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 our physicians and staff members or disclosed to
other health care professionals for the purpose of evaluating your health, diagnosing medical
conditions, and providing treatment.

Payment. Your health information may be used to seek payment from your health plan, other sources
of coverage such as an automobile insurer, or credit card companies that you may use to pay for
services. 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-to-day
activities and management of Birchwood Women's Health. For example, information on the
services you received may be used to support budgeting and financial reporting and activities to
evaluate and promote quality to insure that our practice is meeting state and federal guidelines and
laws designated to protect your health care information.

Law Enforcement. Your health information may be disclosed to law enforcement agencies, without
your permission, 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
required by law. For example, our practice is required to report certain communicable diseases to the
State of Washington Department of Health.

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 the 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.

Additional uses of information.

Appointment reminders. Your health information will be used by our staff to call/send you
appointment reminders.

Information about treatments. Your health information may be used to send you information on

treatment and management of your medical condition that you may find to be of interest. We may also

send you information describing other health-related goods and services that we believe may interest you.

Individual Rights

You have certain rights under the federal privacy standards. These include:

•  the right to request restrictions on me 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 request an amendment or submit corrections to your protected health

•  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

Birchwood Women's Health 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 are also 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 state laws and
regulations. Whatever the reason for these revisions, we will provide you with a revised notice on
your next office visit. The revised policies and practices will be applied to all protected health
information that we maintain.

Requests to Inspect Protected Health Information

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 our office manager, or front desk receptionist, or nurse.

Complaints and Contact Person

If you would like to submit a comment or complaint about our privacy practices, or obtain additional
information about our privacy practices, you can do so by sending a letter outlining your concerns to
the person listed below. You will not be penalized or otherwise retaliated against for filing a
complaint.

C. Michele Ingram ARNP

Birchwood Women's Health
520 Birchwood Ave Ste A
Bellingham WA 98225
360-671-7442

OR

You may also contact the Dept. of Health and Human Services directly at:

Dept. of Health and Human Sevices

200 Independence Ave. SW
Washington, DC 20201

Toll Free: 1-877-696-6775

Effective date

This notice is effective on or after Julv 1. 2003.