Thomas A. Merz, LPC
P.O. Box 53
Menlo, GA 30731
706.506.9151
877.807.5932 (fax)
www.thomasamerz.com
tom@thomasamerz.com

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.

I am required by law to provide you with this notice
that explains our privacy practices with regard to your
medical information and how I may use and disclose
your protected health information for treatment,
payment, and for health care operations, as Ill as for
other purposes that are permitted or required by law.
You have certain rights regarding the privacy of your
protected health information and I also describe those
rights in this notice.

Ways in Which I May Use and
Disclose Your Protected Health
Information:

The following paragraphs describe different ways that
I use and disclose your protected health information. I
have provided an example for each category, but these
examples are not meant to be exhaustive. All of the
ways I are permitted to use and disclose your health
information fall within one of these categories.

Treatment. I will use and disclose your protected
health information to provide, coordinate, or manage
your health care and any related services. I will also
disclose your health information to other health care
providers who may be treating you. Additionally I
may from time to time disclose your health
information to another physician whom I have
requested to be involved in your care. For example - I
would disclose your health information to a specialist
to whom I have referred you for a diagnosis to help in
your treatment.

Payment. I will use and disclose your protected
health information to obtain payment for the health
care services I provide you. For example - I may
include information with a bill to a third-party payer
that identifies you, your diagnosis, procedures
performed, and supplies used in rendering the service.

Health Care Operations. I will use and disclose
your protected health information to support the
business activities of our practice. For example -- I
may use medical information about you to review and
evaluate our treatment and services or to evaluate our
staff's performance while caring for you. In addition, I
may disclose your health information to third party
business associates who perform billing, consulting, or
transcription, or other services for our practice.

Other Ways I May Use and
Disclose Your Protected Health
Information:

Appointment Reminders. I will use and disclose your
protected health information to contact you as a
reminder about scheduled appointments or treatment.

Treatment Alternatives. I will use and disclose your
protected health information to tell you about or
recommend possible alternative treatments or options
that may be of interest to you.

Others Involved in Your Care. I will use and disclose
your protected health information to a family member,
a relative, a close friend, or any other person you
identify that is involved in your medical care or
payment for care.

Research. I will use and disclose your protected
health information to researchers, provided the
research has been approved by an institutional review
board that has reviewed the research proposal and
established protocols to ensure the privacy of your
health information.

As Required by Law. I will use and disclose your
protected health information when required to by
federal, state, or local law.

To Avert a Serious Threat to Public Health or
Safety. I will use and disclose your protected health
information to public health authorities permitted to
collect or receive the information for the purpose of
controlling disease, injury, or disability. If directed by
that health authority, I will also disclose your health
information to a foreign government agency that is
collaborating with the pubic health authority.

Worker's Compensation. I will use and disclose your
protected health information for worker's
compensation or similar programs that provide
benefits for work-related injuries or illness.

Inmates. I will use and disclose your protected health
information to a correctional institution or law
enforcement official if you are an inmate of that
correctional institution or under the custody of the law
enforcement official. This information would be
necessary for the institution to provide you with health
care; to protect the health and safety of others; or for
the safety and security of the correctional institution.

Your Health Information Rights

Although your health record is the physical property
of the practitioner or facility that compiled it, the
information belongs to you. You have the right to:

A Paper Copy of This Notice. You have the right to
receive a paper copy of this notice upon request. You
may obtain a copy in our office lobby at your next
visit or by calling and asking us to mail you a copy.

Inspect and Copy. You have the right to inspect and
copy the protected health information that I maintain
about you in our designated record set for as long as I
maintain that information. This designated record set
includes your medical and billing records, as Ill as any
other records I use for making decisions about you.
Any psychotherapy notes that may have been included
in records I received about you are not available for
your inspection or copying, by law. I may charge you
a fee for the costs of copying, mailing, or other
supplies used in fulfilling your request.
If you wish to inspect or copy your medical
information, you must submit your request in writing
to our Privacy Officer: Attention: Thomas A. Merz,
Privacy Officer, PO Box 53, Menlo, GA 30731
Phone: 706.506.8561. You may mail your
request, or bring it to our office. I will have 30 days to
respond to your request for information that I maintain
at our practice site. If the information is stored off-site,
I am allowed up to 60 days to respond but must
inform you of this delay.

Request Amendment. You have the right to request
that I amend your medical information if you feel that
it is incomplete or inaccurate. You must make this
request in writing to our practice manager, stating
exactly what information is incomplete or inaccurate
and the reasoning that supports your request.
I are permitted to deny your request if it is not in
writing or does not include a reason to support the
request. I may also deny your request if:

• The information was not created by us, or the
person who created it is no longer available to make
the amendment.
• The information is not part of the record which you
are permitted to inspect and copy.
• The information is not part of the designated record
set kept by this practice or if it is the opinion of the
opinion of the health care provider that the
information is accurate and complete.

Request Restrictions. You have the right to request a
restriction of how I use or disclose your medical
information for treatment, payment, or health care
operations. For example - you could request that I not
disclose information about a prior treatment to a
family member or friend who may be involved in your
care or payment for care. Your request must be made
in writing to our practice manager.
I am not required to agree to your request if I feel it is
in your best interest to use or disclose that
information. If I do agree, I will comply with your
request except for emergency treatment.

An Accounting of Disclosures. You have the right to
request a list of the disclosures of your health
information I have made outside of our practice that
Ire not for treatment, payment, or health care
operations. You request must be in writing and must
state the time period for the requested information.
You may not request information for any dates prior
to April 14, 2003, nor for a period of time greater than
six years (our legal obligation to retain information).
Your first request for a list of disclosures within a 12-
month period will be free. If you request an addition
list within 12-months of the first request, I may charge
you a fee for the costs of providing the subsequent list.
I will notify you of such costs and afford you the
opportunity to withdraw your request before any costs
are incurred.

Request Confidential Communications. You have the
right to request how I communicate with you to
preserve your privacy. For example - you may request
that I call you only at your work number, or by mail at
a special address or postal box. Your request must be
made in writing and must specify how or where I are
to contact you. I will accommodate all reasonable
requests.

File a Complaint. If you believe I have violated your
medical information privacy rights, you have the right
to file a complaint with our practice or directly to the
Georgia Secretary of State's office.
To file a complaint with Thomas A. Merz, you must make
it in writing within 180 days of the suspected
violation. Provide as much detail as you can about the
suspected violation and send it to our Privacy Officer.

Uses or Disclosures Not Covered

Uses or disclosures of your health information not covered
by this notice or the laws that apply to us may only be made
with your written authorization. You may revoke such
authorization in writing at any time and I will no longer
disclose health information about you for the reasons stated
in your written authorization. Disclosures made in reliance
on the authorization prior to the revocation are not affected
by the revocation.

For More Information

If you have questions or would like additional
information, you may contact our Privacy Officer.
Effective Date: April 14, 2003