NoticeofUnauthorized Disclosures: Ifthe Practicecausesorallowsyourhealthinformationtobe disclosedtoanunauthorizedperson,thePracticewill notifyyouofthisand helpyoumitigatetheeffects.

Questionsand Complaints

Ifyouwantmoreinformation aboutourprivacy practices orhavequestions orconcerns, pleasecontact us usingtheinformationbelow.

Ifyou believethatwemay haveviolatedyour privacy rights, or you disagree with a decision we madeaboutaccesstoyour protectedhealthinformation or in response to a request you made, you may complaintoususingthecontactinformation below. YoualsomaysubmitawrittencomplainttotheU.S.

Nameof ContactPerson:Gloria Smith

Telephone:719-539-6600 Fax:719-539-6606

Address: 920 Rush Dr. Salida, CO 81201

DepartmentofHealthandHumanServices.Wewill provideyouwiththeaddresstofileyourcomplaint with theU.S.Department ofHealth andHuman Servicesuponrequest.

Wesupportyourrighttoprotecttheprivacyof yourprotected healthinformation.Wewillnotretaliate inanywayifyouchoose tofileacomplaint withusor with theU.S.Department ofHealth andHuman Services