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Life Or Sports, We Get You Back In The Game. SM
Privacy Policy

5. The Right to Receive an Accounting of Disclosures of Protected Health Information.You have the right to request an accounting of disclosures of your protected health information made by us. This right applies to disclosures made by us except for disclosures: to carry out treatment, payment, or health care operations as described in this Notice or incidental to such use; to you or your personal representatives; pursuant to your authorization; for our directory, or other notification purposes, or to persons involved in your care; or for certain other disclosures we are permitted to make without your authorization. Requests for disclosure of accounting must specify a time period sought for the accounting, with the maximum time period being six years prior to the date of the request. We are not required to provide accounting for disclosures made before April 14,2003. We will provide the first disclosure accounting you request during any 12-month period without charge.

Subsequent disclosure accounting request will be subject to a reasonable cost-based fee.
6. The Right to Obtain a Paper Copy of this Notice. Upon request, we will provide a paper copy of this notice.

Your Rights Regarding Your Protected Health Information
We are required by law to maintain the privacy of your health information and to provide you with this Privacy Notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of the Notice currently in effect. We reserve the right to change the terms of this Notice and to make any new provisions effective for all protected health information that we maintain. If we change the Notice, we will provide a copy of the revised notice through in-person contact.

Your Rights Regarding Your Protected Health Information
You have the right to express complaints to us and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. If you wish to complain to us, please do so in writing, and direct your complaint to the Privacy Officer. You will not be penalized for filing a complaint.

Contact Information
PLEASE CONTACT THE PRIVACY OFFICER AT THE SITE YOUR SERVICES WERE GIVEN Effective Date This Notice is effective April 14, 2003. (Signature of patient or responsible party - Date).