NOTICE OF PRIVACY PRACTICE
VILLAGE PEDIATRICS, LLC

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.

• Treatment. We will use and disclose your protected health information to provide,
coordinate, or manage your health care and any related services. We will also disclose your
health information to other physicians who may be treating you. Additionally we may
disclose your health information to another physician whom we have requested to be
involved in your care. For example –we would disclose your health information to a
specialist to whom we have referred you for a diagnosis to help in your treatment.

• Access to Medical Records. You have the right to inspect and copy the protected
health information that we maintain about you in our designated record set for as long as
we maintain that information. This designated record set includes your medical and billing
records, as well as any other records we use for making decisions about you. Any
psychotherapy notes that may have been included in records we received about you are not
available for your inspection or copying by law. We may charge you a fee for the costs of
copying, mailing, or other supplies used in fulfilling your respect. If you wish to inspect or
copy your medical information, you must submit your request in writing to Attn: Privacy
Manager, c/o Village Pediatrics, LLC 319 West Town Place, Suite 1 Saint Augustine,
Florida 32092. You may mail in your request or bring it to the office. We will have 30 days
to respond to your request for information that we maintain at our practice site. If the
information is stored off site, we are allowed up to 60 days to respond but must inform you
of this delay.

• Payment. We will use and disclose your protected health information to obtain
payment for the health care services we provide you. For example – we may include
information with a bill to a third party payer that identifies you, your diagnosis, procedures
performed, and supplies used in rendering the service.

• How We Operate. We will use and disclose your protected health information to
support the business activities of our practice. For example – we may use medical
information about you to review and evaluate our treatment and services or to evaluate our
staff’s performance while caring for you. In addition, we may disclose your health
information to third party business associated who perform billing, consulting, or
transcription services for our practice.

• Appointment Reminders. We will use and disclose your protected health information
to contact you as a reminder about scheduled appointments or treatment.

• Treatment Alternatives. We will use your protected health information to tell you
about or to recommend possible alternative treatments or options that may interest you.

• Others Involved In Your Care. We will use and disclose your protected health
information to a family member, a relative, a close friend, or any other person you identify
that is involved in your medical care or payment care.

• As Required by Law. We will use and disclose your protected health information
when required by federal, state, or local law. You will be notified of any such disclosures.

• To Avert a Serious Threat to Public Health or Safety. We will use and disclose
your protected health information to a public health authority that is permitted to collect or
receive the information for the purpose of controlling disease, injury, or disability. If
directed by that health authority, we will also disclose your health information to a foreign
government agency that is collaborating with the public health authority.

• Confidential Communications. Under the Privacy Rule, you have the right to request
how we communicate with you. For example, you could ask your doctor to call your office
rather than home. Your request must be made in writing. We will accommodate all
reasonable requests.

• Complaints. If you believe we have violated your medical information privacy rights,
you have the right to file a complaint directly to the covered provider, or healthcare plan, or
to the Office for Civil Rights (OCR), which is charged with investigating complaints and
enforcing the privacy regulation. Consumers can find out more information about filing a
complaint at http://www.hhs.gov/ocr/hipaa or by calling (866) 627-7748.