NOTICE OF PRIVACY PRACTICES

Effective Date: 4/14/03

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.

If you have any questions about this notice, please contact the Privacy Officer at 901-747-0040 during regular business hours.

OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This notice will tell you about the ways in which we may use and disclose protected health information about you to carry out treatment, payment or health care operations and for other purposes that are required or permitted by law. It also describes your rights and certain obligations we have regarding the use and disclosure of your protected health information.

Your “protected health information” means any of your written and oral health information, including demographic data that can be used to identity you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.

Mays and Schnapp Pain Clinic and Rehabilitation Center and Pain Clinic Associates, P.C. (referred to in this document as “the practice”) are required by law:
• to keep private protected health information that identifies you;
• to give you this notice of our legal duties and privacy practices with respect to protected health information about you; and
• to follow the terms of the Notice of Privacy Rights currently in effect.

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose protected health information. For better understanding, we have provided some examples in each category. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• For Treatment. We may use protected health information about you to provide, coordinate, or manage your health care and any related services. We may disclose protected health information about you to doctors, nurses, technicians, or other personnel who are involved in taking care of you. For example, we may share protected health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x- rays. We may disclose protected health information about you to others involved in your care, such as family members assisting you or other health care providers, such as other treating physicians or medical equipment providers. In some cases, we may also disclose your protected health information to an outside treatment provider for purposes of the treatment activities of the other provider. We also may use your protected health information to contact you to check that you are progressing in your recovery.

• For Payment. We will use and disclose protected health information about you so that the treatment and services you receive may be billed to and payment may be collected from you, a health plan or a third party. For example, we may disclose protected health information to your health plan to determine whether you are eligible for benefits. We may need to give your health plan information about treatment you received so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a procedure you are going to receive to obtain prior approval or to determine whether your plan will cover the procedure. In order to get payment for services you receive, we may also need to disclose your protected health information to your health plan to demonstrate the medical necessity of the services or, as required by your health plan.

• For Health Care Operations. We may use and disclose protected health information about you for the practice’s operations. These uses and disclosures are necessary to run the practice and make sure that all of our patients receive quality care. For example, we may use protected health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also use protected health information for review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs. In certain situations, we may disclose patient information to another provider or health plan for their health care operations.

• Patient Satisfaction Surveys. We may use a limited amount of information about you to conduct patient satisfaction surveys by telephone and written communications.

• Health Awareness Materials. We may use your demographic information to send general health information to you to create awareness in the community of important health topics.

• Personal Representatives. If you or a court has authorized another individual to act on your behalf, we will share information regarding your
treatment with your personal representative unless we believe that the sharing of information would jeopardize your health or safety.

• Appointment Reminders. We may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care. This practice includes contacting you by telephone.

• Treatment Alternatives. We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. This includes reviewing your protected health information to see if you meet the criteria to be eligible to participate in clinical trials.

• Health-Related Benefits and Services. We may use and disclose protected health information to tell you about health-related benefits or services that may be of interest to you.

• Individuals Involved in Your Care or Payment for Your Care. We may release protected health information about you to a friend or family member who is involved with your medical care or payment for services, unless you inform us that you object to such disclosure. (However, you may not use such an objection to avoid payment for services by a responsible party.)

• As Required By Law. We will disclose protected health information about you when required to do so by federal, state or local law.

• To Avert a Serious Threat to Health or Safety. We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS
• Access by Parents. Some state laws concerning minors permit or require disclosure of protected health information to parents, guardians, and persons acting in a similar legal status. We will act consistently with the law of the state where the treatment is provided and will make disclosures following such laws.

• Military and Veterans. If you are a member of the armed forces, we may release protected health information about you as required by military command authorities. We may also release protected health information about foreign military personnel to the appropriate foreign military authority.

• Workers' Compensation. The practice may release protected health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

• Medical Surveillance of the Workplace. If you are an employee who is being evaluated at the request of your employer for medical surveillance of the workplace or in relation to a work-related illness or injury, we may share information obtained from such evaluation with your employer.

• Public Health Risks. We may disclose protected health information about you for public health activities. These activities generally include the following:
• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report suspected child or adult abuse or neglect;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

• Health Oversight Activities. We may disclose protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights and other laws, regulations, and regulatory advice. We may also disclose protected health information to lawyers or consultants who are providing services to this medical practice or the individual physicians in the practice or related entities regarding a legal or regulatory matter.

• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if we receive written assurances that the party seeking your protected health information has made efforts to tell you about the request or to obtain an order protecting the information requested. We may use your protected health information to defend a legal action against this medical practice or the physicians in the practice or other related legal entity.

• Law Enforcement. We may release protected health information if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• Under certain limited circumstances, when you are the victim of a crime;
• About a death we believe may be the result of criminal conduct;
• As required by law for reporting certain types of wounds or other physical injuries; and • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

• Coroners, Medical Examiners and Funeral Directors. We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release protected health information about patients of the practice to funeral directors as necessary to carry out their duties. If you are an organ donor, protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

• National Security and Intelligence Activities. We may release protected health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

• Protective Services for the President and Others. We may disclose protected health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

• Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU:
You have the following rights regarding protected health information we maintain about you:

• Right to Inspect and Copy. You have the right to inspect and copy protected health information used to make decisions about your care. Usually, this generally includes medical and billing records.

To inspect and copy protected health information used to make decisions about you, you must submit your request in writing to the Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain, limited circumstances. For example, under federal law you may not inspect or copy
the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. If you are denied access to medical information, you may request that the denial be reviewed.

Please contact our Privacy Contact if you have questions about access to your medical record.

• Right to Amend. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the practice.

To request an amendment, your request must be made in writing and submitted to the Privacy Officer. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. If we deny your request, you have a right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. In addition, we may deny your request if you ask us to amend information that:
• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the protected health information kept by or for this medical practice;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

• Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of protected health information about you for reasons other than treatment, payment or health care operations. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. For example, an accounting of disclosures would include disclosures that we are required by law to make, such as in response to a court order.

To request this accounting of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

• Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

The practice is not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If the practice does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Privacy Officer.

• Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work. However, you must provide us with an address to which we can send all written correspondence, including your bill.

You may request a change to your confidential communications address and phone number by submitting a written request to the Privacy Officer. We will not ask you the reason for your request. We will accommodate reasonable requests. Your request must specify how or where you wish to be contacted.

• Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.

CHANGES TO THIS NOTICE

• We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for protected health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the practice. The notice will contain on the first page, in the upper right-hand section, the effective date.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with this medical practice or with the Secretary of the Department of Health and Human Services. To file a privacy complaint with this medical practice, contact the Privacy Officer at 901-747-0040 or submit it in writing to 55 Humphreys Center Drive Suite 200 Memphis, TN 38120 Attn: Privacy Officer.

You will not be penalized for filing a complaint.

OTHER USES OF PROTECTED HEALTH INFORMATION.
Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose protected health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made
with your authorization, and that we are required to retain our records of the care that we provided to you.