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AESTHETIC PLASTIC SURGERY INTERNATIONAL
NOTICE OF PRIVACY PRACTICE

It has long been the mission of Dr. Stephen X. Giunta and the staff at Aesthetic Plastic Surgery International to provide you and/or a family member with the highest quality healthcare and health related services. We are committed to making every effort to protect the privacy and confidentiality of your family's health information. In keeping with recently enacted federal legislation, we are pleased to present you our Notice of Privacy Practice. We believe this notice will help you understand our obligations and commitments regarding your privacy as well as your rights over medical information.

This notice describes how medical information about our patients may be used and disclosed and how you may obtain access to this information. PLEASE READ IT CAREFULLY.

HIPAA (Health Insurance Portability and Accountability Act) Privacy Regulation is a federal regulation that requires that we provide detailed notice in writing of our privacy practices and policies. We realize this document is long and we have provided a contact number at the end of the notice should you have any questions in regard to our privacy practices.

I. OUR COMMITMENT TO PROTECTING HEALTH INFORMATION

This notice describes the ways that AESTHETIC PLASTIC SURGERY INTERNATIONAL may use and disclose health information (medical record) about our patients. The Health Insurance Portability and Accountability Act requires that healthcare organizations protect the privacy of health information that identifies a patient or where the information can reasonably be used to identify a patient. Under the regulation this information is called "protected health information" and we shall refer to this as "PHI." This Notice additionally describes your rights under the regulation and our obligations regarding the use and disclosure of PHI. As a healthcare provider the law requires us to:

• Maintain the privacy of PHI about our patients
• Give our patients this Notice of our legal duties and privacy practice with respect to PHI
• Comply with the terms of our Notice of Privacy Practices that is currently in effect

We reserve the right to make changes to this Notice and to make such changes effective for all PHI we may already have about our patients. If and when this Notice is changed, we will post a copy in our office in a prominent location. We will also provide you with a copy of the revised Notice upon your request made to our Practice Administrator, who serves as our Privacy Officer.

II. HOW AESTHETIC PLASTIC SURGERY INTERNATIONAL MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT OUR PATIENTS

Under the regulation we may use and disclose health information for Treatment, Payment and Health Care (Practice) Operations.

The following categories describe the different ways we may use and disclose PHI for treatment, payment, or health care operations. The examples in each category are not all-inclusive and do not constitute a complete list of all uses and disclosures for that category.

Treatment: We may use and disclose PHI about our patients to provide health care services, coordinate health care services with others or manage our patients' health care and related services. We may consult with other health care providers (physicians, nurse practitioners, laboratory facilities, hospitals, etc) regarding treatment and coordinate and manage our patients' healthcare with others. For example, we may use and disclose PHI when a patient needs a prescription, laboratory tests, an x-ray or other health care services. Additionally, we may use or disclose PHI when we need to refer a patient to another health care provider.

Other areas under treatment include disclosure of PHI about our patients for treatment from another health care provider. For example, we may send a report from us to a physician that we refer you to so that the other physician may properly perform treatment. We are not required under certain circumstances to obtain a written authorization from our patients to carry out treatment of patient care.

Payment: In the event that we must bill an insurance company to receive payment on behalf of the patient we may use and disclose PHI. This may include providing information about treatment or services with you health plan before the service(s) is received. For example, we may ask for payment authorization from your health plan before we provide care or services. To help you fully understand your out-of-pocket expense, we may use or disclose PHI to determine if your health plan will cover the cost of care and services provided. We may use and disclose PHI for billing, claims management, and collection activities. We may disclose PHI to insurance companies or third party administrators providing you with additional coverage. We may disclose limited PHI to consumer reporting agencies relating to collection of payments owed to us.

We may disclose PHI to another health care provider or to a company or health plan required to comply with the HIPAA Privacy Rule for the payment activities of that health care provider, company, or health plan. For example, we may use an outside lab to process your specimens and that entity may require PHI to appropriately bill the service to your health plan.

Business Operations and Planning
• We may use PHI about our patients to cooperate with organizations that review our activity. For example, physicians, accountants, lawyers and others who assist us in complying with the law and managing our business may review your PHI.
• Business planning and development.
• Business management and general administrative activities of our practice.

Communication From Our Office
• We may contact you to remind you of appointments and to provide you with information about treatment alternatives or other health related benefits that may be of an interest to you.

Other Uses and Disclosures
As Required By Law. We may use and disclose PHI as required by federal, state, or local law. Any disclosure is limited to the requirements of the law.

Public Health Activities
• Prevent or control disease, injury, or disability
• Notify a person who may have been exposed to a communicable disease in order to control who may be at risk of contracting or spreading the disease
• Report reaction to medication or problems with products or devices related by the Food and Drug Administration that relates to quality, safety, or effectiveness of FDA-regulated products

Oversight Activities
• We may disclose PHI to a health oversight agency for activities that includes audits, investigations, inspections, licensure and disciplinary activities and other activities conducted to monitor the health care system and compliance with certain laws.

Lawsuit and Other Legal Proceedings
• We may use or disclose when required by a court or in response to subpoenas, discovery requests, or other legal process when efforts have been made to advise you of the request or to obtain an order protecting the information requested.

Law Enforcement Under certain circumstances we may disclose PHI to law enforcement officials for the following purposes:
• Under certain limited circumstances, about a suspected crime victim if we are unable to obtain a person's agreement because of incapacity or emergency
• When required by law
• To identify or locate a suspect, fugitive, material witness, or missing person
• About a crime or suspected crime committed at our office

Avert a Serious Threat to Health or Safety We may use or disclose PHI in limited circumstances when necessary to prevent a threat to the health or safety of a person or to the public. Disclosure can only be made to a person who is able to help prevent the threat.

Special Government Functions Under certain circumstances we may disclose PHI:
• For certain military and veteran activities, including determination of eligibility for veterans benefits and where deemed necessary by military command authorities
• To help provide protective services for the president and others
• For the health and safety of inmates and others at correctional institutions or other law enforcement custodial situations for the general safety and health related to corrections facilities.

Required by HIPAA Privacy Rule
• We are required to disclose PHI to the Secretary of the United States Department of Health and Human Services when requested by the Secretary to review our compliance with the HIPAA Privacy Rule.

Workers' Compensation
• We may disclose PHI as authorized by workers' compensation laws or other similar programs that provide benefits for work-related injuries or illness.

III. PATIENTS RIGHTS REGARDING PROTECTED HEALTH INFORMATION

Under federal law, patients or their legal guardians have the following rights regarding PHI:

Right to Inspect and Copy You have a right to inspect and copy medical information that may be used to make decisions about patient care. Usually, this includes medical and billing records, but DOES NOT include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about treatment and care, you must submit your request in writing to Aesthetic Plastic Surgery International, Release Information Department. If you request a copy of the information, a fee will be charged for the costs of copying, mailing or other supplies associated with your request.

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 medical information about you. We are not required to account for disclosures for treatment, payment, health care operations, disclosures to you, or disclosures made through a written authorization.

To request this list, you must submit your request in writing to Aesthetic Plastic Surgery International, Release of Information Department. Your request must state the time period, which may not be longer that six years and may not include dates before April 14, 2003.

Right to Request Restrictions You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You have the right to request a limit on the medical information we disclose to someone who is involved in your care or the payment for your care, like a family member or friend.

We are not required to agree to your request. If we do agree to your restriction, we will comply with your request unless the information is needed to provide emergency treatment.

To request a restriction, you must make your request in writing to Aesthetic Plastic Surgery International, Release of Information Department. In your request, you must tell us what information you want to limit, whether you want to limit our use, disclosure or both, and to whom you want the limits to apply.

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. Example, you can ask that we only contact you by mail.

To request confidential communications, you must make your request in writing to Aesthetic Plastic Surgery International, Release of Information Department. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

IV. OUR PRIVACY OFFICER

The designated Privacy Officer for Aesthetic Plastic Surgery International is Diane Hartl. Please feel welcome to contact her with any questions you may have regarding this policy. Mrs. Hartl can be reached at 703-845-7400.

Concerns and Complaints
If you have concerns or believe your privacy rights have been violated, please contact our Privacy Officer at the number listed above. Every reasonable attempt will be made to investigate and resolve the complaint. In certain circumstances, our Privacy Officer may request that you submit your complaint in writing.

V. OTHER USES OF MEDICAL INFORMATION

Uses and disclosures not covered by this Notice shall be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information 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 permission and that we are required to retain our records of the care that we provide to our patients.

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