This notice describes Urologic Institute of N.J., P.A. / Center for Male Reproductive Medicine practices and that of:

• All physicians and staff of our Practice.
• Our Practice follows the terms of this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION:

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 are required by law to:

• Make sure that medical information that identifies you is kept private'
• Give you this notice of our legal duties and privacy practices concerning 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.

For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, nursing and medical students, or hospital personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietician if you have diabetes so that we can arrange for nutritional counseling. We also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people who may be involved in your medical care such as family members, clergy, rehabilitation centers, etc.

For Payment. We may use and disclose medical information about you so that the treatment and services you receive at our Practice may be billed for and payment may be collected from you or on your behalf from an insurance company or third party. For example, we may need to give your health plan information about x-rays that you received at our Practice so your health plan will pay us or reimburse you for those services. 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 disclose medical information about you for our Practice's operations. These uses and disclosures are necessary to run our organization and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performances of our staff in caring for you. We may also combine medical information about many of our Practice patients to decide what additional services our Practice should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, nursing and medical students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other similar organizations to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study healthcare and healthcare delivery without learning who the specific patients are.

Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at our Practice.

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.

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 about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you have been seen in our office. In addition, we may disclose medical information about you to a friend or family member should an emergent situation arise while you are at our office.

Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recover of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before wee use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, 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, so long as the medical information they review does not leave our organization. We will always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care with our Practice.

As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and 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.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request, in writing, that the denial be review. Another licensed health care professional chosen by our Practice will review your request and the denial. The person conducting the review will not be the person who previously denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to include additional information in your medical record. You have the right to request an amendment as long as all of the information, both old and new, is kept by or for our practice.

To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, 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 the amendment;
• Is not a part of the medical information kept by or for our practice;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

To request this list or accounting of disclosures, you must submit your request in writing to the Office Manager. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what for you want the list (fore example, on paper, electronically). The first list 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 healthcare 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 could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information needed to provide you emergency treatment. To request restrictions, you must make your request in writing to our Privacy Officer. 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.


Signature:__________________________________________________


Date:__________________