NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

The Connecticut Spine and Disc Institute is dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. The Connecticut Spine and Disc Institute is required by law to abide by the terms of this Notice.

We reserve the right to change the terms of this Notice, making any revision applicable to all the protected health information we maintain. If we revise the terms of this Notice, we will post a revised notice at the Connecticut Spine and Disc Institute and will make paper copies of the revised Notice of Privacy Practices available upon request.

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards or letters.)

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Treatment Information: Your health information may be used to give you information on the treatment and management of your medical condition that you may find to be of interest.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Workers’ Compensation: We may disclose your medical information as authorized by laws relating to workers’ compensation or similar programs.

Family and Friends: Unless you object, we may disclose your medical information to family members, other relatives or close personal friends when the medical information is directly relevant to that person’s involvement with your care.

Notification: Unless you object, we may use or disclose your medical information to notify a family member, a personal representative or another person responsible for your care of your location, general condition or death.

Public Health Reporting/Department of Health and Human

Services: We may disclose medical information for public health activities, including the reporting of disease, injury, vital events and the conduct of public health surveillance, investigation and/or intervention. We may disclose your medical information to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure or

disciplinary actions, administrative and/or legal proceedings. As part of an investigation or determination of our compliance with relevant laws, medical information may be disclosed to the United States Department of Health and Human Services.

Disaster Relief: We may disclose your medical information to a public or private entity, such as the American Red Cross, for the purpose of coordinating with that entity to assist in disaster relief efforts.

Abuse or Neglect: We may disclose your medical information when it concerns abuse, neglect or violence to you in accordance with federal and state law.

Public Safety: We may use or disclose your medical information to prevent or lessen a serious threat to the health or safety of another person or to the public.

Legal Proceedings: We may disclose your medical information in the course of certain judicial or administrative proceedings.

Law Enforcement: We may disclose your medical information for law enforcement purposes or other specialized governmental functions.

Coroners, Medical Examiners and Funeral Directors: We may disclose your medical information to a coroner, medical examiner or a funeral director.

Research: We may use or disclose your medical information for certain research purposes if the review is preparatory to research.

Business Associates: We may disclose your health information to a business associate with whom we contract to provide services on our behalf. To protect your health information, we require our business associates to appropriately safeguard the health information of our patients.

AUTHORIZATIONS:

We will not use or disclose your medical information for any other purpose without written authorization. Once given, you may revoke your authorization in writing at any time. To request a Revocation of Authorization form, you may contact: Maureen Capristo, Administrator at The Connecticut Spine and Disc Institute at 203-758-2003 or by writing to us at 1579 Straits Turnpike, Middlebury, CT 06762

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:

You have the following rights with respect to your medical information:

• You may ask us to restrict certain uses and disclosures of your medical information. We are not required to agree to your request, but if we do, we will honor it.

• You have the right to receive communications from us in a confidential manner.

• Generally, you may inspect and copy your medical information. This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records.

• You may ask us to amend your medical information. We may deny your request for certain specific reasons. If we deny your request, we will provide you with a written explanation for the denial and information regarding further rights you may have at this point.

• You have the right to receive an accounting of the disclosures of your medical information made by The Connecticut Spine and Disc Institute during the last six years (or following April 14, 2003), except for disclosures for treatment, payment or healthcare operations, disclosures which you authorized and certain other specific disclosure types.

• You may request a paper copy of this Notice of Privacy Practices for Protected Health Information.

• You have the right to complain to us and/or to the United States Department of Health and Human Services if you believe that we have violated your privacy rights. If you choose to file a complaint, you will not be retaliated against in any way. To complain to us, please contact: Maureen Capristo, Administrator at The Connecticut Spine and Disc Institute or bywriting to us at 1579 Straits Turnpike, Middlebury, CT 06762.

If you would like any further information regarding your rights, please contact our office.

THIS NOTICE IS EFFECTIVE AS OF OCTOBER 2, 2005.