HIPAA NOTICE OF PRIVACY

Lighthouse Convenience Clinic LLC
145 W. US Hwy 54
Camdenton, MO 65020
(573) 873-7138

NOTICE OF PRIVACY PRACTICES

As Required by the Privacy Regulations Created as a Result of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) THIS NOTICE DESCRIBES HOW
HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE
USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO YOUR
INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.PLEASE REVIEW THIS
NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY: Our practice is dedicated to maintaining the privacy of your individually identifiable
health information (IIHI). In conducting our business, we will create records regarding
you and the treatment and services we provide to you. We are required by law to
maintain the confidentiality of health information that identifies you. We are also
required by law to provide you with this notice of our legal duties and the privacy
practices that we maintain in our practice concerning your IIHI. By federal and state law,
we must follow the terms of the notice of privacy practices that we have in effect at the
time.

We realize that these laws are complicated, but we must provide you with the following
important information:

• how we may use and disclose your IIHI
• your privacy rights in your IIHI
• our obligations concerning the use and disclosure of your IIHI

The terms of this notice apply to all records containing your IIHI that are created or
retained by our practice. We reserve the right to revise or amend this Notice of
Privacy Practices. Any revision or amendment to this notice will be effective for all
of your records that our practice has created or maintained in the past, and for any
of your records that we may create or maintain in the future. Our practice will post
a copy of our current Notice in our office in a visible location at all times, and you
may request a copy of our most current Notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Lighthouse Convenience Clinic LLC.
Attn: Privacy Officer
PO Box 705
Camdenton, MO 65020
(573) 873-7138

C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE
HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS:

The following categories describe the different ways in which we may use and disclose
your IIHI, unless you object:

1. Treatment. Our practice may use your IIHI to treat you. For example, we may
ask you to have laboratory tests (such as blood or urine tests), and we may use the
results to help us reach a diagnosis. We might use your IIHI in order to write a
prescription for you, or we might disclose your IIHI to a pharmacy when we order
a prescription for you. Many of the people who work for our practice—including,
but not limited to, our doctors and nurses—may use or disclose your IIHI in order
to treat you or to assist others in your treatment. Additionally, we may disclose
your IIHI to others who may assist in your care, such as other healthcare
providers, your spouse, your children or your parents.

2. Payment. Our practice may use and disclose your IIHI in order to bill and collect
payment for the services and items you may receive from us. For example, we
may use and disclose your IHII to obtain payment from third parties that may be
responsible for such costs, such as family members. Also, we may use your IIHI
to bill you directly for services and items.

3. Health Care Operations. Our practice may use and disclose your IIHI to operate
our business. As examples of the ways in which we may use and disclose your
information for our operations, our practice may use your IIHI to evaluate the
quality of care you received from us, to develop protocols and clinical guidelines,
to develop training programs, and to aid in credentialing, medical review, legal
services and insurance. We will share information about you with such insurers
or other business associates as necessary to obtain these services.

4. Appointment Reminders. Our practice may use and disclose your IIHI to
contact you and remind you of an appointment.

5. Treatment Options. Our practice may use and disclose your IIHI to inform you
of potential treatment options or alternatives.

6. Health-Related Benefits and Services. Our practice may use and disclose your
IIHI to inform you of health-related benefits or services that may be of interest to
you.

7. Release of Information to Family/Friends. Our practice may release your IIHI
to a friend or family member that is involved in your care, or who assists in taking
care of you. For example, a parent or guardian may ask that a babysitter take their
child to the pediatrician’s office for treatment of a cold. In this example, the
babysitter may have access to this child’s medical information.

8. Disclosures Required by Law. Our practice will use and disclose your IIHI
when we are required to do so by federal, state, or local law.

9. Business Associates. There are some services provided through contracts with
“business associates,” such as accounting, legal representation, consulting,
medical services, etc. When these services are contracted, we may disclose your
IIHI to our business associates so that they can perform the job we have asked
them to do and, if applicable, bill you for services rendered. If we disclose protected
health information to a business associate, we will do so subject to a contract that
provides that the information will be kept confidential.

D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL
CIRCUMSTANCES:

The following categories describe unique scenarios in which we may use or disclose
your identifiable health information:

1. Public Health Risks. Our practice may disclose your IIHI to public health authorities
that are authorized by law to collect information for the purpose of:

• maintaining vital records, such as births and deaths
• reporting child abuse or neglect
• preventing or controlling disease, injury, or disability
• notifying a person regarding potential exposure to a communicable disease• notifying a person regarding a potential risk for spreading or contracting a
disease or condition
• reporting reactions to drugs or problems with products or devices
• notifying individuals if a product or device they may be using has been
recalled
• notifying appropriate government agency (ies) and authority (ies)
regarding the potential abuse or neglect of an adult patient (including
domestic violence); however, we will only disclose this information if the
patient agrees or we are required or authorized by law to disclose this
information
• notifying your employer under limited circumstances related primarily to
workplace injury or illness or medical surveillance.

2. Health Oversight Activities. Our practice may disclose your IIHI to a health
oversight agency for activities authorized by law. Oversight activities can
include, for example, investigations, inspections, audits, surveys, licensure and
disciplinary actions; civil, administrative, and criminal procedures or actions; or
other activities necessary for the government to monitor government programs,
compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your
IIHI in response to a court or administrative order, if you are involved in a lawsuit
or similar proceeding. We also may disclose your IIHI in response to a discovery
request, subpoena, or other lawful process by another party involved in the
dispute, but only if we have made an effort to inform you of the request or to
obtain an order protecting the information the party has requested.

4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement
official:
• regarding a crime victim in certain situations, if we are unable to obtain
the person’s agreement
• concerning a death we believe has resulted from criminal conduct
• regarding criminal conduct at our offices
• in response to a warrant, summons, court order, subpoena or similar legal
process
• to identify/locate a suspect, material witness, fugitive or missing person
• in an emergency, to report a crime (including the location or victim(s) of
the crime, or the description, identity or location of the perpetrator)

5. Deceased Patients. Our practice may release IIHI to a medical examiner or
coroner to identify a deceased individual or to identify the cause of death. If
necessary, we may also release information in order for funeral directors to
perform their jobs.

6. Organ and Tissue Donation. Our practice may release your IIHI to
organizations that handle organ, eye or tissue procurement or transplantation,
including organ donation banks, as necessary to facilitate organ or tissue donation
and transplantation if you are an organ donor.

7. Research. Our practice may use and disclose your IIHI for research purposes in
certain limited circumstances. We will obtain your written authorization to use
your IIHI for research purposes except when: (a) our use or disclosure was
approved by an Institutional Review Board or a Privacy Board; (b) we obtain the
oral or written agreement of a researcher that (i) the information being sought is
necessary for the research study; (ii) the use or disclosure of your IIHI is being
used only for the research and (iii) the researcher will not remove any of your
IIHI from our practice; or (c) the IIHI sought by the researcher only relates to
decedents and the researcher agrees either orally or in writing that the use or
disclosure is necessary for the research and, if we request it, to provide us with
proof of death prior to access to the IIHI of the decedents.

8. Serious Threats to Health or Safety. Our practice may use and disclose your
IIHI when necessary to reduce or prevent a serious threat to your health and safety
or the health and safety of another individual or the public. Under these
circumstances, we will only make disclosures to a person or organization able to
help prevent the threat.

9. Military. Our practice may disclose your IIHI if you are a member of U.S. or
foreign military forces (including veterans) and if required by the appropriate
authorities.

10. National Security. Our practice may disclose your IIHI to federal officials for
intelligence and national security activities authorized by law. We may also
disclose your IIHI to federal officials in order to protect the President, other
officials or foreign heads of state, or to conduct investigations.

11. Inmates. Our practice may disclose your IIHI to correctional institutions or law
enforcement officials if you are an inmate or under the custody of a law
enforcement official. Disclosure for these purposes would be necessary: (a) for
the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health
and safety of other individuals.

12. Workers’ Compensation. Our practice may release your IIHI for workers’
compensation and similar programs.

E. USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION:

The following uses and disclosures will require your authorization:

1. Highly Confidential Information: Federal and State laws require special privacy
protections for certain highly confidential information. We will not disclose your
medical information 1) maintained in psychotherapy notes; 2) related to mental health
treatment, developmental disabilities services, and drug and alcohol abuse treatment;
3) related to HIV status, testing, and treatment as well as any information related to
the diagnosis and treatment of sexually transmitted diseases; and 4) genetic
information, without, in each case, obtaining your authorization unless otherwise
permitted or required by applicable Federal or State law.

2. Other Uses or Disclosures Requiring Your Specific Authorization: Other types
of uses and disclosures of IIHI not identified in this notice will be made only with
your written authorization. Except as permitted under this Notice or as permitted by
law, we will request your written authorization before using or sharing your
information for marketing purposes or selling your information. Your authorization
may be revoked, in writing, at any time. However, should you revoke such an
authorization, you should understand that we are unable to retract any disclosures we
have already made with your permission, and that we are required to retain our
records as proof of the care that we provided you.

E. YOUR RIGHTS REGARDING YOUR IIHI:

The health and billing records we maintain are the physical property of Lighthouse
Convenience Clinic LLC. The information in it, however, belongs to you. You have a
right to:

1. Confidential Communications. You have the right to request that our practice
communicate with you about your health and related issues in a particular manner or at
a certain location. For instance, you may ask that we contact you at home, rather than
work. In order to request a type of confidential communication, you must make a written request to the Privacy Officer, specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable
requests. You do not need to give a reason for your request.

2. Requesting Restrictions. You have the right to request a restriction in our use or
disclosure of your IIHI for treatment, payment or health care operations. Additionally,
you have the right to request that we restrict our disclosure of your IIHI to only certain
individuals involved in your care or the payment for your care, such as family members
and friends. We are not required to agree to your request; however, if we do agree,
we are bound by our agreement except when otherwise required by law, in
emergencies, or when the information is necessary to treat you. In order to request a
restriction in our use or disclosure of your IIHI, you must make your request in writing to
the Privacy Officer. Your request must describe in a clear and concise fashion:

(a) the information you wish restricted;
(b) whether you are requesting to limit our practice’s use, disclosure
or both; and
(c) to whom you want the limits to apply.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI
that may be used to make decisions about you, including patient medical records and
billing records, but not including psychotherapy notes. You must submit your request in
writing to the Privacy Officer Lighthouse Convenience Clinic LLC, PO Box 705,
Camdenton, MO 65020, in order to inspect and/or obtain a copy of your IIHI.
Your request should specifically state what medical information you want to inspect or
copy. We will ordinarily act on your request within thirty (30) days of our receipt of your
request. Our practice may charge a fee for the costs of copying, mailing, labor and
supplies associated with your request. Our practice may deny your request to inspect
and/or copy in certain limited circumstances; however, you may request a review of our
denial. Another licensed health care professional chosen by us who did not participate
in the original decision to deny access will conduct reviews. We will ordinarily act on
your request for review within thirty (30) days.

4. Amendment. You may ask us to amend your health information if you believe it is
incorrect or incomplete, and you may request an amendment for as long as the
information is kept by or for our practice. To request an amendment, your request must
be made in writing and submitted to the Privacy Officer at Lighthouse Convenience
Clinic LLC, PO Box 705, Camdenton, MO 65020. We will ordinarily act
on our amendment request within sixty (60) days after our receipt of your request. You
must provide us with a reason that supports your request for amendment. If we grant
the request, we will inform you of such acceptance in writing. We will make the
appropriate amendment to you IIHI, and we will request that you identify and agree that
we may notify all relevant persons with whom the amendment should be shared. Our
practice will deny your request if you fail to submit your request (and the reason
supporting your request) in writing. Also, we may deny your request if you ask us to
amend information that is in our opinion: (a) accurate and complete; (b) not part of the
IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to
inspect and copy; or (d) not created by our practice, unless the individual or entity that
created is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an
“accounting of disclosures.” An “accounting of disclosures” is a list of certain nonroutine disclosures our practice has made of your IIHI for non-treatment or operationspurposes. Use of your IIHI as part of the routine patient care in our practice is not
required to be documented. For example, the doctor sharing information with the nurse.
In order to obtain an accounting of disclosures, you must submit your request in writing
to the Privacy Officer Lighthouse Convenience Clinic LLC, PO Box 705, Camdenton,
MO 65020. All requests for an “accounting of disclosures” must state a time period,
which may not be longer than six (6) years from the date of disclosure and may not
include dates before April 14, 2003. The first list you request within a 12-month
period is free of charge, but our practice may charge you for additional lists within the
same 12-month period. Our practice will notify you of the costs involved with additional
requests, and you may withdraw your request before you incur any costs. We will
ordinarily act on your accounting request within sixty (60) days of your request. We are
permitted to extend our response time for a period of up to thirty (30) days if we notify
you of the extension. We may temporarily suspend your right to receive an accounting
of disclosures of your health information, if required to do so by law.
6. Right to Breach Notification: You have a right to receive written notification when
a breach (as defined by HIPAA) of your IIHI has occurred. You will receive notification
no later than sixty (60) days after the breach has been discovered.
7. Right to a Paper Copy of this Notice. You are entitled to receive a paper copy of
our notice of privacy practices. You may ask us to give you a copy of this notice at any
time. To obtain a paper copy of this notice, contact the Privacy Officer.
8. Right to File a Complaint. If you believe your privacy rights have been violated,
you may file a complaint with our practice or with the Secretary of the Department of
Health and Human Services. To file a complaint with our practice, contact:

Lighthouse Convenience Clinic LLC.
Attn: Privacy Officer
PO Box 704
Camdenton, MO 65020
(573) 873-7183

All complaints must be submitted in writing. You will not be penalized for filing a
complaint.

9. Right to Provide an Authorization for Other Uses and Disclosures. Our practice
will obtain your written authorization for uses and disclosures that are not identified by
this notice or permitted by applicable law. Any authorization you provide to us regarding
the use and disclosure of your IIHI may be revoked at any time in writing. After you
revoke your authorization, we will no longer use or disclose your IIHI for the reasons
described in the authorization. Please note: we are required to retain records of your
care.

Again, if you have questions regarding this notice or our health information privacy
policies, please contact the Privacy Officer listed above.

Acknowledgement
I hereby acknowledge that I have received and read the Lighthouse Convenience Clinic
LLC HIPAA Privacy Policy Notice. I understand that I may request additional copies of
this notice at any time