KETAMINE GREATER BOSTON | PRIVACY PRACTICES

This notice describes how medical information about you may be used, disclosed and safeguarded, and how you can get access to this information. Please review it carefully.

I. Our Responsibility

The confidentiality of your personal health information is very important to us. Your health information includes records that we create and obtain when we provide care, such as a record of your symptoms, examination and test results, diagnoses, treatments and referrals for further care. It also includes bills, insurance claims, or other payment information that we maintain related to your care. This Notice describes how we handle your health information as required by law;

• Maintain the privacy of your health information as required by law
• Provide you with this Notice of our duties and privacy practices regarding the health information about you that we collect and maintain

II. Uses & Disclosures of Information

Under federal law, we are permitted to use and disclose personal health information without authorization for treatment, payment and health care operations. Whenever possible, we will obtain your consent before disclosing such information. Below are some examples to clarify these terms:

• Treatment: We consult with your therapist or family doctor about your condition
• Payment: Your health information is disclosed to your insurer to obtain reimbursement. In these situations, we will only disclose the minimum amount of information necessary. As we are not a participating provider in any insurance plans, you will be responsible for providing us with the appropriate forms and, therefore, aware of the information they are requesting.
• Health Care Operations: This refers to administrative activities, such as services or audits, that relate to the operation of our practice.

III. Other Uses & Disclosures

In addition to uses and disclosures related to treatment, payment and health care operations, we may also use and disclose your personal information without authorization for the following additional purposes:

Serious threat to health or safety
We may disclose your health information to protect you or others from a serious threat of harm by you.

Abuse, neglect or domestic violence
As required or permitted by law, we may disclose health information about you to a state or federal agency to report suspected abuse, neglect or domestic violence. If such a report is optional, we will use our professional judgement in deciding whether to make such a report.

Business associates
We may share health information about you with business associates who are performing services on our behalf. For example, we may contract with a company to service and maintain our computer systems, or to do our billing. Our business associates are obligated to safeguard your health information. We will share with our business associates only the minimum amount of personal health information necessary for them to assist us.

Communication with family & friends
We may disclose information about you to persons who are involved in your care or payment for you care, such as family members, relatives or close personal friends. Any such disclosure will be limited to information directly related to the persons involvement in your care. If you are available, we will provide you and opportunity to object before disclosing any such information. If you are unavailable because, for example, you are incapacitated or because of some emergency circumstance, we will use our professional judgement to determine what is in your best interest regarding any such disclosure.

Coroners, medical examiners & funeral directors
We may disclose health information about you to a coroner or medical examiner, for example, to assist in the identification of a descendant or determining cause of death. We may also disclose health information to funeral directors to enable them to carry out their duties.

Food & Drug Administration (FDA)
We may disclose health information about you to the FDA, or to an entity regulated by the FDA, in order, for example, to report an adverse event or a defect related to a drug or medical device.

Health care oversight
We may disclose health information about you for oversight activities authorized by law or to an authorized health oversight agency to facilitate auditing, inspection, or investigation related to our provision of health care, or to the health care system.

Judicial or administrative proceedings
In cases where you are involved in a court proceeding and a request is made for your personal health information, this information is privileged under state law, and we will not release it without your consent or a court order.

Law enforcement
We will disclose health information about you to a law enforcement official only if obligated by law.

Notification
We may notify a family member, your personal representative, or other personal responsible for your care, of your location, general condition, or death. If you are available, we will provide you an opportunity to object before disclosing any such information. If you are unavailable because, for example, you are incapacitated, or because of some other emergency circumstance, we will use our professional judgement to determine what is in your best interest regarding any such disclosure.

Personal representative
If you are an adult or emancipated minor, we may disclose health information about you to a personal representative authorized to act on your behalf in making decisions about your health care.

Public health activities
As required or permitted by law, we may disclose health information about you to a public health authority, for example, to report disease, injury or vital events such as death.

Required by law
We may disclose health information about you as required by federal, state or other applicable law.

Any other use or disclosure (authorization required)
Before using or disclosing your personal health information for any other purpose not identified above, we will obtain your written authorization. Unless action has already been taken in reliance on the authorization, you have a right to revoke such authorization by submitting your request in writing to us.

IV. Your Health Information Rights

Under the law, you have certain rights regarding the health information that we collect and maintain about you. This includes the right to:

• Request that we restrict certain uses and disclosures of your health information; we are not, however, required to agree to a requested restriction
• Request that we communicate with you by alternative means, such as making records available for pickup, or mailing them to you at an alternative address, such as a P.O. Box. We will accommodate reasonable requests for such confidential communications.
• Request to review, or to receive a copy of, a summary of the health information about you that is maintained in our files. If we are unable to satisfy your request, we will tell you in writing the reason for the denial and your right, if any, to request a review of the decision.
• Request that we amend the health information about you that is maintained in our files. Your request must explain why you believe our records about you are incorrect, or otherwise require amendment. If we are unable to satisfy your request, we will tell you in writing the reason for the denial and tell you how you may contest the decision, including your right to submit a statement (of reasonable length) disagreeing with the decision. The statement will be added to your records.
• Request a list of our disclosures, such as those made for treatment, payment or health care operations. We will provide you the accounting free of charge, however, if you request more than one accounting in any 12-month period, we may impose a reasonable, cost-based fee for any subsequent request. Your request should indicate the period of time in which you are interested (for example, from May 1, 2003, through June 1, 2003). We will be unable to provide you an accounting for any disclosures for a period of longer than six (6) years.
• Request a paper copy of this Notice; in order to exercise any of your rights describes above, you must submit your request in writing. If you have any questions about your rights, please speak with us in person or by phone during normal business hours.

V. To Request Information or File a Complaint

If you believe your privacy rights have been violated, you may file a written complaint by mailing it to us or delivering it in person. You may complain to the Secretary of Health & Human Services (HHS) by writing to the Office for Civil Right, U.S. Department of Health & Human Services, 200 Independence Avenue S.W., Room 509F, HHH Building, Washington, D.C. 20201; by calling 1-800-368-1019; or by sending an email to OCRprivacy@hhs.gov. We cannot, and will not, make you waive your right to file a complaint on condition of receiving care from us, or penalize you for filing a complaint.

VI. Revisions of this Notice

We reserve the right to amend the terms of this Notice. If this Notice is revised, the amended terms that apply to all health information we maintain, including information about you collected or obtained before the effective date of the revised Notice. If the revisions reflect a material change to the use and disclosure of your information, your rights regarding such information, our legal duties, or other privacy practices described in the Notice, we will promptly distribute the revised Notice.

VII. Effective Date

February 18, 2014