KNEIBERT CLINIC L.L.C.
NOTICE OF PRIVACY PRACTICES
Effective Date - April 14, 2003

I . This notice describes how medical information about you may be used and disclosed as well as how you can get access to the information. Please review it carefully.

II. Our Duty to Safeguard Your Protected Health Information.

Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care is considered “Protected Health Information” (“PHI”). We are required to extend certain protections to your PHI, and to give you this Notice about our privacy practices that explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the purpose of use or disclosure.

We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. If we do so, we will post a new Notice in our Business Office. You may request a copy of the new notice from the Business Office, and it will also be posted on our website at http://www.kneibertclinic.com.

III. How We May Use and Disclose Your Protected Health Information.

We use and disclose PHI for a variety of reasons. For most uses/disclosures, we must obtain your consent. For others, we must have your written authorization. However, the law provides that we are permitted to use and disclose your PHI:

For treatment: We may disclose your PHI to doctors, nurses and other health care personnel who are involved in providing your health care.

To obtain payment: We may use/disclose your PHI in order to bill and to collect payment for your health care services.

For healthcare operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of our practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your PHI to medical school students that see patients at our office. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

Subject to certain rules, we may use or disclose your health data without your prior permission for other reasons including: for public health issues, to report abuse or neglect, as part of research studies, to arrange funerals and organ donation, for workers’ compensation claims, and in an emergency.

When required to by law, we also may disclose health care data. In certain cases, we must respond to requests from law enforcement officials or valid court orders.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

IV. Your Rights

Following is a statement of your rights with respect to your PHI.

You have the right to inspect and copy your PHI. If you request copies, we will charge you a fee for the cost of copying, mailing and related supplies. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected PHI that is subject to law that prohibits access to PHI.

You have the right to request a restriction on your PHI. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or health care operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another healthcare professional.

You have the right to request that your health data be given to you in a private manner. You may ask us to send mail to an address other than your home, or tell us in writing about certain way or place we can use to inform you.

You have the right to request that your physician amend your PHI. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of disclosures we have made of your PHI except for treatment, payment, healthcare operations, or where you gave written permission.

We reserve the right to change the terms of this notice and will inform you by mail or any changes. You then have the right to object or withdraw as provided in this notice.

V. Questions and Complaints

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Kneibert Clinic L.L.C.
Robert E. Christian
Administrator
686 Lester Street
Poplar Bluff, MO 63901
Telephone (573) 686-2411

If you think that we may have violated your privacy rights, contact person named above. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.