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

Uses and Disclosures

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 insurer or other entity responsible for payment. 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-t-

-day activities and management of the iPT. For example, information on the services you received

may be used to support budgeting and financial reporting, and activities to evaluate and promote

quality as statistic not by name.

Law Enforcement. Your health information may be disclosed to law enforcement agencies

to support government audits and inspections, to facilitate law-enforcement investigations and

to comply with government mandated reporting.

Public Health Reporting. Your health information may be disclosed to public health agencies as

requirement by law. For example, we are required to report certain communicable diseases to the

state’s public health department.

Other uses and disclosures require your 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 that 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 to

revoke your authorization.

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 copy 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 health information has been

disclosed

The right to receive a printed copy of this notice

iPT Duties

We are required by law to maintain the privacy of your protected health information and to provide

you with this notice of privacy practices.

We also are required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and

practices. These changes in our policies and practices may be required by changes in federal

and/or states laws and regulations. Upon request, we will provide you with the most recently

revised notice on any office visit. The revised policies and practices will be applied to all

protected health information we maintain.

Requests to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we maintain. As permitted

by federal regulation, we require that requests to inspect or copy protected health information be

submitted in writing. You may obtain a form to request access to your records by contacting iPT Your

request will be reviewed and will generally be approved unless there are legal or medical reasons to

deny the request.

Complaints

If you would like to submit a complaint about our privacy practices, you can do so by sending a letter

outlining your concerns to:

iPT

326 Hance Road

Fair Haven, New Jersey 07704

If you believe that your privacy rights have been violated, you should call the matter to our attention

by sending a letter describing the cause of your concern to the same address. You will not be

penalized or otherwise retaliated against for filing a complaint.

Contact Person

The name and address of the person you can contact for further information concerning our privacy

practices is:

iPT

326 Hance Road

Fair Haven, New Jersey 07704

646-397-7869

Effective Date

This notice is effective on or after June 19, 2013.

Acknowledgement of Receipt of Notice of Privacy Practices iPT reserves the right to modify the

privacy practices outlined in the notice.