RENAISSANCE PLASTIC SURGERY CENTER
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW PROTECTED MEDICAL NFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE READ CAREFULLY.

1. Renaissance Plastic Surgery Center is permitted to make uses and disclosure of protected health information for treatment, payment and health care operations as described in the following examples.
   a. For treatment (such as giving the radiology dept. or surgery scheduling dept. 
   your diagnosis and summary of your problems when scheduling surgery, ordering x-rays, etc.)
   b. For payment such as giving your insurance company your diagnosis and/or operation to be performed when filing an insurance claim.
   c. For healthcare operations-review of your medical record by other physicians at Renaissance Plastic Surgery Center for quality control.
   
2. Renaissance Plastic Surgery is permitted or required, under specific circumstances, to use or disclose protected health information without the individual's written authorization. Other uses or disclosures will be made only with the individual's written authorization. The individual can revoke this authorization at any time.
   
3. Renaissance intends to engage in one or more of the following activities:
   a. Renaissance may contact the patient to provide appointment reminders or information about treatment alternatives or other health related benefits or services that may interest the patient.
   b. A group health plan, or a health insurance provider or HMO with respect to a group health plan, may disclose protected health information to the sponsor of the plan.
   
4. The patient has the following rights regarding protected health information:
   a. The right to request restrictions on certain uses and disclosures of protected health information. Renaissance is not required to agree to a requested restriction.
   b. The right to receive confidential communications of protected health information as applicable.
   c. The right to inspect and copy protected health information as provided in the Privacy Regulation.
   d. The right to amend protected health information as provided in the Privacy Regulation.
   e. The right to receive an accounting of disclosures of protected health information.
   f. The right to obtain a paper copy of the notice from the covered entity upon request. The right extends to a patient who has agreed to receive the Notice electronically.
   
5. Renaissance is required by law to maintain the privacy of protected health information and to provide patients with notice of its legal duties and Privacy practices with respect to protected health information.
   
6. Renaissance is required to abide by the terms of the Notice currently in effect.
   
7. Renaissance reserves the right to changes the terms of this Notice. The new Notice
   Provisions will be effective for all protected health information that it maintains.
   
8. Renaissance will provided individuals or patients with a revised Notice at the first office visit.
   
9. Individuals may complain to Renaissance Plastic Surgery Center without fear of retaliation by the practice, if they believe their privacy rights have been violated.
   
10. Renaissance Plastic Surgery Center contact persons for complaint matters are Deniz F. Bastug, M.D., (319) 272-8550 or 2710 St. Francis Dr. Suite 419, Waterloo IA 50702-5634.
    
11. This Notice is Effective April 14, 2003.

I hereby acknowledge that I have been informed that I may receive Renaissance Plastic Surgery Center's Notice of Privacy Practices.