As my practice has limited availability and there is difficulty filling cancelled sessions without timely notice, there will be a $75 charge for cancellations of appointments within 48 hours of the scheduled appointment time. The only exception to this rule is when both the patient and Dr. Hartman agree that the cancellation of the session is due to an unforeseen emergency.

Purpose: This form - Notice of Privacy Practices - presents information that federal law requires us to give our patients regarding privacy practices. We must provide this Notice to each patient beginning no later than the date of our first service delivery to the patient, including service delivered electronically, after April14, 2003. We must make a good-faith attempt to obtain written acknowledgement of receipt of the Notice from the patient. We must also have the Notice available at the office for patients to request to take with them. We must post the Notice in our office in a clear and prominent location where it is reasonable to be accessed by any patient seeking services and readable. Whenever the Notice is revised, we must make the Notice available upon request on or after the effective date of the revision in a manner consistent with the above instructions. Thereafter, we must distribute the NotiF8 to each new patient at the time of service delivery and to any person requesting a Notice. We must also post the reviewed Notice in our office as discussed above.

THIS NOTICE DESCRIBES HOW HEAL. TH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY: We are required by applicable federal and slate law to maintain the privacy of your information: We
are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice lakes effect(April 14, 2003) and will remain in effect until we replace it.
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We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our private practice and the new terms of our Notice effective for all health information that we maintain. Before we make a significant change in our privacy practices, we will change this Notice and the new Notice will be posted as previously stated. You may request a copy of our Notice at any time. For more information about our privacy practices. or for additional copies of this Notice, please contact us using the information listed al the end of this Notice.'

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment:- We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use your health information in conjunction with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training prognams; accredidation, certification, licensing or credentialing activities. ­

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or share it with anyone for any purpose. If you give us an authorization, you may revoke it in writing at any lime. Your decision will not effect use or disclosures permitted during the time frame that your authorization was in effect. Unless you give us a written authaurization, we cannot share or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person, to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so in writing.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personally, or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information; we will provide you with an opportunity to object to such uses or disclosures, in the event of your incapacity or circumstances. we will disclose health information based on a determination using our professional judgment disclose only health information that is directly relevant to the person's involvement in your healthcare. We also use our professional Judgement and our experience to make reasonable inferences of your best interest in allowing a person to pick up forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim other crimes. We may disclose your health information to the extent necessary to avert any serious dangers to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful Intelligence, counterintelligence, and other national security activities. We may disclose to institutions of law enforcement, officials having lawful custody of protected health information of inmate or patient circumstances. "':
Appointment Reminders: We may use or disclose your health information, to-provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS
Access: You have the right to look at or get Copies of your health information, with limited exceptions.. You may request that we provide copies in a format other than photocopies. We must comply with your request unless we cannot plausibly do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for information such as copies and staff time, as well as postage for mailed documents.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health Information. If you make this request more than once in a 12c month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate to you about your health information by
alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the all
means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this
in written form.

QUESTIONS AND COMPLAINTS: If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with the decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information to have us communicate with you by alternative means, you may complain to us using the contact information listed at the end of this Notice. You also may submit written complaints to the U.S. Department of Health and Human Services. We will provide you with the address for your complaint.with the U.S. Department of Health and Human Service upon request. We support your right to the privacy of your health Information. We will not retaliate in any way if you choose to file a complaint with us or with the U,S. Department of Health and Human Services.

Contact Officer: Steven Hartman

Address:
775 Park Avenue – Suite 112, Huntington, NY 11743

Phone:(516) 521-8972

Your signature below indicates you have read and agreed to the terms and policies stated in the above notice.