Notice of Privacy

Practices

DeeAnna Merz Nagel, LPC

P.O. Box 392

Highlands, NJ 07732

877.773.5591

732.708.9265 (fax)

www.DeeAnnaMerzNagel.com

DA@DeeAnnaMerzNagel.com

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.

I am required by law to provide you with this notice

that explains our privacy practices with regard to your

medical information and how I may use and disclose

your protected health information for treatment,

payment, and for health care operations, as Ill as for

other purposes that are permitted or required by law.

You have certain rights regarding the privacy of your

protected health information and I also describe those

rights in this notice.

Ways in Which I May Use and

Disclose Your Protected Health

Information:

The following paragraphs describe different ways that

I use and disclose your protected health information. I

have provided an example for each category, but these

examples are not meant to be exhaustive. All of the

ways I are permitted to use and disclose your health

information fall within one of these categories.

Treatment. I will use and disclose your protected

health information to provide, coordinate, or manage

your health care and any related services. I will also

disclose your health information to other health care

providers who may be treating you. Additionally I

may from time to time disclose your health

information to another physician whom I have

requested to be involved in your care. For example – I

would disclose your health information to a specialist

to whom I have referred you for a diagnosis to help in

your treatment.

Payment. I will use and disclose your protected

health information to obtain payment for the health

care services I provide you. For example — I 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.

Health Care Operations. I will use and disclose

your protected health information to support the

business activities of our practice. For example -– I

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, I

may disclose your health information to third party

business associates who perform billing, consulting, or

transcription, or other services for our practice.

Other Ways I May Use and

Disclose Your Protected Health

Information:

Appointment Reminders. I will use and disclose your

protected health information to contact you as a

reminder about scheduled appointments or treatment.

Treatment Alternatives. I will use and disclose your

protected health information to tell you about or

recommend possible alternative treatments or options

that may be of interest to you.

Others Involved in Your Care. I 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 for care.

Research. I will use and disclose your protected

health information to researchers, provided the

research has been approved by an institutional review

board that has reviewed the research proposal and

established protocols to ensure the privacy of your

health information.

As Required by Law. I will use and disclose your

protected health information when required to by

federal, state, or local law.

To Avert a Serious Threat to Public Health or

Safety. I will use and disclose your protected health

information to public health authorities permitted to

collect or receive the information for the purpose of

controlling disease, injury, or disability. If directed by

that health authority, I will also disclose your health

information to a foreign government agency that is

collaborating with the pubic health authority.

Worker’s Compensation. I will use and disclose your

protected health information for worker’s

compensation or similar programs that provide

benefits for work-related injuries or illness.

Inmates. I will use and disclose your protected health

information to a correctional institution or law

enforcement official if you are an inmate of that

correctional institution or under the custody of the law

enforcement official. This information would be

necessary for the institution to provide you with health

care; to protect the health and safety of others; or for

the safety and security of the correctional institution.

Your Health Information Rights

Although your health record is the physical property

of the practitioner or facility that compiled it, the

information belongs to you. You have the right to:

A Paper Copy of This Notice. You have the right to

receive a paper copy of this notice upon request. You

may obtain a copy in our office lobby at your next

visit or by calling and asking us to mail you a copy.

Inspect and Copy. You have the right to inspect and

copy the protected health information that I maintain

about you in our designated record set for as long as I

maintain that information. This designated record set

includes your medical and billing records, as Ill as any

other records I use for making decisions about you.

Any psychotherapy notes that may have been included

in records I received about you are not available for

your inspection or copying, by law. I may charge you

a fee for the costs of copying, mailing, or other

supplies used in fulfilling your request.

If you wish to inspect or copy your medical

information, you must submit your request in writing

to our Privacy Officer: Attention: DeeAnna Merz

Nagel, Privacy Officer, PO Box 392, Highlands, NJ

07732, Phone: 706.506.9151. You may mail your

request, or bring it to our office. I will have 30 days to

respond to your request for information that I maintain

at our practice site. If the information is stored off-site,

I am allowed up to 60 days to respond but must

inform you of this delay.

Request Amendment. You have the right to request

that I amend your medical information if you feel that

it is incomplete or inaccurate. You must make this

request in writing to our practice manager, stating

exactly what information is incomplete or inaccurate

and the reasoning that supports your request.

I are permitted to deny your request if it is not in

writing or does not include a reason to support the

request. I may also deny your request if:

· The information was not created by us, or the

person who created it is no longer available to make

the amendment.

· The information is not part of the record which you

are permitted to inspect and copy.

· The information is not part of the designated record

set kept by this practice or if it is the opinion of the

opinion of the health care provider that the

information is accurate and complete.

Request Restrictions. You have the right to request a

restriction of how I use or disclose your medical

information for treatment, payment, or health care

operations. For example – you could request that I not

disclose information about a prior treatment to a

family member or friend who may be involved in your

care or payment for care. Your request must be made

in writing to our practice manager.

I are not required to agree to your request if I feel it is

in your best interest to use or disclose that

information. If I do agree, I will comply with your

request except for emergency treatment.

An Accounting of Disclosures. You have the right to

request a list of the disclosures of your health

information I have made outside of our practice that

Ire not for treatment, payment, or health care

operations. You request must be in writing and must

state the time period for the requested information.

You may not request information for any dates prior

to April 14, 2003, nor for a period of time greater than

six years (our legal obligation to retain information).

Your first request for a list of disclosures within a 12-

month period will be free. If you request an addition

list within 12-months of the first request, I may charge

you a fee for the costs of providing the subsequent list.

I will notify you of such costs and afford you the

opportunity to withdraw your request before any costs

are incurred.

Request Confidential Communications. You have the

right to request how I communicate with you to

preserve your privacy. For example – you may request

that I call you only at your work number, or by mail at

a special address or postal box. Your request must be

made in writing and must specify how or where I are

to contact you. I will accommodate all reasonable

requests.

File a Complaint. If you believe I have violated your

medical information privacy rights, you have the right

to file a complaint with our practice or directly to the

New Jersey Division of Consumer Affairs.

To file a complaint with DeeAnna Merz Nagel, you must make

it in writing within 180 days of the suspected

violation. Provide as much detail as you can about the

suspected violation and send it to our Privacy Officer.

Uses or Disclosures Not Covered

Uses or disclosures of your health information not covered

by this notice or the laws that apply to us may only be made

with your written authorization. You may revoke such

authorization in writing at any time and I will no longer

disclose health information about you for the reasons stated

in your written authorization. Disclosures made in reliance

on the authorization prior to the revocation are not affected

by the revocation.

For More Information

If you have questions or would like additional

information, you may contact our Privacy Officer.

Effective Date: April 14, 2003

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