THIS NOTICE OF PRIVACY PRACTICES (“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.

We are required by law to keep your protected health information private and to provide you with a copy of this Notice. We are also required by law to follow the terms of this Notice as long as it is in effect. If you have any questions about this Notice, please contact our Privacy Official at 220 W. Capitol Drive, Milwaukee, WI 53212 or (414) 906-5306.

We May Use and Disclose your Health Information:

A. To provide you with treatment or services. This includes sharing protected health information with providers we refer you to so that they can diagnose and treat you. We may also share health information about you with people outside of our clinic (or other program in which you receive services) who may be involved in your medical care. These people include family members (unless you object), subcontracted agencies, hospitals, home health agencies and others we use to help provide services that are part of your ongoing care.

B. To bill and collect payments. We may use and disclose your medical information to be able to bill and may collect from you or on your behalf from an insurance company or a third party. For example, we may need to provide information about care you received in order to be reimbursed for the service or to determine your eligibility or coverage for the service. We may also tell your health plan about a treatment you are going to receive to obtain to obtain a prior approval or determine whether your plan will cover the treatment. We may also share information with our business associates who assist in billing and collection. These business associates may include billing companies, collection agencies, claims processing and pre-certification companies and others that process our health claims.

C. To assist with our healthcare operations. These activities may include quality improvement activities, employee performance evaluations, medical reviews, audits and fund-raising. If you wish to opt out of receiving fund-raising communications, please contact the Privacy Official. Outreach Community Health Centers (OCHC) is part of an organized health care arrangement including participants in OCHIN. A current list of OCHIN participants is available at www.ochin.org. As a business associate of OCHC, OCHIN supplies information technology and related services to OCHC and other OCHIN participants. OCHIN also engages in quality assessment and improvement activities on behalf of its participants. For example, OCHIN coordinates clinical review activities on behalf of participating organizations to establish best practice standards and assess clinical benefits that may be derived from the use of electronic health record systems. OCHIN also helps participants work collaboratively to improve the management of internal and external patient referrals.

Your health information may be shared by OCHC with other OCHIN participants when necessary for health care operations purposes of the organized health care arrangement.

D. To inform you. We may contact you about treatment alternatives or other health-related benefits or services that may be of interest to you.

E. To those trying to locate you in our facilities. Unless you object, we will only disclose general information, such as your name and location in our facilities, to people who ask for you by name.

F. To those involved in your care. Unless you object, we may share health information about you with family members or friends, whom you indicate are involved in your medical care. In certain emergency situations, we may share health information about you with disaster relief organizations (i.e. Red Cross) in order that your family can be notified about your condition, status and location.

G. For research purposes. In some situations, we may share health information about you for research purposes. All research projects are subject to special review and an approval process to ensure the privacy of your health information.

H. As required by law, to assist with law enforcement purposes, court proceedings or other government functions. For example, we may disclose medical information to report child abuse, to respond to a court order, to assist a law enforcement official in locating a missing person or in response to government requests related to national security.

I. For purposes related to death. We may disclose information in response to requests from coroners or medical examiners.

J. To address public health issues, or threats to health or safety. We may disclose your information to public health agencies in regard to communicable diseases, disease prevention or control, or problems with medications or medical devices. We may also disclose information in limited circumstances to organizations to prevent serious threats to health or safety of someone or the general public.

K. For health oversight activities. We may provide information to agencies allowed by law to conduct audits, inspections or other activities related to health care oversight.

L. For workers compensation. We are permitted to disclose your health information in response to a worker’s compensation claim.

M. For marketing purposes. We use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Official to request that these materials not be sent to you.

Other Uses of Health Information:

Other uses or disclosures of health information not covered by this Notice or the law will only be provided with your written permission. This list includes uses and disclosures for marketing and sale of protected health information, as well as most uses and disclosures of psychotherapy notes. You may revoke this permission in writing at any time. If you revoke your authorization, we will no longer use or disclose the protected health information you specified for the reasons you noted in writing. You are then unable to retrieve any information that we may have already shared with your permission. We are also required to maintain original records of the care that we provide to you.

You Have the Right:

A. To see and receive a copy of your health information. You must submit your request in writing. Requests

for clinic records should be submitted to our Medical Records Department at 220 W. Capitol Drive, Milwaukee, WI 53212. Requests for other records should be addressed to the manager of that program at the same address. If you request a copy, it must be requested in advance and we may charge a fee for this. In certain situations, we may deny your request. We will inform you in writing why your request was denied and explain your right to have the denial reviewed. Under federal law, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in a civil, criminal or administrative proceeding; and lab results that are subject to law.

B. To request to amend your health record, if you feel that the information is incorrect or incomplete. You

may do this by sending your request in writing to the Medical Records Department or program manager as indicated under Section A, including your reason for the request. We may deny your request if the information was not created by us, is not part of the health information maintained by us, or if it is determined that the health information is correct. You may appeal this decision by sending a written request to us.

C. To request a list of all disclosures of your health information, except for information disclosed for

treatment, payment or health care operations, or for those disclosures you specifically authorized, and other purposes in accordance with State or Federal law. You must send your request in writing to the Medical Records Department or program manager as indicated under Section A. Your request must tell us a specific time period of not more than six years. The first disclosure list you request in any 12-month period is free. We may charge a fee for additional lists.

D. To ask that we limit how we use and disclose health information about you. You may submit a request in

writing to the Medical Records Department or program manager as indicated under Section A informing us on what information to limit. We will consider your request but are not legally required to accept it unless it’s to a health plan for services for which you paid in full. If we do agree, we will follow your request unless the information is needed to provide you with emergency treatment.

E. To have information sent to you in a specific manner. This may include sending information to your work

address instead of your home, or having information mailed in an unmarked envelope. You must submit your request in writing to the Medical Records Department or program manager as indicated under Section A. We have the right to decide whether the request is reasonable. We do not have to comply with an unreasonable request.

F. To receive a paper copy of this Notice even if you have agreed to receive this notice electronically. You

may ask us to give you a copy of this at any time.

G. To be notified in the event of a breach of unsecured health information.

Complaints:

If you feel that your privacy rights have been violated you may file a complaint with our Privacy Official at 220 W. Capitol Drive, Milwaukee, WI 53212 or (414) 906-5306. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

Changes to this Notice:

We reserve the right to change this Notice and our privacy policies at any time. Any changes will apply to the health information that we have on file and health information we create or receive after the effective date of the new Notice. The revised Notice will be posted in a clear and prominent location. Copies will also be available upon request.