Ferstl Chiropractic Clinic Privacy Policy 5

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Copyright 2010 Ferstl Chiropractic Clinic, P.C. Web Design and Hosting by MEMNetService (d) Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written request to Ferstl Chiropractic Clinic, PC's Privacy Officer. Ferstl Chiropractic Clinic, PC can charge you a fee for the cost of copying, mailing or other supplies associated with your request. In certain situations that are defined by law, Ferstl Chiropractic Clinic, PC may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written denial notice. (e) Amend your PHI as provided by law. To request an amendment, you must submit a written request to Ferstl Chiropractic Clinic, PC's Privacy Officer. You must provide a reason that supports your request. Ferstl Chiropractic Clinic, PC may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by Ferstl Chiropractic Clinic, PC (unless the individual or entity that created file information is no longer available), if the information is not part of your PHI maintained by Ferstl Chiropractic Clinic, PC, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with Ferstl Chiropractic Clinic, PC's denial, you will have the right to submit a written statement of disagreement. (f) Receive an accounting of disclosures of your PHI as provided by law. To request an accounting, you must submit a written request to Ferstl Chiropractic Clinic, PC's Privacy Officer. The request must state a time period, which may not be longer than six (6) years and may not include dates before April 14, 2003. The request should indicate in what form you want the list (such as a paper or electronic copy); The first list you request within a twelve- (12) month period will be free, but Ferstl Chiropractic Clinic, PC may charge you for the cost of providing additional lists. Ferstl Chiropractic Clinic, PC will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred. (g) Receive a paper copy of this Privacy Notice from Ferstl Chiropractic Clinic, PC upon request to Ferstl Chiropractic Clinic, PC's Privacy Officer. (h) Complain to Ferstl Chiropractic Clinic, PC or to the Secretary of HHS if you believe your privacy rights have been violated. To file a complaint with Ferstl Chiropractic Clinic, PC, you must contact Ferstl Chiropractic Clinic, PC's Privacy Officer. All complaints must be in writing. (i) To obtain more information on, or have your questions about your rights answered, you may contact Ferstl Chiropractic Clinic, PC's Privacy Officer, Joseph F. Ferstl, at 847-741-3355 or via e-mail at info@ferstlchiropractic.com. PRACTICE'S REQUIREMENTS 1. Ferstl Chiropractic Clinic, PC: (a) Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing Ferstl Chiropractic Clinic, PC's legal duties and privacy practices with respect to your PHI. -5-

Privacy Policy Ferstl Chiropractic Clinic, P.C. If you have any questions regarding our privacy policies, please feel free to contact us during regular business hours. Joseph F Ferstl DC FACO Director at Large, Illinois Chiropractic Society Second Vice President American College of Chiropractic Orthopedics 1557 Weatherstone Ln Elgin IL 60123 847-741-3355 847-741-3597 fax info@ferstlchiropractic.co m