This notice describes how medical information about you may be used and disclosed and how you can get access to this information. We are required by law to give you this notice. Please read and review this information. If you have any questions about this notice, you may contact our Privacy Officer. You may keep this copy of this notice for your records. This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your right to access and control your Protected Health Information. “Protected Health Information” is information about your health, health status, and the health care and services you receive at this office. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. This notice will be effective for all Protected Health Information that we maintain. We will post any changes and will provide you with a copy of the changes at your request. Uses and Disclosures of Protected Health Information You will be asked by our office to sign an acknowledgement form indicating that you have received the Privacy Practice Notice. If you choose not to sign the acknowledgement form, it will not delay any treatment you receive, but will be noted in your medical record. Your Protected Health Information may be used or disclosed by your physician, our office staff and others outside our office that are involved in your care for the purpose of providing health care services to you. Your Protected Health Information may also be used and disclosed to pay your health care bills and to support the operation of the practice. Following are examples of the types of uses and disclosures of your Protected Health Information that the physician’s office is permitted to make. Treatment: We will use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related services. This includes the coordination of management of your health care with physicians, nurses, technicians, office staff, or other personnel that are involved in your care. Examples: a home health care agency that provides care to you, or other physicians who may be treating you. Your Protected Health Information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose and treat you. Different personnel in our office may share your Protected Health Information to people who do not work in our office, such as phoning in prescriptions to your pharmacy, scheduling lab work or x-rays. Payment: Your Protected Health Information will be used, as needed, to obtain payment for your health care services. This information will be used to bill you, an insurance company, or third party. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making determination of eligibility; coverage of benefits; reviewing services provided to you for medical necessity; and undertaking utilizations review activities. Health Care Operations: We may disclose, as needed, your Protected Health Information in order to support the business activities of our practice. The activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students and licensing. In this office we use a sign-in sheet at the registration desk where you will be asked to sign your name. We will also announce your name in the waiting room when the physician is ready to see you, or when we are ready to administer your allergy injection. We may also contact you to remind you of your appointment. If we are unable to speak with you, we will leave a message on an answering machine or with the individual at your home number. We will share Protected Health Information with a third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between or office and a business associate involves the use or disclosure of your Protected Health Information, we will have a written contract that contains terms that will protect the privacy of your Protected Health Information. Others Involved in Your Health Care: Unless you object, we may disclose to a member of your family, a friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose information as necessary if we determine that it is in your best interest based on our professional judgment. We will disclose only health information relevant to the person’s involvement in your care. Examples are allowing another to pick up samples, written prescriptions or allergy extract. We will assume if you bring a spouse or significant other into the exam room with you, treatment and health care issues may be disclosed. Emergencies: We may disclose your Protected Health Information in an emergency treatment situation. If this happens, your physicians will try to obtain your consent at soon as is reasonably practical after delivery of treatment. Other Permitted and Required Uses and Disclosures That May be Made Without Your Consent, Authorization or Opportunity to Object” Required by Law: We will disclose health information when required to do so by Federal, State, or local law enforcement. Public Health: We may disclose health information to a public health authority to prevent, control disease, injury or disability. Communicable Diseases: We may disclose health information, if authorized by law, to a person who may have been exposed to a communicable disease, or may be at risk of contracting a spreading disease. Abuse or Neglect: We may disclose health information to a public authority if we believe there has been child abuse or neglect. We may also disclose health information if we believe that you have been a victim of abuse, neglect, or domestic violence. Food and Drug Administration: We may disclose health information to a person or company required by the FDA to report adverse event, product defects, or problems, track products, or enable product recall. Health Oversight: We may disclose health information to a health oversight agency for audits, inspections, investigations, or licensing purposes. These disclosures may be necessary for state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws. Legal Proceedings: We may disclose health information in response to any judicial proceeding. Protected Health Information will be released upon a court order, subpoena, or discovery request, or other lawful purpose. Coroner, Medical Examiners and Funeral Directors: We may disclose health information to the above-named people for identification purposes, determining cause of death, or to be able to perform other duties as authorized by law. Organ and Tissue Donation: If you are an organ and tissue donor, we may release information to the health organizations that handle these procedures so that such transplantation may be facilitated. Criminal Activity: We may disclose health information about you if we believe that the disclosure is necessary to prevent a serious threat to the health and safety of you, another person, or the public. Inmates: We may disclose your health information if you are an inmate of a correctional facility and your physician created or received your Protected Health Information in the course of providing care to you. Military Activity and National Security: If you a member of the Armed Forces, or National Security Divisions, we may disclose Protected Health Information about you when required by military command or governmental authorities. Workers Compensation: Your Protected Health Information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs. Your Rights Regarding Health Information About You: Right to Inspect and Copy: You have the right to inspect and copy your health information, such as medical and billing records. However, under Federal Law, you may not inspect and copy the following records: psychotherapy notes, information compiled in anticipation or use in a civil, criminal, or administrative action or proceeding. You must submit a written request to the Privacy Officer of this office to inspect or copy your health information. If you request a copy of your record, there will be processing fees for the cost of copying, mailing other associated supplies. If you request to inspect your record, you will be asked to set an appointment time for that inspection to take place. We may deny your request to inspect and/or copy in certain circumstances. If you are denied access, you may ask that the denial be reviewed. Right to Amend: You may request an amendment to your Protected Health Information as long as we maintain this record in the office. If you wish to make an amendment, you will submit a Medical Record Amendment/Correction Form to the Privacy Officer of this office. We may deny your request if you ask us to amend information that: a. We did not create the information that you wish to amend. b. The information is not part of the health information that we keep. c. You would not be permitted to inspect or copy. d. Is accurate and complete. If we deny your request, you may file a statement of disagreement with us and we may prepare a rebuttal to the same. A copy will be provided to you. Right to Request Restrictions: You may request a restriction of limitation on health information we disclose about you for treatment, payment, or health care operations. You may also request a limit on the amount of information we may disclose to someone involved in your care. We are not required to agree with your request. If we do agree we will comply with your request unless the information is needed in an emergency situation. If you would like a restriction, you must notify us in writing. Complaints: You may complain to us or the Secretary of Health and Human Services if you believe that your privacy rights have been violated by us. You may file a complaint with our Privacy Officer at 517.349.0027, or write to Okemos Allergy Center, P.C., 3955 Okemos Rd, Suite A1, Okemos, MI 48864, Attn: Privacy Officer. We will not retaliate for filing such a complaint.

Please list person(s) with whom we may discuss your medical information.

If the person is a minor, list the names of both parents. (Please note: Michigan law allows both Parents access to medical information, unless prohibited by a court order.)