NOTICE OF PRIVACY PRACTICES

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.

Marshall Clinic Effingham, S.C. duties: We are required by law to maintain the privacy of your protected health information (PHI) and to provide you with this Notice of Privacy Practices. We are also required to abide by the privacy policies that are outlined in this Notice.

Provision of Notice: Marshall Clinic Effingham, S.C. provides its Notice of Privacy Practices to every patient with whom it has a direct treatment relationship. The Notice is provided no later than the date of the first treatment to the patient after April 13, 2003.

We make our Notice available to any member of the public to enable prospective patients to evaluate our clinic's privacy practices when making his or her decision regarding whether to seek treatment from our health care providers. Our practice provides this Notice of Privacy Practices on our website (www.effingham.net/marshall), and also prominently displays the Notice in our waiting room and in the exam rooms.

Documentation of Provision of Notice: When a direct treatment patient receives the Notice from Marshall Clinic Effingham, S.C., we ask the patient to sign a "Receipt of Notice of Privacy Practices" form. The form is filed with the patient's medical record. One Notice of Privacy Practices and one Receipt of Notice of Privacy Practices form may be used for the entire family. However, if you would like separate forms for each family member, please let us know. If the patient refuses to sign the form, it is noted in the medical record that the patient was given the Notice and refused to sign the form. Our Notice of Privacy Practices is written in English. We will do our best to provide translations and/or other explanations promptly upon request.

Right to Revise Privacy Practices: As permitted by law, we reserve the right to amend or modify this Notice. These changes in our policies and practices may be required by changes in federal and state laws and regulations. The revised policies and practices will be applied to all protected health information that we maintain. Except when required by law, a material change to any term of the Notice will not be implemented prior to the effective date of the notice in which such material change is reflected.

If the Notice is revised, Marshall Clinic Effingham, S.C. will make the revised Notice available upon request beginning on the revision's effective date. The revised notice will be posted in our reception area and made available to all patients, including those who have received a previous Notice. Upon receipt of a revised Notice, a patient is asked to acknowledge receipt of the Notice.

Complaints: Marshall Clinic Effingham, S.C. allows all patients and their agents to file complaints with the practice and with the Secretary of the federal Department of Health and Human Services (DHHS). A patient or his or her agent may file a complaint with the practice whenever he or she believes that the practice has violated their rights. Complaints to the practice must be in writing, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient

became aware or should have become aware of the violation. The practice investigates each complaint and will, at its discretion, reply to the patient or the patient's agent.

If you would like to submit a comment or complaint about our privacy practices or if you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter outlining your concerns to:

Privacy Officer

Marshall Clinic Effingham, S.C.

300 North Maple Street P.O. Box 1268

Effingham, Illinois 62401

Complaints to the Secretary of the Department of Health and Human Services must be in writing, must name the practice, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to:

Department of Health and Human Services

200 Independence Avenue S.W.

Washington, D.C. 20201

Marshall Clinic Effingham, S.C. does not take any adverse action against any patient who files a complaint (either directly or through an agent) against the practice.

USES AND DISCLOSURES

OF PROTECTED HEALTH INFORMATION

Marshall Clinic Effingham, S.C. reasonably ensures that the protected health information (PHI) it requests, uses, and discloses for any purpose is the minimum amount of PHI necessary for that purpose.

The practice treats all qualified individuals as personal representatives of patients. The practice generally allows individuals to act as personal representatives of patients. The two general exceptions to allowing individuals to act as personal representatives relate to emancipated minors and abuse, neglect, or endangerment situations.

We make reasonable efforts to ensure that protected health information is only used by and disclosed to individuals that have a right to the protected health information. Toward that end, the practice makes reasonable efforts to verify the identity of those using or receiving protected health information.

Uses and Disclosures - Treatment, Payment, and Health Care Operations

The practice uses and discloses protected health information for payment, treatment, and health care operations. Treatment includes those activities related to providing services to the patient. Payment relates to all activities associated with getting reimbursed for services provided, including submission of claims to insurance companies and any additional information requested by the insurance company so they can determine if they should pay the claim. Health care operations include a number of areas, including quality assurance and peer review activities.

Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

Payment: Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurance, or from credit card companies that you may use to

pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

Health Care Operations: Your health information may be used as necessary to support the day-to-day activities and management of Marshall Clinic Effingham, S.C. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Uses and Disclosures - Not Requiring Authorization

Disclosure to Those Involved in An Individual's Care: The practice discloses protected health information to those involved in a patient's care when the patient approves or, when the patient is not present or not able to approve, when such disclosure is deemed appropriate in the professional judgment of the practice.

Law Enforcement: Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting. When the patient is not present, the practice determines whether the disclosure of the patient's protected health information is authorized by law and if so, discloses only the information directly relevant to the person's involvement with the patient's health care. The practice does not disclose protected health information to a suspected abuser, if, in its professional judgment, there is reason to believe that such a disclosure could cause the patient serious harm.

Uses and Disclosures Required by Law: The practice uses and discloses protected health information to appropriate individuals as required by law.

Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state's public health department. Other conditions that require reporting include sexually transmitted diseases, lead poisoning, Reyes Syndrome, and mandated reports of injury, medical conditions or procedures, or food-borne illness including but not limited to adverse reactions to immunizations, cancer, adverse pregnancy outcomes, death, and birth.

The practice discloses protected health information regarding victims of abuse, neglect, or domestic violence. The practice discloses information about a minor, disabled adult, nursing home resident, or person over 60 years of age whom the practice reasonably believes to be a victim of abuse or neglect to the appropriate authorities as required by law or, if not required by law, if the individual agrees to the disclosure. This includes child abuse and neglect, elder abuse and exploitation, abused and neglected nursing home residents, or disabled adults abuse.

The practice informs the individual of the reporting unless the practice, in the exercise of professional judgment, believes informing the individual would place the individual at risk of serious harm or the practice would be informing a personal representative, and the practice believes the personal representative is responsible for the abuse, neglect, or other injury, and that informing such person would not be in the best interests of the individual as determined by the professional judgment of the practice.

Uses and Disclosures for Health Oversight Activities: The practice uses and discloses PHI as required by law for health oversight activities. The information may be used and released for audits, investigations, licensure issues, and other health oversight activities, including, but limited to hospital peer review, managed care peer review, or Medicaid or Medicare peer review.

Disclosures for Judicial and Administrative Proceedings: In general, the practice discloses information for judicial and administrative proceedings in response to an order of a court or an administrative tribunal; or a subpoena, discovery request or other lawful process, not accompanied by a court order or an ordered administrative tribunal.

Uses and Disclosures Related to Decedents: The practice uses and discloses PHI as required to a coroner or medical examiner and funeral directors as required by law. The attending physician is required to sign the death certificate and provide the coroner with a copy of the decedent's protected health information.

Uses and Disclosures Related to Cadaveric Organ, Eye or Tissue Donations: The practice may use and disclose protected health information to facilitate organ, eye or tissue donations.

Uses and Disclosures to Avert a Serious Threat to Health or Safety: The practice uses and discloses protected health information to public health and other authorities as required by law to avert a serious threat to health or safety.

Uses and Disclosures for Specialized Government Functions: The practice uses and discloses protected health information for military and veteran's activities, national security and intelligence activities, and other activities as required by law.

Uses and Disclosures in Emergency Situations: The practice uses and discloses protected health information as appropriate to provide treatment in emergency situations. In those instances where the practice has not previously provided its Notice of Privacy Practices to a patient who receives direct treatment in an emergency situation, the practice provides the Notice to the individual as soon as possible following the provision of the emergency treatment.

Uses and Disclosures - Requiring Authorization

Other Uses and Disclosures Require Authorization: Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

Marketing Purposes: The practice does not use or disclose any protected health information for marketing purposes. The practice may engage in communications about products and services that encourages recipients of the communication to purchase or use the product or service for treatment, to direct or recommend alternative treatments, therapies, health care providers, or settings of care to the individual. These activities are not considered marketing.

Additional Uses of Information.

Appointment reminders: Your health information may be used by our staff to send you appointment reminders.

Information About Treatment: Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you.

Uses and Disclosures That Do Not Apply to Practice

Research: The practice does not engage in any research activities that require it to use or disclose protected health information.

Other Uses and Disclosures: The practice does not use or disclose protected health information to an employer or health plan sponsor, for underwriting and related purposes, for facility directories, to brokers and agents, or for fundraising.

If an individual wants the practice to release his or her protected health information to employers or health plan sponsors, for underwriting and related purposes, for facility directories, or to brokers and agents, then he or she can contact the practice and complete an appropriate written authorization.

INDIVIDUAL RIGHTS

Individual Rights: You have certain rights under the federal privacy standards. These include:

· The right to request restrictions on the use and disclosure of your protected health information.

· The right to receive confidential communications concerning your medical condition and treatment.

· The right to inspect and request a copy of your protected health information.

· The right to amend or submit corrections to your protected health information.

· The right to receive an accounting of how and to whom your protected information has been disclosed.

· The right to receive a printed copy of this Notice.

Individual Rights - Accounting for Disclosures of Protected

Health Information

The practice tracks all disclosures of a patient's protected health information that occur for other than the purposes of treatment, payment, and health care operations, that are not made to the individual or to a person involved in the patient's care, that are not made as a result of a patient authorization, and that are not made for national security or intelligence purposes or to correctional institutions or law enforcement officials.

The practice allows an individual to request one accounting within a 12-month period free of charge. The practice charges a reasonable fee for more frequent accounting requests. The charge will be $5.00. An individual can request an accounting of disclosures for a period of up to six years prior to the date of the request. Requests for shorter accounting periods will be accepted. However, patients may only request an accounting of disclosures made on or after April 14, 2003.

The practice responds to all requests for an accounting of disclosures within 60 days of receipt of the request. If the practice intends to provide the accounting for disclosures and cannot do so within 60 days, the practice informs the requestor of such and provides a reason for the delay and the date the request is expected to be fulfilled. Only one 30-day extension is permitted.

A request for an accounting for disclosures must be made in writing and mailed or sent to the practice. It should be marked "Attention: Privacy Officer."

Individual Rights - Inspect and Copy Protected Health Information

The practice allows individuals to inspect and request a copy of their protected health information, documents all requests, responds to those requests in a timely fashion, informs individuals of their appeal rights when a request is rejected in whole or in part, and charges a reasonable fee for the copying of records.

The practice reviews the request in a timely fashion and acts on a request for access generally within 30 days. The practice may have a single extension of 30 days, if needed to act on the request. Each request will be accepted or denied and the requestor notified in writing. If a request is denied, the requestor is

informed if the denial is "reviewable" or not. The requestor has the right to have any denial reviewed by a licensed health care professional who is designated by the practice as a reviewing official and who did not participate in the original decision to deny. The practice informs the requestor of the decision of the reviewing official and adheres to the decision.

The practice charges reasonable fees based on the actual cost of fulfilling the request. The practice will determine the appropriate charge for providing the requested records and inform the requestor in advance of providing the records. If the requestor agrees to pay the fee in advance, the records will be provided. Otherwise, the records will not be provided, unless the Privacy Officer determines that the charge is burdensome to the requestor.

Illinois law prohibits charges that exceed the following: $20 handling fee plus 75 cents each for pages 1-25, 50 cents each for pages 26-50, and 25 cents each for pages 51 to end; plus actual expenses related to the copying of x-rays, CAT scans, and similar tests. The practice limits charges for records to the amounts allowed under Illinois law.

As permitted by federal regulations, we require that requests to inspect or copy protected health information be submitted in writing. The request should be marked "Attention: Privacy Officer." You may also obtain a form to request access to your records by contacting our medical records personnel or the physician who is responsible for your care.

Individual Rights - Request Amendment to Protected Health Information

The practice allows an individual to request that the practice amend the protected health information maintained in the patient's medical record or the patient's billing record. The practice documents all requests, responds to those requests in a timely fashion, and informs individuals of their appeal rights when a request is denied in whole or in part. Generally the practice will act on a request for amendment no later than 60 days after receipt of such a request. If the practice cannot act on the amendment within 60 days, the practice extends the time for such action by 30 days and, within the 60-day time limit, provides the requestor with a written statement of the reasons for the delay and the date by which the practice will complete action on the request. Only one such extension is allowed.

If the practice denies the request, in whole or in part, the practice provides the requestor with a written denial in a timely fashion. The practice allows a requestor to submit a written statement disagreeing with the denial of all or part of the initial request. The statement must include the basis of the disagreement. The practice limits the length of a statement of disagreement to one page.

The practice accepts requests to amend the PHI maintained by the practice. The requests must be in writing and should be marked "Attention: Privacy Officer."

Individual Rights - Request Confidential Communications

IMPORTANT: If you do not live alone and/or you share a mailing address, telephone, e-mail, voice mail, or other communication device with another person(s) and you do not want these devices used to communicate your personal health information, please let us know so other arrangements can be made. We assume family billing and family communications are acceptable unless you indicate otherwise. The practice considers "family" to be a spouse or a parent of a minor child. In the case of divorced parents, communications concerning the minor child will be given to either parent unless a court order prevents us from disclosing information to one or both of the parents.

A request for confidential communications must be in writing, must specify an alternative address or other method of contact, and must provide information about how payment will be handled. The request must be addressed to the practice's privacy officer. No reason for the request needs to be stated.

The practice accommodates all reasonable requests to keep communications confidential. The reasonableness of a request is determined solely on the basis of the administrative difficulty of complying with the request. The practice will reject a request due to administrative difficulty if no independently verifiable method of communication such as a mailing address or published telephone number is provided for communications, including billing or if the requestor has not provided information as to how payment will be handled.

The practice will not refuse a request if the requestor indicates that the communication will cause endangerment or based on any perception of the merits of the requestor's request.

Individual Rights - Request Restriction of Disclosures

The practice accepts all requests for restrictions of disclosures of protected health information. However, the practice is not required to agree to any restrictions in the use or disclosure of protected health information if the practice feels that a restriction is unlawful or unreasonable.

All requests for restrictions of disclosures must be submitted in writing. They must be sent to the attention of the practice's privacy officer. The privacy officer or her representative will notify the requestor in writing if the practice does not accept requested restrictions of disclosure.

Individual Rights - Authorizations

The practice obtains a written authorization from a patient or the patient's representative for the use or disclosure of protected health information for other than treatment, payment, or health care operations; however, the practice is not required to get an authorization for the use or disclosure of protected health information in certain circumstances as specifically defined under the Privacy Rule. Situations not requiring authorization have been previously outlined in this Notice - see "Use of Disclosures - Not Requiring Authorization". The practice will provide a patient upon request a copy of any authorization initiated by the practice and signed by the patient.

The practice does not condition treatment of a patient on the signing of an authorization, except disclosure necessary to determine payment of claims (excluding authorization for use or disclosure of psychotherapy notes). Also, treatment and other health care that is to be performed solely for the purpose of creating protected health information for disclosure to a third party (e.g., pre-employment or life insurance physicals) will not be performed without a signed authorization.

In Illinois, a specific written authorization is required to disclose or release mental health treatment, alcoholism treatment, drug abuse treatment or HIV/Acquired Immune Deficiency Syndrome (AIDS) information.

The practice allows an individual to revoke an authorization at any time. The revocation must be in writing and must be sent to the attention of the practice's privacy officer; however, in any case the practice will be able to use or disclose the protected health information to the extent the practice has taken action in reliance on the authorization.

Individual Rights - Waiver of Rights

The practice never requires an individual to waive any of his or her individual rights as a condition for the provision of treatment, except under very limited circumstances allowed under the law.

Effective Date

This Notice is effective on or after April 14, 2003.

Receipt of Notice of Privacy Practices Form

I, _________________________________________, hereby acknowledge receipt

(Patient's Name)

of the physician's Notice of Privacy Practices. The Notice of Privacy Practice provides

detailed information about how Marshall Clinic Effingham, S.C. may use and disclose

my confidential information.

I understand that the clinic has reserved the right to change its privacy practices that

are described in the Notice. I also understand that a copy of any Revised Notice will be

provided to me or made available upon request.

Signed: ___________________________ Date: _______________________

If you are not the patient, please specify your relationship

to the patient: ___________________________________

Clinic Witness: _____________________________ Date: ____________________

- cc: Patient's file

PATIENT QUESTIONNAIRE

Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care operations):

____________________________________________________________________

____________________________________________________________________

Please list the family members or significant others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY:

Name _______________________________ Phone Number _______________

Name _______________________________ Phone Number _______________

Please print the address of where you would like your billing statements and/or correspondence from our office to be sent if other than your home.

____________________________________________________________________

____________________________________________________________________

Please indicate if you want all correspondence from our office sent in a sealed envelope marked "CONFIDENTIAL":

YES _______ NO _______

Please print the telephone number where you want to receive calls about your

appointment, lab and x-ray results, or other health care information if other than your

home phone number: ___________________

· I am fully aware that a cell phone is not a secure and private line.

Can confidential messages (i.e., appointment reminders) be left on your telephone answering machine or voicemail?

YES _______ NO _______

PATIENT NAME _______________________________ (guardian if under 18 years)

_______________________________ __________________ _____________

PATIENT/GUARDIAN SIGNATURE Relationship to patient DATE