ÿWPCù *ÿ´B•$S‘<íà†êAs}ÄÝ´;®EÛùÐJ/æ0S™<“D·˜Tfòâ±ñ6úNüþ»Ü™¸Bœ©ÙL§'ƒü{W™„0á¯y‚Ï'<öìo#\q¸ãÄá ÌNb¥SÆ›¦1…ôB+ç1Ú%­x>ñ':ꬦNóF;>(Õ_ÿÚþ#Ùù55‰J~ÇÄp&YïÑù]%Âîxïp¤[-`s¨&öx©Lµ¨ôÊpyézhé览¤ç Ÿr¦bëÇÖ æJãõô 5–¦<žŸ.q-ФÕF¿~W„fPøáÄϸüPË#êÊwœxsàŠoæ“æ RuÐq¯0ͪÔ$?gæúnkÓ ¦û f+íkbú´XßI]ÔKLñTS‘–|bE{yÞ»-FðŽÝi ¸#6NájÞ Ý:áRd¨Å_Ú·ÖÕ>¬:COùVÌú†à;"뤮?â±Ý#«ÖsÏMÄTðsŒ_gm!ÉŽ²í˜-ly=©g¦¿Vä(QvßÔ2J‡÷þC§@Nc2¾.ha†<÷ä\¢û%`ªØ¨£Æ©·Ú¶ÏÈÚÇŸ‡CnÞl69aä9Ìô šÍs#ÉÄUN %Û 0:áUJU@e^ ¥w±4µÉØ mÚñ˜Brother HL-5140 series (Copy 1)ÈÈ,,,,ÈÈ0(ÖÃ9 Z‹6Times New Roman RegularX(üœ$¡¡ÔUSUS.,ÔýB qZ ‹2English111 Vivace BT (ÖÃ9 Z‹(Times New Roman Uoþ:¸ §Pi6ê:i¢×+003|xÿU‹ÿÀÀÀ Ý ƒüœ!ÝÔUSUS.,ÔÝ  ÝÔ_ÔÑÈ°ÑÓ  ÓÔ€Xm¨XXXÔò òÔ€™£˜XXm¨ÔÓ8ûÓÔ‡xËûv˜™£ÔMidtown€Sports€MedicineÔ#†™£˜vxËûª#Ôó óÐ È Ðò òÔ€™¶Ž ˜˜™£ÔÔ‡ô… ò ˜™¶ŽÔEric€Furie€M.D.Ô#†™¶Ž ˜ òô…=#ÔÐ F ÐÔ€èÂ æ ˜™¶ŽÔÔ‡‡fŠ† æèÂÔÌÓ  ÓEffective€Date:€April€1,€2003Ð a™ ÐÌÓ  ÓNOTICE€OF€PRIVACY€PRACTICESÐ ‹Ã ÐÌÓ  ÓTHIS€NOTICE€DESCRIBES€HOW€MEDICAL€INFORMATION€ABOUT€YOU€MAY€BE€USED€AND€DISCLOSED€AND€HOW€YOUÐ µí ÐCAN€GET€ACCESS€TO€THIS€INFORMATION.Ð J‚ ÐÓ  ÓòòPLEASE€REVIEW€IT€CAREFULLY.Ð ß  ÐÔ#†è 憇fŠÂ#ÔÌÓ  ÓÔ€‡fŠ† æèÂÔóóòòHOW€WE€MAY€USE€AND€DISCLOSE€MEDICAL€INFORMATION€ABOUT€YOU.óóó ó€€The€following€categories€describe€different€ways€that€weÐ ( `  Ðuse€and€disclose€medical€information.€€For€each€category€of€uses€or€disclosures,€we€will€elaborate€on€the€meaning€and€provide€more€specific€examples,Ð Á ù  Ðif€you€request.€€Not€every€use€or€disclosure€in€a€category€will€be€listed.€€However,€all€of€the€ways€we€are€permitted€to€use€and€disclose€information€willÐ X  Ðfall€within€one€of€the€categories.Ð ï '  Ðò òòòFOR€PAYMENT.óóó ó€We€may€use€and€disclose€medical€information€about€you€so€that€the€treatment€and€services€you€receive€at€the€practice€may€beÐ † ¾  Ðbilled€to€and€payment€may€be€collected€from€you,€an€insurance€company€or€a€third€party.€€For€example,€we€may€disclose€your€record€to€an€insuranceÐ  W  Ðcompany,€so€that€we€can€get€paid€for€treating€you.Ð ¶ î  Ðò òòòFOR€TREATMENT.óóó ó€We€may€use€medical€information€about€you€to€provide€you€with€medical€treatment€or€services.€€We€may€disclose€medicalÐ M …  Ðinformation€about€you€to€doctors,€nurses,€technicians,€medical€students€or€other€personnel€who€are€involved€in€taking€care€of€you€at€the€practice€or€theÐ æ   Ðhospital.€€For€example,€we€may€disclose€medical€information€about€you€to€people€outside€the€practice€who€may€be€involved€in€your€medical€care,€suchÐ }µ  Ðas€family€members,€clergy,€or€other€persons€that€are€part€of€your€care.Ð L Ðò òòòFOR€HEALTH€CARE€OPERATIONS.ó óóó€€We€may€use€and€disclose€medical€information€about€you€for€health€care€operations.€€These€uses€andÐ «ã Ðdisclosures€are€necessary€to€run€the€practice€and€ensure€that€all€of€our€patients€receive€quality€care.€€We€may€also€disclose€information€to€doctors,Ð D| Ðnurses€technicians,€medical€students,€and€other€practice€personnel€for€review€and€learning€purposes.€€For€example,€we€may€review€your€record€toÐ Û Ðassist€our€quality€improvement€efforts.Ð rª Ðò òòòWHO€WILL€FOLLOW€THIS€NOTICE.óóó ó€€This€notice€describes€our€practiceððs€policies€and€procedures€and€that€of€any€health€care€professionalÐ  A Ðauthorized€to€enter€information€into€your€medical€chart,€any€member€of€a€volunteer€group€which€we€allow€to€help€you,€as€well€as€all€employees,€staffÐ ¢Ú Ðand€other€practice€personnel.Ð 9q Ðòòò òPOLICY€REGARDING€THE€PROTECTION€OF€PERSONAL€INFORMATION.ó óóó€€We€create€a€record€of€the€care€and€services€you€receive€at€theÐ Ð Ðpractice.€€We€need€this€record€in€order€to€provide€you€with€quality€care€and€to€comply€with€certain€legal€requirements.€€This€notice€applies€to€all€of€theÐ i¡ Ðrecords€of€your€care€generated€by€the€practice,€whether€made€by€practices€personnel€or€by€your€personal€doctor.€€The€law€requires€us€to:€make€sureÐ 8 Ðthat€medical€information€that€identifies€you€is€kept€private;€give€you€this€notice€of€our€legal€duties€and€privacy€practices€with€respect€to€medicalÐ —Ï  Ðinformation€about€you;€and€to€follow€the€terms€of€the€notice€that€is€currently€in€effect.€€Other€ways€we€may€use€or€disclose€your€protected€healthcareÐ .f! Ðinformation€include;€appointment€reminders;€as€required€by€law;€for€health€related€benefits€and€services;€to€individual€involved€in€your€care€orÐ Åý" Ðpayment€for€your€care;€research;€to€avert€a€serious€threat€to€health€or€safety;€and€for€treatment€alternatives.€€Other€uses€and€disclosures€of€yourÐ \”# Ðpersonal€information€could€include€disclosure€to€,€or€for:€coroners,€medical€examiners€and€funeral€directors;€health€oversight€Ô_Ôactivities;Ô_Ô€lawÐ ó+$ Ðenforcement;€lawsuits€and€disputes;€military€and€veterans;€nation€security€and€intelligence€activities;€organ€and€tissue€donation;€protective€services€forÐ ŠÂ% Ðthe€President€and€others;€public€health€risk;€and€workerððs€compensation.Ð !Y& ÐÌÓ  Óò òòòNOTICE€OF€INDIVIDUALS€RIGHTSóóó óÐ O‡( ÐÓ  ÓÌYou€have€the€following€rights€regarding€medical€information€we€maintain€about€you:Ð {³* Ðò òòòRIGHT€TO€PAPER€COPY€OF€THIS€NOTICE.óóó ó€€You€have€the€right€to€a€paper€copy€of€this€notice.€€You€may€ask€us€to€give€you€a€copy€of€thisÐ J+ Ðnotice€at€any€time.Ð «ã, Ðò òòòRIGHT€TO€INSPECT€AN€COPY.óóó ó€You€have€the€right€to€inspect€and€copy€medical€information€that€may€be€used€to€decisions€about€your€care.€€WeÐ Bz- Ðmay€deny€your€request€to€inspect€and€copy€in€certain€very€limited€circumstances.Ð Û. Ðò òòòRIGHT€REQUEST€RESTRICTIONS.óóó ó€€You€have€the€right€to€request€a€restriction€or€limitation€on€the€medical€information€we€use€or€disclose€aboutÐ rª/ Ðyou€for€treatment,€payment€or€health€care€operations.€€You€also€have€the€right€to€request€a€limit€on€the€medical€information€we€disclose€about€you€toÐ  C0 Ðsomeone€who€is€involved€in€your€care€of€the€payment€for€you€care,€like€a€family€member€or€friend.€€ò òòòWe€are€not€required€to€agree€to€your€request.ó óóó€€IfÐ ¢Ú1 Ðwe€do€agree,€we€will€comply€with€your€request€unless€the€information€is€needed€to€provide€you€emergency€treatment.€€To€request€restrictions,€youÐ 9 q2 Ðmust€make€your€request€in€writing€to€the€Privacy€Officer.Ð Ð  3 Ðò òòòRIGHT€TO€REQUEST€CONFIDENTIAL€COMMUNICATIONS.óóó ó€€You€have€the€right€to€request€that€we€communicate€with€you€about€medicalÐ g!Ÿ 4 Ðmatters€in€a€certain€way€or€at€a€certain€location.€€You€must€make€your€request€in€writing€and€you€must€specify€how€or€where€you€wish€to€contacted.Ð "8!5 Ðò òòòRIGHT€TO€AN€ACCOUNTING€OF€DISCLOSURES.óóó ó€€You€have€the€right€to€request€an€ð ðaccounting€of€disclosures.ðð€€This€is€alist€of€theÐ —"Ï!6 Ðdisclosures€we€made€of€medical€information€about€you.€€To€request€this€list€or€accounting€of€disclosures,€you€must€submit€your€request€in€writing€toÐ 0#h"7 Ðthe€Privacy€Officer.Ð Ç#ÿ"8 Ðò òòòCHANGES€TO€THIS€NOTICE.óóó ó€€We€reserve€the€right€to€change€this€notice.€€We€will€post€a€copy€of€the€current€notice€in€the€practiceððs€waitingÐ ^$–#9 Ðroom.Ð ÷$/$: Ðòòò òCOMPLAINTS.ó óóó€€If€you€believe€your€privacy€rights€have€been€violated,€you€may€file€a€complaint€with€the€practice€or€with€the€Secretary€of€theÐ Ž%Æ$; ÐDepartment€of€Health€and€Human€Services.€€To€file€a€complaint€with€the€practice,€contact€the€Office€Manager€404„522„5828.€€All€complaints€must€beÐ '&_%< Ðsubmitted€in€writing.€€You€will€not€be€penalized€for€filing€a€complaint.Ð ¾&ö%= Ðò òòòOTHER€USES€OF€MEDICAL€INFORMATION.ó óóó€€Other€uses€and€disclosures€of€medical€information€not€covered€by€this€notice€or€the€laws€thatÐ U'&> Ðapply€to€use€will€be€made€only€with€your€written€authorization.€€If€you€provide€us€permission€to€use€or€disclose€medical€information€about€you€,€youÐ î'&'? Ðmay€revoke€that€permission,€in€writing,€at€any€time.Ð …(½'@ ÐIf€you€have€any€questions€about€this€notice€or€would€like€to€receive€a€more€detailed€explanation,€please€contact€our€Privacy€Officer.Ð )T(A ÐÌò òI€acknowledge€by€signing€below€that€I€have€received€the€òòNotice€of€Privacy€Practices€and€Notice€of€Individual€Rights.óóó óÐ J*‚)C ÐÌÌÌò òòò€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€à  àà p à€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€Ð ¤,Ü+G ÐóóÓ9û8ûÓPatient€or€Patientððs€Personal€Representativeà0 h àà0Àh(#h(#àà0À(#À(#àà0p(#(#àà0Èp(#p(#àTodayððs€DateÔ€c=†‡fŠÔó ó