HIPAA Notice Of Privacy Practices
Effective April 14, 2003

We maintain protocols to ensure the security and confidentiality of your personal information. Within our practice, access to your information is limited to those who need it to perform their jobs.

At the offices of Dr.'s Capella we are committed to treating and using protected health information about you responsibly. This Notice of Privacy Policies describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 14, 2003, and applies to all protected health information as defined by federal regulations:

Understanding Your Health Record
Each time you visit Dr.'s Capella a record of your visit is made. Typically, this record contains your symptoms, examination and test resulis, diagnoses. treatment, and a plan for future care of treatment. This information, often referred to as your health or medical record, serves as a:

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy; better understand who, what, when, where, and why others may access your health information; and make more informed decisions when authorizing disclosure to others.

Our Responsibilities
Our practice is required to:

We will not use or disclose your health information in a manner other than described in the section regarding Examples Of Disclosures For Treatment, Payment, And Health Operations, without your written authorization, which you may revoke as provided by 45 CFR I 64.508(b)(5), except to the extent that action has already been taken.

Examples Of Disclosures For Treatment, Payment, And Health Operations
We will use your health information for treatment.
We may provide medical information about you to health care providers, our practice personnel, or third parties who are involved in the provision, management, or coordination of your care.

For example:
lnformation obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course at treatment that should work best for you: Your medical information will be shared among health care professionals involved in your care.

We will also provide your other physician(s) or subsequent health care provider(s) (when applicable) with copies of various reports that should assist them in treating you.

We will use your health information for payment.
We may disclose your information so that we can collect or make payment for the health care services you receive.

For example:
If you participate in a health insurance plan, we will disclose necessary information to that plan to obtain payment for your care.

For More Information Or To Report A Problem
If you have questions and would like additional information, you may contact our practice's Privacy Officer, Jeannette Abondano, at (201) 818-0199. If you believe your privacy rights have been violated, you can either file a complaint with Jeannette Abondano, or with the Office for Civil Rights, U.S. Department of Health and Human Services (OCR). There will be no retaliation for filing a complaint with either our practice or the OCR. The address for the OCR regional office for New Jersey is: Office for Civil Rights, U.S. Department of Health and Human Services, Jacob Javitz Federal Building, 26 Federal Plaza, Suite 3312, NY, NY 10278.

If you would like a copy of this Privacy Notice, please ask a member of our medical staff.

I have read the above Notice of Privacy Practices, detailing how my health information may be used/disclosed as permitted under federal and state law.



Signed:____________________________     Date: ________________________

I wish to place the following restrictions on disclosure of my health information: