Grady Baccus

1. Introduction to our Clients
This notice has been formulated to inform you about how we handle the information we have about you. It explains how we use
this information in our office, how we share it with other professionals and organizations, and how you can see it. It is
important to us that you know this so that you can make the very best decisions for yourself and your family. We are also
required to inform you of this because of the Federal Law surrounding Privacy regulations. The Health Insurance Portability
and Accountability Act of 1996 (HIPAA).

This law can be complicated to understand. We have simplified it as much as possible to give you the best opportunity to
understand it and we again invite you to contact our Privacy Officer should you require more explanation or clarification.
privacy@gradybaccus.com

2. What we mean when we say 'your medical information'
Each time you visit Dr. Baccus or any doctor's office, hospital, clinic or any other healthcare provider, information is collected
about you and your mental health. In some cases it is information about your past, present, or future health or conditions. It
could be about the treatment or other services you received from us or others, or about payment for healthcare. The
information we collect from you is referred to as "Protected Health Information" and this information goes into your medical or
healthcare record on file at our office.

The protected health information we hold on file is likely to include information such as:
o Your history as a child, in school and at work.
o Marital and personal history
o The reason you came to us for treatment, and any concerns, problems, goals or needs you have
o Diagnoses. Which is the medical term for the symptoms or problems you have
o Treatment Plan. Being a record or the treatments or other services we have recommended to help you
o Progressive Notes taken at each of your visits that detail how you are responding, any observations we have and of course,
anything you tell us.
o Records that other providers have made available of their evaluation
o Psychological test scores or school records
o Details of any medication you have or are taking
o Any legal matters that relate to you
o Billing and Insurance information

The list above is designed to give you an idea of the types of information that goes to make up your healthcare record in our
office.

Some of the purposes that we may use your informaton for:
o To plan your care and treatment
o To assess how well our treatment is working for you
o As reference when we have discussions with other healthcare professionals who are treating you, or perhaps the professional
who referred you to us
o For verification of the services that we have provided that we billed you or your health insurance company for
o For teaching or training other healthcare professionals
o For Medical or Psychological research
o For public health care officials trying to make improvements
o For continuous improvement of the effectiveness of our services

Having an understanding of what is in your record and how that information is used, will help you to make better decisions
regarding who, when or why others should also have this information.

Although your health record is the physical property of the healthcare provider or facility that collected it, the information
belongs to you. You can inspect, read or review it. Should you want, a copy can be made for you, however, we may charge
costs for copying and sending the information to you.

In some rare instances, you may not be able to see all of what is in your records, if you find anything in your records that you
feel is incorrect. Or if something important is missing, you can ask us to make amendments and add information to your record.
Again there are some rare occasions where we do not have to agree to do that. Further explanation can be gained from our
Privacy Officer.

3. Privacy and the Laws about Privacy
The HIPAA Privacy Rule requires that we keep your PHI private and that we give you this notice of our legal duties and privacy
practices, referred to as the 'Notice of Privacy Practices' (NFP). We will obey the rules of this notice as long as it is in effect,
and if we change it, the rules of the new NFP will apply to the entire PHI we keep. If we do change the notice, the new one will
be posted in our office where everyone can see. You, or anyone else can obtain a copy from our Privacy Officer at any time and
it is also posted on our website at www.gradybaccus.com

4. How your protected health information (PHI) can be used and shared
Whenever your information is read by Dr.Baccus or anyone else in our office, this is called 'use' by definition of the Law. Should
your information be shared with or sent to anyone outside our office that is referred to as 'disclosure'. Except in some special
and cases when we use your PHI here or disclose it to others, we do so by sharing only the minimum necessary PHI that is
required to fulfill the purpose.

Within the Law you have rights to know about how your PHI is used and to have input into how it is disclosed. Therefore we will
tell you more about what we do with your information.

We use and disclose PHI for several reasons. Mostly we will use and disclose (share) information for routine purposes that we will
explain more of later. For other uses however, we must inform you and have written Authorization. An exception is when the
law states that we can make some disclosures and uses without your consent of authorization.

5. Uses and disclosures of your PHI with your consent
After you have read this notice you will be asked to sign a consent form that allows us to use and share your PHI. In almost all
cases we intend to use your PHI here or to share your PHI with other people in organizations to provide treatment to you,
arrange payment for our services to you, or some other business functions that are called health care operations. Together
these routine purposes are called TPO and the consent form allows us to use and disclose your PHI for TPO. It is best that you
read over that last statement again to be sure you understand it as it is very important.

6. Basic uses and disclosures for treatment, payment and health care operations (TPO)
We need information about you and your condition to provide care to you. To do this, you have to agree to let us collect the
information and to use it and share it as necessary to care for you properly. You must sign the consent form before we
commence working with you because if you do not agree and consent then we are unable to be of any assistance to you.
Any time you visit with Dr. Baccus either he or another member of staff may collect information about you and all of it may go
into your healthcare records with us. Generally we may disclose your PHI for three (3) purposes. For treatment, obtaining
payment, and for healthcare operations.

For Treatment
We use your information to provide you with psychological treatment or services. These might include individual, family or
group therapy, psychological, educational or vocational testing, treatment planning or measuring the effects of our services.

We may share or disclose your PHI to others who provide treatment to you. We are likely to share your personal information
with your personal physician. If your treatment is being administered by more than one entity we can share some of your PHI
with them so that the services you receive will be coordinated. They will also enter their findings, actions they took, and their
plans into your record so collaborative decisions can be made on which treatments work best for you in order to make up your
treatment plan.

These examples are provided so that you can see how we use and disclose your PHI for treatment.

For Payment
We may use your information to bill you, your insurance, or others to be paid for the treatment we provide to you. We may
contact your insurance company to check on exactly what your insurance covers. We may have to tell them about your
diagnoses, what treatments you have received, and what we expect as we treat you. We will need to tell them about when we
met, your progress, and other similar things.

For Health Care Operations
There are some other ways we may use or disclose your PHI which are called health care operations. As an example, we may be
required to supply some information to some government health agencies so they can study disorders and treatment and make
plans for services that are needed. If we do, your name and identity will be removed from what we send, except in the case that
the agency has referred you to Dr. Baccus in the first instance.

7. Other uses and disclosures in health care

Appointment Reminders: We may use and disclose medical information to reschedule or remind you of appointments for
treatment or other care. If you want us to call or write to you only at your home or your work or if you prefer alternative
methods of reaching you, we can usually arrange that if you give us sufficient notification.

Treatment Alternatives: We may use and disclose your PHI to tell you about or recommend possible treatments, benefits,
services or alternatives that may be of interest to you.

Research: We may use or share your information for the purpose of research or treatment improvements. As an example; we
may compare two treatments for the same disorder to see which works better, faster or costs less. In all cases your name,
address and other information that reveals who you are will be removed from the information supplied to researchers. If we
should need to know who you are, we will contact you, and explain the project to you and have you sign a separate special
authorization form before any information is shared.
Business Associates: There are some aspects of the facilitation of our services for which we hire other personnel to perform for
us. In the scope of the law these people are called our Business Associates. An example of a 'Business Associate' would be a
service that we might use to make copies of your health record, or a billing service you calculates, prints and mails our bills for
services. For these people to be able to perform these tasks, they need to receive some of your PHI to do so. As a safeguard for
your information these associates have agreed in their contract with us to adhere to the same privacy protections as we are
outlining for you here.

8. Uses and disclosures that require your Authorization
If an occasion should arise where we wish to use your information for any purpose besides the TPO or those that are described
above, we need your permission on an Authorization Form. It is our expectation that such occasions will be very rare. If you do
authorize us to use or disclose your PHI, you can also revoke, or cancel that permission. You would do so, by advising us in
writing at any time. When we receive such a cancellation we will not disclose your information for the purpose that we agreed
to, however it will be impossible to take back any information that has already been disclosed while your permission was in
place.

9. Uses and disclosures where your Authorization is not required
There are parameters of the Law that allow us to use and disclose some of your PHI without your consent or authorization such
as:
When required by law
There are some federal, state, or local laws that require us to disclose PHI
o We are obligated to report suspected child abuse
o If you are involved in a lawsuit or legal proceeding, and we receive a subpoena, discovery request, or other lawful process, we
may require the releasing some of your PHI. We will only do so after making attempts to advise you of the request, consulting
your lawyer, or making attempts to obtain a court order to protect your information.
o We will be required to release some of your information to the Government Agencies who check our adherence and compliance
with the Privacy laws.
For Law Enforcement Purposes
We may release or disclose if a request is made of us to do so, by a law enforcement official to investigate a crime or criminal.
For Public Health Activities
We may disclose some of your PHI to agencies that investigate diseases or injuries as relevant.
Relating to descendents
We might disclose PHI to coroners, medical examiners or funeral directors, or to organizations relating to organ, eye, or tissue
donations or transplants.
For specific Government functions
We may disclose PHI of military personnel and veterans to Government benefit programs relating to eligibility and enrollment, to
Workers' Compensation programs, to correctional facilities if you are an inmate, and for national security reasons.
To prevent a serious threat to health or safety
If we come to believe that there is a serious threat to your health or safety or that of another person, or the public generally,
we can disclose some of your PHI. We will only do this to persons who can divert or prevent this danger.

10. Uses and disclosures that require you to have an opportunity to object
We can share some information about you with your family or persons who are close to you. WE will only share information with
those involved with your case and anyone else you choose, such as close friends or clergy. We will ask you about who you want
us to supply information with as well as what information you want shared about your condition or treatment. You can tell us
what you want and we will honor your wishes as long as it is not against the law.

In the event of an emergency, where we cannot ask you if you disagree, we can share information if we believe that it is what
you would have wanted and if we believe it will help you if we do share it. If we do share information in an emergency, we will tell
you as soon as we are able. Should you then advise us that you do not approve we will stop, providing it is not against the law.

11. An accounting of disclosures
When we disclose you PHI we keep records of whom we have provided it to, when we provided it, and what we have provided.
The accountings (lists) of many of these disclosures can be made available to you.

12. How to direct your questions and concerns
If you need more information or if you have questions about the privacy practices described above, please make contact with
the Privacy Officer whose name is listed below. If you have a concern with how your PHI has been handled or if you believe your
privacy rights have been violated contact the Privacy Officer.

You have the right to file a complaint with us and with the Secretary of the Federal Department of Health and Human Services.
We give you our assurances that we will not in any way limit your care here or take any actions against you should you make a
complaint.

If you have any questions regarding this notice or our health information privacy policies please contact Diane King, who is our
Privacy Officer. Diane can be reached by phone at (614) 888 5133 or by email to privacy@gradybaccus.com

The effective date of this notice is April 14, 2003
� Copyright 2003 by Diane King