ASSOCIATES IN PRIMARY CARE, P.A.
25 East Willow Street
Millburn, New Jersey 07041
Phone #: 973-379-5055 Fax #: 973-379-5324

NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THISINFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this Notice please contact
our Privacy Officer who is Allison Xenakis.
This Notice of Privacy Practices describes how we may use and disclose your protected healthinformation to carry out treatment, payment or health care operations and for other purposes thatare permitted or required by law. It also describes your rights to access and control yourprotected health information. “Protected health information” is information about you, including
demographic information, that may identify you and that relates to your past, present or future
physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change theterms of our notice, at any time. The new notice will be effective for all protected healthinformation that we maintain at that time. Upon your request, we will provide you with any
revised or updated Notice of Privacy Practices. You may request a revised version by calling theoffice and requesting that a revised copy be sent to you in the mail or asking for one at the timeof your next appointment.
1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATIONYour protected health information may be used and disclosed by your physician, our office staff
and others outside of our office who are involved in your care and treatment for the purpose ofproviding health care services to you. Your protected health information may also be used anddisclosed to pay your health care bills and to support the operation of your physician’s practice.
Following are examples of the types of uses and disclosures of your protected health informationthat your physician’s office is permitted to make. These examples meant to describe the types ofuses and disclosures that may be made by our office. This is not an exhaustive list and there may
be permitted uses and disclosures that are not listed below.
Treatment: We will use and disclose your protected health information to provide, coordinate,
or manage your health care and any related services, including coordination and management of
your health care with another provider. For example, we would disclose your protected healthinformation, as necessary, to a home health agency that provides care to you or other physicians

who may be treating you. Your protected health information may be provided to a physician towhom you have been referred to ensure that the physician has the necessary information todiagnose or treat you. In addition, we may disclose your protected health information from time totime to another physician or health care provider (e.g., a specialist or laboratory) who, at therequest of your physician, becomes involved in your care by providing assistance with yourhealth care diagnosis or treatment to your physician.
Payment: Your protected health information will be used and disclosed, as needed, to obtain
payment for your health care services provided by us or other providers. This may include
certain activities that your health insurance plan may undertake before it approves or pays for thehealth care services we recommend for you such as: making a determination of eligibility or
coverage for insurance benefits, reviewing services provided to you for medical necessity, andundertaking utilization review activities. For example, obtaining approval for a hospital stay
may require that your relevant protected health information be disclosed to the health plan toobtain approval for that stay.
Health Care Operations: We may use or disclose, as needed, your protected health informationin order to support the business activities of your physician’s practice. These activities include,
but are not limited to, quality assessment activities, employee review activities, training of
medical students, licensing, fundraising activities, and conducting or arranging for other businessactivities.
We will share your protected health information with third party “business associates” that
perform various services (for example, billing or transcription services) for our practice.
Whenever an arrangement between our office and a business associate involves the use or
disclosure of your protected health information, we will have a written contract that contains
terms to protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you withinformation about treatment alternatives or other health-related benefits and services that may beof interest to you. You may contact our Privacy Officer to request that these materials not besent to you.
We may use or disclose your demographic information and the dates that you received treatment
from your physician, as necessary, in order to contact you for fundraising activities supported byour office. If you do not want to receive these materials, please contact our Privacy Officer andrequest that these materials not be sent to you.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your
Authorization or Opportunity to Agree or Object:
We may use or disclose your protected health information in the following situations without
your authorization or providing you the opportunity to agree or object. These situations include:
Required By Law: We may use or disclose your protected health information to the extent thatthe use or disclosure is required by law. The use or disclosure will be made in compliance withthe law and will be limited to the relevant requirements of the law. You will be notified, if
required by law, of any such uses or disclosures. Such disclosures include, but are not limited to:Legal Proceedings: We may disclose protected health information in the course of any
judicial or administrative proceeding, in response to an order of a court or administrative
tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in
response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as
applicable legal requirements are met, for law enforcement purposes. These law
enforcement purposes include (1) legal processes and otherwise required by law,(2) limited information requests for identification and location purposes, (3) pertaining tovictims of a crime, (4) suspicion that death has occurred as a result of criminal conduct,(5) in the event that a crime occurs on the premises of our practice, and (6) medical
emergency (not on our practice’s premises) and it is likely that a crime has occurred.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose
your protected health information, if we believe that the use or disclosure is necessary to
prevent or lessen a serious and imminent threat to the health or safety of a person or the
public. We may also disclose protected health information if it is necessary for law
enforcement authorities to identify or apprehend an individual.
Abuse or Neglect: We may disclose your protected health information to a public healthauthority that is authorized by law to receive reports of child abuse or neglect. In
addition, we may disclose your protected health information if we believe that you havebeen a victim of abuse, neglect or domestic violence to the governmental entity or agency
authorized to receive such information. In this case, the disclosure will be madeconsistent with the requirements of applicable federal and state laws.
Public Health: We may disclose your protected health information for public health purposes toa public health authority that is permitted by law to collect and/or receive the information. For
example, a disclosure may be made for the purpose of preventing or controlling disease, injury or
disability.
Communicable Diseases: We may disclose your protected health information, if authorized bylaw, to a person who may have been exposed to a communicable disease or may otherwise be atrisk of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight agency
for activities authorized by law, such as audits, investigations, and inspections. Oversightagencies seeking this information include government agencies that oversee the health caresystem, government benefit programs, other government regulatory programs and civil rights
laws.
Food and Drug Administration: We may disclose your protected health information to aperson or company required by the Food and Drug Administration for the purpose of quality,
safety, or effectiveness of FDA-regulated products or activities including, to report adverse
events, product defects or problems, biologic product deviations, to track products; to enableproduct recalls; to make repairs or replacements, or to conduct post marketing surveillance, as
required.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected healthinformation to a coroner or medical examiner for identification purposes, determining cause ofdeath or for the coroner or medical examiner to perform other duties authorized by law. We may
also disclose protected health information to a funeral director, as authorized by law, in order topermit the funeral director to carry out their duties. We may disclose such information inreasonable anticipation of death. Protected health information may also be used and disclosed
for cadaveric organ, eye or tissue donation purposes.
Research: We may disclose your protected health information to researchers when theirresearch has been approved by an institutional review board that has reviewed the research
proposal and established protocols to ensure the privacy of your protected health information.
Military Activity and National Security: When the appropriate conditions apply, we may use
or disclose protected health information of individuals who are Armed Forces personnel (1) for
activities deemed necessary by appropriate military command authorities; (2) for the purpose ofa determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) toforeign military authority if you are a member of that foreign military services. We may also
disclose your protected health information to authorized federal officials for conducting national
security and intelligence activities, including for the provision of protective services to the
President or others legally authorized.
Workers’ Compensation: We may disclose your protected health information as authorized tocomply with workers’ compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of acorrectional facility and your physician created or received your protected health information in
the course of providing care to you.
Uses and Disclosures of Protected Health Information Based upon Your Written
Authorization:
Other uses and disclosures of your protected health information will be made only with yourwritten authorization, unless otherwise permitted or required by law. You may revoke thisauthorization in writing at any time. If you revoke your authorization, we will no longer use or
disclose your protected health information for the reasons covered by your written authorization.
Please understand that we are unable to take back any disclosures already made with yourauthorization.
Other Permitted and Required Uses and Disclosures That Require Providing You theOpportunity to Agree or Object:
We may use and disclose your protected health information in the following instances. You havethe opportunity to agree or object to the use or disclosure of all or part of your protected healthinformation. If you are not present or able to agree or object to the use or disclosure of theprotected health information, then your physician may, using professional judgment, determine
whether the disclosure is in your best interest.
Others Involved in Your Health Care or Payment for Your Care: Unless you object, we
may disclose to a member of your family, a relative, a close friend or any other person you
identify, your protected health information that directly relates to that person’s involvement inyour health care. If you are unable to agree or object to such a disclosure, we may disclose such

information as necessary if we determine that it is in your best interest based on our professional
judgment. We may use or disclose protected health information to notify or assist in notifying afamily member, personal representative or any other person that is responsible for your care ofyour location, general condition or death. We may also use or disclose your protected healthinformation to an authorized public or private entity to assist in disaster relief efforts and tocoordinate uses and disclosures to family or other individuals involved in your health care.
2. YOUR RIGHTS
Following is a statement of your rights with respect to your protected health information.
You Have the Right to Inspect and Copy Your Protected Health Information. This means
you may inspect and obtain a copy of protected health information about you for so long as we
maintain the protected health information. You may obtain your medical record that contains
medical and billing records and any other records that your physician and the practice uses formaking decisions about you. As permitted by federal or state law, we may charge you areasonable copy fee for a copy of your records.
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 laboratory results that are subject to law that prohibits
access to protected health information. Depending on the circumstances, a decision to denyaccess may be reviewable. In some circumstances, you may have a right to have this decision
reviewed. Please contact our Privacy Officer if you have questions about access to your medical
record.
You Have the Right to Request a Restriction of Your Protected Health Information. Thismeans you may ask us not to use or disclose any part of your protected health information for the
purposes of treatment, payment or health care operations. You may also request that any part ofyour protected health information 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 your physician
does agree to the requested restriction, we may not use or disclose your protected healthinformation in violation of that restriction unless it is needed to provide emergency treatment.
With this in mind, please discuss any restriction you wish to request with your physician. You
may seek a restriction by making a written request to our Privacy Officer.
You Have The Right to Request to Receive Confidential Communications From us By
Alternative Means or at an Alternative Location. We will accommodate reasonable requests.
We may also condition this accommodation by asking you for information as to how payment
will be handled or specification of an alternative address or other method of contact. We will not
request an explanation from you as to the basis for the request. Please make this request in
writing to our Privacy Officer.
You May Have The Right to Have Your Physician Amend Your Protected Health
Information. This means you may request an amendment of protected health information about

you in a designated record set for so long as we maintain this information. In certain cases, we
may deny your request for an amendment. If we deny your request for amendment, you have theright 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. Please contact our Privacy Officer if you
have questions about amending your medical record.
You Have The Right to Receive an Accounting of Certain Disclosures we Have Made, if
Any, of Your Protected Health Information. This right applies to disclosures for purposes
other than treatment, payment or health care operations as described in this Notice of Privacy
Practices. It excludes disclosures we may have made to you if you authorized us to make thedisclosure, for a facility directory, to family members or friends involved in your care, or for
notification purposes, for national security or intelligence, to law enforcement (as provided in theprivacy rule) or correctional facilities, as part of a limited data set disclosure. You have the rightto receive specific information regarding these disclosures that occur after April 14, 2003. The
right to receive this information is subject to certain exceptions, restrictions and limitations.
You Have The Right to Obtain a Paper Copy of This Notice From us, upon request, even if
you have agreed to accept this notice electronically.
3. COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you believe yourprivacy rights have been violated by us. You may file a complaint with us by notifying ourPrivacy Officer of your complaint. We will not retaliate against you for filing a complaint.
You may contact our Privacy Officer, Allison Xenakis at (973) 379- 5055 forfurther information about the complaint process.
This notice was published and becomes effective on May 23, 2013.
This document was produced by: