NIRVANA CLINIC

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.

This privacy policy is adopted to ensure that NIRVANA CLINIC(" NIRVANA CLINIC") fully complies with all federal and state privacy protection laws and regulations, in particular, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Protection of patient privacy is of utmost importance to NIRVANA CLINIC. Violations of any of these provisions will result in disciplinary action which may include termination of employment and possible referral for criminal prosecution.

This policy shall become effective as of May 30, 2005 , and shall remain in effect until it is either amended or cancelled.

If you have any questions or comments concerning this policy, you should contact the Privacy Officer,

Privacy Officer

9550 Baymeadows Rd. Suite 9

Jacksonville, FL. 32256

Phone: (904) 739-7398

by mail or by telephone at

Telephone: (904) 739-7398

DEFINITIONS

For the purposes of this policy, the following defined terms shall have the following definitions.

a. "HHS" shall mean the United States Department of Health and Human Services.

b. " Health Information" or "Protected Health Information" shall mean, certain Individually Identifiable Health Information, as defined in 45 C.F.R. § 164.501 of the Privacy Standards.

I. Information Collected

In the ordinary course of business NIRVANA CLINIC may receive personal information such as:

Patient's name, address, and telephone number;

Information relating to treatment, diagnostic or other medical information concerning a patient;

Patient's insurance information and coverage.

In addition, other information will be gathered about a patient and we will create a record of the care and/or services provided to the patient by NIRVANA CLINIC. Some of the information also may be provided to us by other individuals or organizations that are part of the patient's "circle of care"- such as referring physician, other physicians, their health plan and family members, hospitals or other health care providers.

II. How NIRVANA CLINIC Will Use or Disclose Your Protected Health Information

NIRVANA CLINIC collects Protected Health Information from you and stores it on a computer. This is your medical record. The medical record is the property of NIRVANA CLINIC, but the information in the medical record belongs to you. NIRVANA CLINIC protects the privacy of your Protected Health Information. It is the policy of NIRVANA CLINICthat all Protected Health Information may not be used or disclosed unless it meets one of the following conditions:

1. The patient who is the subject of the information has consented to the use or disclosure and the use or disclosure is for the treatment, payment or health care operations.

a. Treatment . NIRVANA CLINIC collects information from you regarding your past medical history, present medical problems and/ or complaints, as well as any diagnose and/or treatment at NIRVANA CLINIC. This information may be transmitted to your referring physician and any other entities associated or involved in your treatment. This information may also be disclosed to your physicians or your primary care physician in association with your treatment.

b. Payment . NIRVANA CLINIC will collect billing information from you such as your present address, social security number, date of birth, health insurance carrier, policy number and other related billing information. NIRVANA CLINIC may disclose to your health insurance provider, Medicare and Medicaid, or any other payor of health care claims the minimum amount necessary of your patient health care information in order to process your health insurance claim.

c. Regular Health Care Operations. NIRVANA CLINIC will disclose your healthcare information to our physicians, medical assistants, nurses, x-ray technologists, billing clerks, administrative staff and other employees involved in your healthcare treatment.

2. The patient who is the subject of the information has authorized the use or disclosure of the information; or

3. The patient who is the subject of the information does not object to the disclosure and the disclosure is to persons involved in the health care of the individual or for facility directory purposes.

a. Notification and communication with family . We may disclose your Protected Health Information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

4. Voice Mail Message. It is the policy of NIRVANA CLINIC that a voice mail or answering machine message may be left at a patient's home or other number the patient provides to NIRVANA CLINIC regarding appointments, billing or payment issues, or other PHI, related to treatment, payment or health care operations.

5. As Required by Law. It is the policy of NIRVANA CLINIC that we may use and disclose your Protected Health Information as required by law.

a. Public health. As required by law, we may disclose your Protected Health Information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.

b. Health oversight activities. We may disclose your Protected Health Information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings.

c. Judicial and administrative proceedings. We may disclose your Protected Health Information in the course of any administrative or judicial proceeding.

d. Law enforcement . We may disclose your Protected Health Information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and/or for other law enforcement purposes.

e. Deceased person information. We may disclose your Protected Health Information to coroners, medical examiners and funeral directors.

f. Organ donation . We may disclose your Protected Health Information to organizations involved in procuring, banking or transplanting organs and tissues.

g. Research . We may disclose your Protected Health Information to researchers conducting research that has been approved by an Institutional Review Board.

h. Public safety . We may disclose your Protected Health Information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

i. Specialized government functions . We may disclose your Protected Health Information for military, national security, prisoner purposes.

j. Worker's compensation . We may disclose your Protected Health Information as necessary to comply with worker's compensation laws.

k. Marketing . We may contact you to provide appointment reminders or to give you information about other treatments or health-related benefits and services that may be of interest to you.

l. Change of Ownership . In the event that NIRVANA CLINIC is sold or merges with another organization, your Protected Health Information/record will become the property of the new owner.

III. OTHER POLICIES, USES AND DISCLOSURES

1. Notice of Privacy Practices . It is the policy of NIRVANA CLINIC that privacy practices must be published and that all uses and disclosures of Protected Health Information are done in accordance with NIRVANA CLINIC privacy policy.

2. Deceased Individuals . It is the policy of NIRVANA CLINIC, that privacy protections extend to information concerning deceased individuals.

3. Restriction Requests . It is the policy of NIRVANA CLINIC that serious consideration must be given to all requests for restrictions on uses and disclosures of Protected Health Information as published in this privacy policy. You have the right to request restrictions on certain uses and disclosures of your Protected Health Information. NIRVANA CLINIC is not required to agree to the restriction that you requested. If a particular restriction is agreed to, NIRVANA CLINICis bound by that restriction.

4. Minimum Necessary Disclosure . It is the policy of NIRVANA CLINIC that it shall make reasonable efforts to limit the disclosure to the minimum amount of information needed to accomplish the purpose of the disclosure. It is also the policy of NIRVANA CLINIC that all requests for Protected Health Information must be limited to the minimum amount of information needed to accomplish the purpose of the request.

5. Access to Information . It is the policy of NIRVANA CLINIC that you have the right to inspect and copy your Protected Health Information. It is NIRVANA CLINIC's policy that access to Protected Health Information must be granted to a patient when such access is requested. Such request shall be submitted in writing. Costs associated with the copying of any Protected Health Information shall be in accordance with applicable state and federal law.

6. Designation of Personal Representative . It is the policy of NIRVANA CLINIC that access to protected health information must be granted to your designated personal representative as specified by you when such access is requested. This designation of a personal representative must be made in writing.

7. Confidential Communications Channels. It is the policy of NIRVANA CLINIC that you have the right to receive your protected health information through a reasonable alternative means or at an alternative location. Confidential communication channels can be used within the reasonable capability of NIRVANA CLINIC, (i.e. do not call me at work, call me at home) as requested by you. Such request shall be made in writing.

8. Amendment of Incomplete or Incorrect Protected Health Information. It is the policy of NIRVANA CLINIC that you have a right to request that NIRVANA CLINIC amend your protected health information that is incorrect or incomplete. NIRVANA CLINIC is not required to change your protected health information and will provide you with information about NIRVANA CLINIC denial and how you can disagree with the denial. A request to amend your protected health information shall be made in writing.

9. Accounting of Disclosures . It is the policy of NIRVANA CLINIC that an accounting of disclosures of Protected Health Information made by NIRVANA CLINICis given to you whenever such an accounting is requested in writing. You have a right to receive an accounting of disclosures of your Protected Health Information made by NIRVANA CLINIC, except that NIRVANA CLINIC does not have to account for the disclosures described in Section II (1) (a)(b)(c), of this Notice of Privacy Practices. Such written request for an accounting shall be made in writing.

10. Complaints. It is the policy of NIRVANA CLINIC that all complaints by employees, patients, providers or other entities relating to Protected Health Information be investigated and resolved in a timely fashion. Complaints about this Notice of Privacy Practices or how NIRVANA CLINIC handles your Protected Health Information should be directed to:

Privacy Officer

9550 Baymeadows Rd. Suite 9

Jacksonville, FL. 32256

Phone: (904) 739-7398

by mail or by telephone at

Telephone: (904) 739-7398

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Department of Health and Human Services

Office of Civil Rights

Hubert H. Humphrey Bldg.

200 Independence Avenue, S.W.

Room 509F HHH Building

Washington , DC 20201

11. Prohibited Activities . It is the policy of NIRVANA CLINIC that no employee may engage in any intimidating or retaliatory acts or actions against any person who files a complaint or otherwise exercises their rights under HIPAA regulations. It is also the policy of NIRVANA CLINIC that no disclosure of protected health care information will be withheld as a condition for payment for services from the patient or from an entity.

12. Responsibility. It is the policy of NIRVANA CLINIC that the responsibility for designing and implementing procedures related to this policy lies with the designated Privacy Officer.

13. Mitigation . It is the policy of NIRVANA CLINIC that the effects of any unauthorized use or disclosure of Protected Health Information be mitigated (to decrease the damage caused by the action) to the extent possible.

14. Business Associates . It is the policy of NIRVANA CLINIC that business associates must be contractually bound to protect your Protected Health Information to the same degree as set forth in this policy.

15. Preemption of State Law . It is the policy of NIRVANA CLINIC that the federal privacy regulations are the minimum standard to be used regarding the privacy of a patient's protected health care information. If the laws of the State of Washington are more stringent in certain areas, the state laws in these areas shall prevail. In all other areas, the federal privacy regulations shall prevail.

16. Cooperation with Privacy Oversight Authorities . It is the policy of NIRVANA CLINIC that oversight agencies such as the Office for Civil Rights of the Department of Health and Human Services be given full support and cooperation in their efforts to ensure the protection of Protected Health Information within this organization. It is also the policy of NIRVANA CLINIC that all personnel cooperate fully with all privacy compliance review and investigations.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the designated Privacy Office of NIRVANA CLINIC.

IV. Changes to this Notice of Privacy Practices

NIRVANA CLINIC reserves the right to amend this Notice of Privacy Practices at any time in the future and will provide a copy of such amendment to you upon request or upon your next visit. Until such amendment is made, NIRVANA CLINIC is required by law to comply with this Notice.

Nirvana Clinic is Jacksonville, Florida's premier location for medically supervised weight loss and comprehensive non-surgical cosmetic medicine. The highly trained medical staff at Nirvana Clinic specialize in mesotherapy, weight loss using OPTIFAST®, medical microdermabrasion, facials, photo rejuvenation, sclerotherapy, laser vein therapy, laser hair removal, stretch mark and scar revision, as well as relaxing massage therapy.

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