Chandler Neurolugy &, Sle.epDlsQrd:efs AssQCiaies. PCPATlLENT DEMQ.AApm~m~filRMA't@NSHEET

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May we leave messages regardir:l-g test results and appoi:li1ltliTl,ents··en y.Ol;Jrali,lswef'iingmach'itile? Yes No

• .... ... I' '; .• . . . . '.'I hav,e received a copy of tlie Prt,v,acy Rules from this provider and authorized the above list of persons whe may recew,e my ProtectedItea1th InfQrmaticm. I may ~e'lQke this at ally time by g.iving written noJificatlon,tothi's prp-wdel'.

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CHANDLER NEUROLOGY &SLEEP DISORDERS

I have received the HIPPA Privacy Notice regarding the uses and disclosures of my protected Healthinformation and I understand my rights and responsibilities with respect to my medical records.

I hereby authorize Chandler Neurology & Sleep Disorders, PCto release any medical or incidentalInformation to my referring physician or any other physicians who have been or may become involvedwith my care.

I also authorize the release of information that may be necessary in the processing of any insuranceclaims.

I also authorize the release of any medical records including pharmacy records to Chandler Neurology &Sleep Disorders Associates, PC upon request.

PERSONAL REPRESENTATIVES (family members, attorneys, etc): I hereby authorize Chandler Neurology& Sleep Disorders, PCand its employee's permission to discuss, send and/or receive medical informationto/with the following individuals:

Name, _ Relationship to the Patient, _

Name _ Relationship to the Patient. _

Messages

Y__ N_ It is okay to leave a message on my home voice mail

Y__ N__ It is okay to leave a message on my work voice mail

Faxes: When expedient, I authorize the transmittal of my records by fax. I understand that transmissionby fax, by its very nature is not confidential.

Patient Name _ Date of Birth _

Signature, _ Date _

: .

NOTICE OF PRIVACY POLICYFOR PROTECTED HEALTH

INFORMATION (PHI)

WHY WE COLLECT THISINFORMATION:We coned this information so that we can treatyour medical condition and obtain paymentfrom you or your health insurance.

The office of Chandler Neurology & SleepDisorders Associates PC is dedicated to protectyour "nonpublic personal health information".This notice is to tell you how and why we collectthat information, and who has access to thatinformation.

MAINTAINING ACCURATE ANDTIMELY INFORMATION:To ensure that the information we maintain isaccurate, each time you visit this office you willbe asked if any of your information needs to beupdated.

HOW WE COLLECT YOURINFORMATION:Your personal demographic information suchas name, address, birth date, social securitynumber, and medical insurance information isobtained from you. This is why we ask you tofill out the patient information sheet and whywe ask for a copy of your insurance card. Thisensures that the information we collect iscorrect.

WHO HAS ACCESS TO THISINFORMATION:Any person or persons you designate in writing,people directly involved in your medical care,people creating and maintaining your medicalrecord, and those entities that need yourinformation to process health care claims andobtain payment fer our services have access toyour Protected Health Information.

If you came to our practice through a hospitalencounter, we may obtain that informationfrom the hospital. However, on your first visitto this office, we will ask you to fill out ourinformation sheet to ensure that theinformation we received from the hospital wascorrect.

Entities such as Governmental Oversightagencies, Judicial and AdministrativeProceedings, Law Enforcement Agencies,Coroners and Medical Examiners, and OrganProcurement Organizations may obtain copiesof your Protected Health Information. Theseentities are mandated by Law and this practicehas no jurisdiction over such entities.We may also ask a doctor or other health care

provider who referred you to this practice togive us health information that will enable us tobetter treat your medical condition. Thisbenefits you in that we will have test resultsthat have already been obtained by thereferring entity ..

HOW WE PROTECT YOURINFORMATION:We release your information only to those peoplewho need your information. We maintainphysical. electronic. and procedural safeguards sothat no one but persons involved in yourhealthcare or entities who need this informationfor claims processing have access to yourProtected Healthcare Information.

YOUR RIGHTS:You have the right to inspect your ProtectedHealthcare Information. You also have theright to amend any errors you may find in yourrecord.

If you leave this practice, your ProtectedHealthcare Information will continue to receivethe protection outlined in this notice.

COMPLAINT/COMMENTS:If you have any complaints concerning ourprivacy practices, you may contact theSecretary of the Department of Health andHuman Services, at 20~ Independence Avenue,S. W. Room 509F. HHI! Building, WashingtonD.C. 20201. You also may contact the PrivacyOfficer of this practice at (480)722-0239.

THIS PRACTICE reserves the right toamend our privacy policy as dictated by law,without sending you a copy of the amendment.Any changes to this policy will be posted in ouroffice.

This notice is effective as of June 1, 2008.