NOTICE OF PRIVACY PRACTICES

(Effective April 14, 2003)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS INFORMATION CAREFULLY.

Note: If you have questions about this Notice, please contact the Privacy Officer at The Galesburg Clinic, P.C. That person may be contacted at 309-344-1000.

WHO WILL FOLLOW THIS NOTICE:

This notice describes the privacy practices of The Galesburg Clinic, P.C., its employees and staff, and its affiliated entities. A list of the entities that are covered by this Notice is attached to the Notice. “We” and The Galesburg Clinic, P.C., as used in this Notice refer to The Galesburg Clinic, P.C., and all of the listed affiliated entities and to all offices where The Galesburg Clinic, P.C., and the other listed entities provide services to you.

All of The Galesburg Clinic, P.C., physicians and staff may have access to information in your chart for treatment, payment and health care operations, and may use and disclose information as described in this Notice. This Notice also applies to any volunteer or trainee we allow to help you while seeking services at The Galesburg Clinic, P.C. and any of its locations.

OUR PLEDGE REGARDING THE PRIVACY OF YOUR MEDICAL INFORMATION:

Your medical information includes information about your physical and mental health. We understand that information about your physical and mental health is personal. The Galesburg Clinic, P.C. is committed to protecting medical information about you. We create a record of the care and services you receive at any Galesburg Clinic office. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to any and all of the records of your care generated by The Galesburg Clinic, P.C. and any of its offices.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We reserve the right to revise or amend our Notice of privacy practices without additional Notice to you. Any revision or amendment to this Notice will be effective for all of your records our practice has created or maintained in the past, and for any of your records we may create or maintain in the future. The Galesburg Clinic, P.C. will post a copy of our current Notice and any amended Notice in our offices in a prominent place and will post any such Notice on our web site.

OUR OBLIGATIONS TO YOU

We are required by law to:

§ make sure that medical information that identifies you is kept private except as otherwise provided by state or federal law;

§ give you this Notice of our legal duties and privacy practices with respect to medical information about you; and

§ follow the terms of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:

The following categories describe the different ways that we may use and disclose medical information about you without your consent or authorization. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. This Notice covers treatment, payment, and what are called health care operations, as discussed below. It also covers other uses and disclosures for which a consent or authorization are not necessary. Where applicable state law is more protective of your medical information, we will follow state law, as explained below.

For Treatment. We may use medical information about you to provide you with medical treatment or services without consent or authorization unless otherwise required by applicable state law. We may disclose medical information about you to doctors, nurses, medical students, pharmacists or other health care providers who are involved in taking care of you whether or not they are affiliated with The Galesburg Clinic, P.C. For example, we may disclose medical information concerning you to St. Mary Medical Center, Galesburg Cottage Hospital, other medical clinics in and out of Galesburg, as well as to any other entity that has provided or will provide care to you. The Galesburg Clinic, P.C. will disclose psychotherapy notes only with a specific authorization signed by you or your legal representative. The Galesburg Clinic, P.C., will disclose other mental health treatment records, AIDS or HIV-related information, or substance abuse treatment information only with written authorization as required by applicable state law and/or federal regulation.

During the course of your treatment with The Galesburg Clinic, P.C. we may refer you to other health care providers such as radiologists or independent laboratories with which you may not have direct patient contact. These providers are called “indirect treatment providers.” “Indirect treatment providers” are required to maintain and comply with the privacy requirements of state and federal law and keep your medical information confidential.

For Payment. We may use and disclose medical information about you without consent or authorization so that the treatment and services you receive at The Galesburg Clinic, P.C. may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your information about treatment received so your Health Plan will pay us or reimburse you for the treatment. We may also tell your Health Plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. We may use and disclosed medical information about you without consent or authorization for “health care operations”. These uses and disclosures are necessary to operate The Galesburg Clinic, P.C., and make sure that all of our patients receive quality care. For example, we may use medical information or mental health treatment information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose your protected health information to doctors, nurses, medical students and other Galesburg Clinic employees or consultants for review and learning purposes.

Appointment Reminders. Unless you tell us otherwise in writing, we may use and disclose medical information to contact you to remind you that you have an appointment for treatment.

Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. However, we will not use or disclose medical information to market other products or services, either ours or those of third parties, without your authorization.

Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. We may release medical information, including mental health information, about you to a family member who is involved in your medical care without consent or authorization if the individual’s involvement is related to such information. We may also give medical information, including prescription information or information concerning your appointments to friends who are involved in your care. We may also give such information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

As Required By Law.

We will disclose medical information about you when required to do so by federal, state or local law without your consent or authorization.

To Avert a Serious Threat to Health or Safety.

We may disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

To Business Associates.

The Galesburg Clinic, P.C. from time to time will hire “business associates”, who render services to The Galesburg Clinic, P.C. We may disclose your medical information to such business associates without your consent or authorization. Business associates are required to maintain and comply with the privacy requirements of state and federal law and keep your medical information confidential. Examples of “business associates” are accounting firms that we hire to perform audits of billing and payment information, and computer software vendors who assist The Galesburg Clinic, P.C. in maintaining and processing medical information.

For Research.

From time to time The Galesburg Clinic, P.C. participates in research studies with entities such as drug companies. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. Before we use or disclose medical information for research, the project will have been approved through a research approval process required by federal law. We may disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs as permitted by federal law. As a general rule, we will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are. We will also comply with all other requirements under federal law to seek your written authorization to disclose protected health information in connection with research studies.

Military and Veterans.

If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Worker’s Compensation.

We may release medical information about you for worker’s compensation or similar programs without consent or authorization. These programs provide benefits for work-related injuries or illnesses. For example, if you are injured on the job, we may release information regarding that specific injury.

Public Health Risks.

We may disclose medical information about you for public health activities without your consent or authorization. These activities generally include the following:

§ to prevent or control disease, injury or disability;

§ to report reactions to medications or problems with products;

§ to notify people of recalls of products they may be using;

§ to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

§ to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when disclosure is required or authorized by law.

Health Oversight Activities.

We may disclose medical information to a health oversight agency, such as the Department of Health and Human Services, for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Administrative Proceedings. If you are involved in a lawsuit or dispute as a party, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in a response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute. In addition, we may disclose medical information, including mental health treatment information, AIDS or HIV-related information or substance abuse treatment information, to the opposing party in any lawsuit or administrative proceeding where you have put your physical or mental condition at issue once you have signed a written authorization to release information. Similarly, we may disclose medical information about you in proceedings where you are not a party, but only if efforts have been made to tell you or your attorney about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release medical information, excluding mental health information, if asked to do so by a law enforcement official:

§ in response to a court order, subpoena, warrant, summons or similar process;

§ to identify or locate a suspect, fugitive, material witness, or missing person;

§ about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;

§ about a death we believe may be the result of criminal conduct;

§ about criminal conduct at The Galesburg Clinic, P.C., and;

§ in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release medical information including mental health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others; or 3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU:

You have the following rights regarding medical information we maintain about you:

Right to Inspect and/or Request a Copy. You have the right to inspect and/or request a copy of your medical information that may be used to make decisions about your care which is contained in a data set designated by The Galesburg Clinic, P.C. Usually this includes medical and billing records, but does not include psychotherapy notes.

If you wish to be provided a copy of medical information that may be used to make decisions about you, you must submit your request in writing to The Galesburg Clinic, P.C., Attn: Medical Records, 3315 N. Seminary, Galesburg, IL 61401. Their telephone number is 309-344-1000. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing and or other supplies associated with your request. If you wish to inspect your records, we may charge a reasonable fee for the inspection that reflects staff time in pulling the records and participating in the inspection.

We may deny your request to inspect and/or obtain a copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by The Galesburg Clinic, P.C., will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Request Amendment. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for The Galesburg Clinic, P.C., and is contained in The Galesburg Clinic, P.C. designated record set, which usually includes medical and billing records, but does not include psychotherapy notes.

To request an amendment, you will need to contact the Privacy Officer so that a Health Information Request for Amendment Form can be mailed to you. The form will need to be completely filled out and returned to the Privacy Officer. You must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

§ was not created by us, unless the person or entity that created the information is no longer available to make that amendment.

§ is not part of the medical information kept by The Galesburg Clinic, P.C.

§ is not part of the information which you would be permitted to inspect and copy; or

§ is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we have made of medical information about you that are not disclosures for treatment, payment and health care operations.

To request this list or accounting of disclosures, you must submit your request to the Privacy Officer so that a Health Information Request for Accounting of Disclosure Form can be mailed to you. This form will need to be completely filled out and returned to the Privacy Officer, The Galesburg Clinic, P.C., 3315 N. Seminary Street, Galesburg, IL 61401. Your request must state a time period which commences on April 15, 2003 and which may not be longer than six years. Your request will be provided to you on paper. The first accounting of disclosures you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you may request that your spouse or child who is involved in your care not receive certain information about your condition.

We are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to the Privacy Officer, The Galesburg Clinic, P.C., 3315 N. Seminary Street, Galesburg, IL 61401. In your request, you must tell us 1) what information you want to limit; 2) whether you want to limit our use, disclosure, or both; and 3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Privacy Officer, The Galesburg Clinic, P.C., 3315 N. Seminary Street, Galesburg, IL 61401. We will not ask the reason for your request. We will accommodate all requests that The Galesburg Clinic, P.C., in its discretion, determines to be reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of this Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice or any amended Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.

You may obtain a copy of the Notice or Amended Notice at any of the locations of The Galesburg Clinic, P.C.

COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with The Galesburg Clinic, P.C., or with the Secretary of the Department of Health and Human Services. To file a complaint with The Galesburg Clinic, P.C., contact the Galesburg Clinic, P.C., Administration Department or submit your complaint in writing to Administration. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION. Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with our written permission as set out in an authorization signed by you. If you provide us permission to use or disclose medical information about you, you may revoke that permission at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. While we will do our best to comply with oral requests to revoke, revocation may not be effective until we receive a right to revoke in writing. The written request should be made to The Galesburg Clinic, P.C., Medical Records, 3315 N. Seminary, Galesburg, IL 61401. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

The Galesburg Clinic, P.C., Affiliated Entities and Offices