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.

What is Protected Health Information (PHD)?
Our practice values your privacy and is committed to protecting medical information about you. Protected Health Information, or PHI, is ANY HEALTH INFORMATION that can be used to identify you, which we maintain or transmit in written, oral, or electronic form. It may relate to your past, present, or future medical health or services. This Notice of Privacy Practices tells you how we may use and disclose your PHI that deals with your Treatment, Payment or Health Care Operations (TPO), or for other lawful purposes. It also describes your rights under the Health Insurance Portability and Accountability Act
(HIPAA) of 1996 (Public Law 104-191).

This notice is EFFECTIVE April 14,2003.
We will abide by all terms of this notice as required by HIPAA including our right to change the terms of this notice, at any time. Any changes will be effective for your entire PHI that we maintain at the time of the change. We will prominently post any notice of changes in our office lobby and on our web site for your review. You may also request a revised notice by calling or writing our office.

Summary
This document describes how we safeguard your Protected Health Information (PHI) to make sure only the minimum amount of information is used and disclosed only to individuals with a legal right to access or view your PHI.
Use is the sharing, utilization, or examination of information by individuals within our practice. Disclosure is the release, transfer, or divulging of information by us to individuals, outside our practice. Consent is your granting us permission to disclose your PHI in order to provide you treatment, provide for payment of your health services, or manage our health care operations. Authorization is when you give us written permission to release your information to you, another person, or an organization.

This document teBs you the circumstances in which we can use or disclose your PHI.
1. With Your Written Consent
These areas cover your Treatment, Payment and Health Care Operations.
2. With Your Written Authorization
This covers times when you wish to have your information used or disclosed to another person or
organization.
3. With Your Authorization or Opportunity To Object
This document describes those times when you may agree or object to the use of certain PHI.
4. Without Your Consent, Authorization or Opportunity To Object
This document lists times when we are permitted or required to use or disclose your PHI without your consent or authorization.
5. Your Rights
Your rights regarding your PHI and procedures for appealing a decision regarding the use or disclosure of your PHI are listed in this document.
6. Complaints
Your rights to complain and the method for making the complaint are also listed in this document.
Please read this document and sign the attached acknowledgment that you have received a copy of our Notice of Privacy Practices. If you have any questions you may contact our privacy officer at the below address. We appreciate serving you.

Minneapolis Plastic Surgeiy,Ltd.
Privacy Officer Contact Information:
Diamne Birk
Minneapolis Plastic Surgery, Ltd.
4825 Olson Memorial Highway
Suite 200
Minneapolis, MN 55422
763-545-0443

1. Uses and Disclosures of PHI With Your Written Consent
Prior to receiving treatment, or at a reasonably practical time after receiving emergency treatment you will be asked to sign a consent form regarding me use and disclosure of your protected health information (PHT). This consent will allow us to use your Protected Health Information (PHI) for providing you with treatment, making payment arrangements regarding your treatment, or for health care operations. Your PHI may be used or disclosed by those within our office with a necessary reason to have access to the information, or we may use or disclose your PHI to those outside our office who have a need to know that information in order to provide you with health care services related to your treatment, payment, or health care operations. We will always make reasonable efforts to limit me use and disclosure of your PHI to the minimum necessary. Listed below are examples of me use and disclosure we may make of your PHI once we have received your signed consent form. We may also use and disclose your PHI for routine or recurring requests. We will always review on an individual basis non-routine requests for. use or disclosure of your PHI.

-Treatment - We may use and disclose your PHI for use by staff; physicians, or other health care professionals involved in providing you with health care services in our office that have a need to know in order to provide you with evaluation, diagnostic, and health care services. Examples may include but are not limited to: other physicians who are treating you; home health care services, pharmacies, laboratories, radiologists, specialists, or diagnostic facilities necessary for your treatment.

- Payment - We will use your PHI as necessary to assist you in providing us with payment for your health care services, or for obtaining other medical services on your behalf. This may include but is not limited to: providing health care plans or insurance companies with information about the dates of service, services provided, and the medical condition you are being treated for in order for them to make a decision regarding eligibility, coverage or payment for those services.

- Health Care Operations - We may use and disclose your PHI in order to conduct me normal, ordinary, and reasonable business operations of our office on a day-to-day to basis. These activities may include but are not limited to: me planning, organizing, controlling, and budgeting activities of our office, and the directing and
managing of our staff in performing their duties. From time to time we may use or disclose your PHI in order to train medical students, physician assistants, nurses, or nursing assistants. We may also use or disclose your PHI in order to evaluate me actions or performance of our staff members. As needed, your PHI maybe used or disclosed to state regulatory agencies (as required by law), accrediting agencies, or licensing review boards. We may use your PHI to keep ordinary and necessary business records including asking you to sign-in when you visit our office, contacting you to remind you of an appointment, and calling your name or identifying number in the waiting room. We may email or use a facsimile (fax) to contact you if you give us permission. Marketing: We may use or disclose your PHI in order to provide you with information about health care benefits, services, or products that may be of interest to you. Additionally, we may use your name for a newsletter, or email notification about other services, products, or for general health information. If you do not wish to receive any of these you may opt out by completing the Information Form attached to this document
• Business Associates: If we contract with any Business Associates, such as diagnostic services, medical records copying services, transcription services, billing services, or any other associate involved with your PHI, we signify to you that we will have a legal contract with them allowing them to perform such services and by that contract they will be bound to terms that will protect your PHI.

2. Uses & Disclosures With Your Written Authorization Any other uses and disclosures of your PHI will only be made after we have received your written authorization, unless we are allowed, permitted or required by law to do so. Revocation: You may revoke any authorization you have made at any time, providing that your request for revocation be in writing and states which authorization you wish to revoke. However, if we have already relied upon your authorization to use or disclose your PHI, or if the authorization was obtained as a conation of obtaining insurance coverage you may not revoke your authorization regarding releases prior to the date of your revocation.

3. Uses & Disclosures With Your Consent, Authorization, or Opportunity To Object there are other instances in which may use and disclose your PHI. There is an optional form at the end of this document, which you may agree or object to the use or disclosure of all or part of your PHI. If you are unable to agree or object we will use our professional judgment in making a decision about which portions of your PHI should be used or disclosed. When you are able to give us your opinion about our decision regarding the use of your PHI you may modify our decision. Family Members, Friends, Guardians and Caregivers: We may disclose a portion of your PHI that relates to the listed persons' need to know to provide you with healthcare. In making this decision we will determine what we believe your best interest to be. This may include notifying one of the parties of your location and general condition. We may also disclose a portion of your PHI to assist authorized persons in disaster or emergency relief efforts. Other Disclosures: We may use or disclose your PHI to provide you with emergency treatment, until such a time that you are able to consent, or if we attempt to obtain your consent but cannot because of a substantial communication, barrier and in our professional judgment, we believe you intend to consent to the requested use or disclosure.

4. Uses and Disclosures of your PHI Without your Consent, Authorization or Opportunity to Object

- As Required By Law - If any county, state, or federal law requires that we use or disclose your PHI we will do so to the degree required by such law, or such disclosure will be made in response to an order of any court of proper jurisdiction- If the law requires us we will notify you of such disclosure.

-Law Enforcement - If we are presented with a proper court order or other legal presentations or lawful demand from a law enforcement agency or officer we will disclose your PHI to the extent that such order, presentation or demand requires. These requests may include court orders, subpoenas, warrants issued by a court of proper jurisdiction, or government audits and inspections. We will also disclose PHI if necessary for law enforcement authorities to identify, arrest, or apprehend a suspect or other individual; or if we believe that by reporting such information the disclosure will help protect the health or safety of a person. We may disclose to authorized agencies child abuse or neglect, instances of neglect or violence, or other injuries, which we are required to report by law. - Public Health - As required by law we may report your PHI to any county, state, or federal health agency whom we are required to report to for specific purposes. These purposes may include the controlling of disease, injury or disability, investigation, oversight, and audit.

- Food and Drug Administration - As required by law, we may disclose your PHI to me FDA or their lawful representative in order to control adverse effects with respect to food, drugs, or products. This may involve product improvements or product recalls.

-Personal Notification - We may use or disclose your PHI to assist in notifying a family member, guardian, caregiver, or personal representative of your general condition and location.

- Research - We may disclose your, PHI to researchers when an institutional review board has approved me research and ensured the privacy of your PHI.

- National &, Homeland Security - We may disclose your PHI to any authorized county, state, or federal official who is authorized by state or federal law, or who has an order fiom a court of competent jurisdiction to receive such information for homeland or national security reasons.

- Organ Donation - We may use or disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for donation and transplantation.

- Other - We may use or disclose your PHI to the institution or its agents if you are an inmate of a correctional facility. We may use or disclose your PHI as required by Worker's Compensation Laws. We may use or disclose your PHI as required by law, and under appropriate conditions to me appropriate military authorities if you are a member of the Armed Forces. We may use and disclose your PHI to Coroners, Medical Examiners, and Funeral Directors as necessary in order for them to perform their duties as required by law.

- In Accordance with Public Law 104-191 (HIPAA-1996) - We must make disclosures regarding your PHI to the Department of Health & Human Services, as necessary and required, in order for them to determine our compliance with HEPAA standards. If a use or disclosure for any of the above purposes is prohibited or materially limited by any applicable law, we will use and disclose your PHI to reflect the more stringent law.

5. Your Rights Your rights to your Protected Health Information (PHI) and how you may exercise these rights are listed below.

-You have the right to request that we not use or disclose any, or part of, your PHI in order to carry out your treatment, payment, or health care operations or other disclosures as listed in this notice. This right to request restriction does not extend to uses or disclosures required by law. This includes your right to request that your PHI not be disclosed to family members, guardians, caregivers, or others who may be involved in your care as described in this Notice of Privacy Practices.
We are not required, by law, to agree to your request for restriction, but if we do agree to your request for restriction we will not use or disclose your PHI as specified in your request unless me use or disclosure of the restricted PHI is necessary to provide you with necessary or emergency treatment by us or another health care provider Any request for such restrictions must state the specific restrictions you are requesting, and to whom the restrictions apply. You should make such requests to your attending physician or else submit a written request to our office. We will document the.request in your records and discuss this request with you at your next visit. - You have the right to receive confidential communications of your PHI by alternative means or at
alternative locations. Your request must be in writing and be reasonable, and we reserve me right to charge you a reasonable, cost-based fee for making copies of any records you request. This fee may include cost of supplies, labor for copying, postage, and if you agree the cost of preparing an explanation or summary of the requested PHL You have no responsibility to tell us why you are requesting such information. You may make the request to our Privacy Officer listed at the bottom of this notice .

- You have the right of access to inspect and obtain a copy of your Protected Health Information in a designated record set, for as long as we maintain the PHI in that designated record set. A "designated record set" contains medical and billing records and other PHI records that we use in making decisions about you or your
medical care. Making A Request: Your request must be made to the Privacy Officer listed below. We will act upon your request and notify you in writing no later than 30 days after receipt of your request. If your request for access is for PHI that we do not maintain or is not accessible at our office we will act on the request no later than 60 days from the receipt of your request.

- You have the right to amend your Protected Health Information: You have the right to request that we amend your PHI or a record about you in a designated record set as long as we maintain the information. Your request for amendment must be in writing and provide a reason to support your requested amendment. We
will act on your request for an amendment no later than 60 days after the receipt of your request. If we deny your request for amendment, in whole or part we will provide you, with a timely, written denial within 60 days of me denial stating the reason for the denial. We will also inform you of your right to submit a written
statement disagreeing with the denial and give you information on filing such a statement. You may make your request for amendments to the Privacy Officer listed below.

- You have the right to receive an accounting of any disclosures of your PHI, which we have made m the six years prior to the date on which the accounting is requested, except for disclosures...

(1) We have made to carry out treatment, payment, and health care operations as listed in this Notice, (2) Made to you, (3) required and protected by law, (4) made in compliance with a valid authorization, (5) Made for a facility directory, (6) to family members, guardians or friends involved in your care, (7) For national security or intelligence proposes or to correctional institutions of law enforcement officials as
required by law, or (8) that occurred prior to the original date of or Notice of Privacy Practices.

- You may request to receive a full printed copy of bur Notice of Privacy Practices, even if you have requested this document in electronic form.

6. How To Make A Complaint
-You have the right to complain to us if you believe your privacy rights have been violated by us. Any complaints should be in writing and state me nature of the complaint and how to contact you. You will not be retaliated against for filing a complaint and your complaint will not ajffect your diagnosis or any treatment we are
providing you. You may contact our Privacy Officer or the Secretary of Health and Human Services, whose contact information is listed below.

Who To Contact
Dianne Birk Secretary of Health & Human Services
Minneapolis Plastic Surgery, Ltd. The U.S. Department of Health and Human
4825 Olson Memorial Highway 200 Independence Avenue, S.W.
Suite 200 Washington, D.C. 20201
Minneapolis, MN 55422
(202) 619-0257, Toll Free: 1-877-696-6775

763-545-0443 HHS.Mail@hhs.gov
Publication Date April 14.2003

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