9423 Holy Cross Lane
St. Joseph's Hospital
Medical Arts Bldg One, Suite 111
Breese, IL 62230

1941 Frank Scott Parkway E
Suite A
Shiloh, IL 62269

Phone (618) 526-8850

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HIPAA NOTICE OF PRIVACY PRACTICES currently in effect (1/1/2005)

This practice acts to maintain the privacy of protected health information and provide individuals with notice of the practice’s legal duties and privacy practices with respect to protected health information (PHI) as described in this Notice and abide by the terms of the Notice currently in effect. Since this is a pediatric practice, please note that any time the word ‘patient’ is mentioned below, this may be taken to mean the parent or legal guardian of that child.

PROVISION OF NOTICE The practice provides its Notice of Privacy Practices to every patient with whom it has a direct treatment relationship. The Notice is provided no later than the date of the first treatment to the patient after September 23, 2004, the date of establishment of Right From The Start Pediatrics, SC, as a Corporation. The practice makes its Notice available to any member of the public to enable prospective patients to evaluate the practice’s privacy practices when making his or her decision regarding whether to seek treatment from the practice. The practice provides its Notice via e-mail to any patient or other individual who so requests the Notice.

DOCUMENTATION OF PROVISION OF NOTICE When a direct treatment patient receives the Notice from the practice, the practice asks the patient to sign its ‘Acknowledgment of Receipt of Notice of Privacy Practices (or NOPP)’ form. The form is filed with the patient’s medical record. If the patient refuses to sign the form, it is noted in the medical record that the patient was given the Notice and refused to sign the form.

EFFECTIVE DATE AND CHANGES TO NOTICE This notice is effective January 1, 2005. The practice reserves the right to revise this Notice whenever there is a material change to the uses or disclosures, the individual’s rights, the covered entity’s legal duties, or other privacy practices stated in the Notice. Except when required by law, a material change to any term of the Notice will not be implemented prior to the effective date of the notice in which such material change is reflected. If the Notice is revised, the practice makes the revised Notice available upon request beginning on the revision’s effective date. The revised notice is posted in the practice’s reception area and made available to all patients, including those who have received a previous Notice. Upon receipt of a revised Notice, a patient is asked to acknowledge receipt of the Notice.

COMPLAINTS The practice allows all patients and their agents to file complaints with the practice and with the Secretary of the federal Department of Health and Human Services (DHHS). A patient or his or her agent may file a complaint with the practice whenever he or she believes that the practice has violated their rights. Complaints to the practice must be in writing, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to the attention of Dr. Morra at 9423 Holy Cross Lane, Breese, IL 62230. The practice investigates each complaint and may, at its discretion, reply to the patient or the patient’s agent. Complaints to the Secretary of the DHHS must be in writing, must name the practice, must describe the acts or omissions that are the subject of the complaint and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to: Daniel R. Morra, MD, 9423 Holy Cross Lane, Breese, IL 62230. The practice does not take any adverse action against any patient who files a complaint (either directly or through an agent) against the practice.

CONTACT PERSON The practice has a privacy officer that serves as the contact person for all issues related to the Privacy Rule. The privacy officer is Daniel R. Morra, MD. If you have any questions regarding this Notice, please direct them to Dr. Morra.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION (PHI) The practice reasonably ensures that the protected health information (PHI) it requests, uses, and discloses for any purpose is the minimum amount of PHI necessary for that purpose. The practice treats all qualified individuals as personal representatives of patients. The practice generally allows individuals to act as personal representatives of patients. The two general exceptions to allowing individuals to act as personal representatives relate to unemancipated minors and abuse, neglect, or endangerment situations. The practice makes reasonable efforts to ensure that PHI is only used by and disclosed to individuals that have a right to the PHI. Toward that end, the practice makes reasonable efforts to verify the identity of those using or receiving PHI.

USES AND DISCLOSURES - TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS RESEARCH: The practice does not engage in any research activities that require it to use or disclose PHI.

OTHER USES AND DISCLOSURES: The practice does not use or disclose PHI to an employer or health plan sponsor, for underwriting and related purposes, for facility directories, to brokers and agents or for fundraising. If an individual wants the practice to release his or her PHI to employers or health plan sponsors, for underwriting and related purposes, for facility directories, or to brokers and agents, then he or she can contact the practice and complete an appropriate written authorization.

INDIVIDUAL RIGHTS INDIVIDUAL RIGHTS - ACCOUNTING FOR DISCLOSURES OF PHI The practice tracks all disclosures of a patient’s PHI that occur for other than the purposes of treatment, payment and health care operations, that are not made to the individual or to a person involved in the patient’s care, that are not made as a result of a patient authorization, and that are not made for national security or intelligence purposes or to correctional institutions or law enforcement officials. The practice allows an individual to request one accounting within a 12-month period free of charge. The practice charges a reasonable fee for more frequent accounting requests. The charge will be twenty (20) dollars. An individual can request an accounting of disclosures for a period of up to six years prior to the date of the request. Requests for shorter accounting periods will be accepted. However, patients may only request an accounting of disclosures made on or after January 1, 2005. The practice responds to all requests for an accounting of disclosures within 60 days of receipt of the request. If the practice intends to provide the accounting for disclosures and cannot do so within 60 days, the practice informs the requestor of such and provides a reason for the delay and the date the request is expected to be fulfilled. Only one 30-day extension is permitted. A request for an accounting for disclosures must be made in writing and mailed or sent to the practice. It should be marked ‘Attention: Privacy Officer.’

INDIVIDUAL RIGHTS - INSPECT AND COPY PHI The practice allows individuals to inspect and copy their PHI, documents all requests, responds to those requests in a timely fashion, informs individuals of their appeal rights when a request is rejected in whole or in part, and charges a reasonable fee for the copying of records. The practice reviews the request in a timely fashion and acts on a request for access generally within 30 days. The practice may have a single extension of 30 days, if needed, to act on the request. Each request will be accepted or denied and the requestor notified in writing. If a request is denied, the requestor is informed if the denial is ‘reviewable’ or not. The requestor has the right to have any denial reviewed by a licensed health care professional who is designated by the practice as a reviewing official and who did not participate in the original decision to deny. The practice informs the requestor of the decision of the reviewing official and adheres to the decision. The practice charges reasonable fees based on actual costs of fulfilling the request. The practice will determine the appropriate charge for providing the requested records and inform and requestor in advance of providing the records. If the requestor agrees to pay the fee in advance, the records will be provided. Otherwise, the records will not be provided, unless the Privacy Officer determines that the charge is burdensome to the requestor. Illinois law prohibits charges that exceed the following: $20 handling fee plus 75 cents each for pages 1-25, 50 cents each for pages 26-50, and 25 cents each for pages 51 to end; plus actual expenses related to the copying of x- rays, CAT scans and similar. The practice limits charges for records to the amounts allowed under Illinois law. Requests for inspection and copying of records must be sent to the practice in writing. It should be marked ‘Attention: Privacy Officer.’

INDIVIDUAL RIGHTS - REQUEST AMENDMENT TO PHI The practice allows an individual to request that the practice amend the PHI maintained in the patient’s medical record or the patient’s billing record. The practice documents all requests, responds to those requests in a timely fashion, and informs individuals of their appeal rights when a request is denied in whole or in part. Generally, the practice will act on a request for amendment no later than 60 days after receipt of such a request. If the practice cannot act on the amendment within 60 days, the practice extends the time for such action by 30 days, and, within the 60-day time limit, provides the requestor with a written statement of the reasons for the delay and the date by which the practice will complete action on the request. Only one such extension is allowed. If the practice denies the request, in whole or in part, the practice provides the requestor with a written denial in a timely fashion. The practice allows a requestor to submit a written statement disagreeing with the denial of all or part of the initial request. The statement must include the basis of the disagreement. The practice limits the length of a statement of disagreement to one page. The practice accepts requests to amend the PHI maintained by the practice. The requests must be in writing and should be marked ‘Attention: Privacy Officer.’

INDIVIDUAL RIGHTS - REQUEST CONFIDENTIAL COMMUNICATIONS The practice accommodates all reasonable requests to keep communications confidential. The practice determines the reasonableness based on the administrative difficulty of complying with the request. A request for confidential communications must be in writing, must specify an alternative address or other method of contact, and must provide information about how payment will be handled. The request must be addressed to the practice’s privacy officer. No reason for the request needs to be stated. The practice will reject a request due to administrative difficulty; if no independently verifiable method of communication such as a mailing address or published telephone number is provided for communications, including billing; or if the requestor has not provided information as to how the payment will be handled. The practice will not refuse a request; if the requestor indicates that the communication will cause endangerment; or based on any perception of the merits of the requestor’s request.

INDIVIDUAL RIGHTS - REQUEST RESTRICTION OF DISCLOSURES The practice accepts all requests for restrictions of disclosures of PHI, but does not agree to any restrictions in the use or disclosure of PHI. All requests for restrictions of disclosures must be submitted in writing. They must be sent to the attention of the practice’s privacy officer. The privacy officer will then notify the requestor in writing that the practice does not accept restrictions of disclosure.

INDIVIDUAL RIGHTS - AUTHORIZATIONS The practice obtains a written authorization from a patient or the patient’s representative for the use or disclosure of PHI for other than treatment, payment, or health care operations; however, the practice will not get an authorization for the use or disclosure of PHI specifically allowed under the Privacy Rule in the absence of an authorization. The practice will provide a patient upon request a copy of any authorization initiated by the practice (as opposed to requested by the patient) and signed by the patient. The practice does not condition treatment of a patient on the signing of an authorization, except disclosure necessary to determine payment of a claim (excluding authorization for use or disclosure of psychotherapy notes); or provision of health care solely for purpose of creating PHI for disclosure to a third party (e.g. pre- employment or life insurance physicals). In the state of Illinois, a specific written authorization is required to disclose or release records of mental health treatment, alcoholism treatment, drug abuse treatment, or HIV / Acquired Immune Deficiency Syndrome (AIDS) information. The practice allows an individual to revoke an authorization at any time. The revocation must be in writing and must be sent to the attention of the practice’s privacy officer; however, in any case the practice will be able to use or disclose the protected health information to the extent the practice has taken action in reliance on the authorization.

INDIVIDUAL RIGHTS - WAIVER OF RIGHTS The practice never requires an individual to waive any of his or her individual rights as a condition for the provision of treatment, except under very limited circumstances allowed under law.