This notice describes how information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.

NOTICE OF INFORMATION PRACTICES
Effective Date: April 14, 2003

1. Seven Hills Urology Center, Inc., may use and disclose protected health information for treatment, payment and healthcare operations. Examples of these include, but are not limited to requested preschool, life insurance or sports physicals, referral to nursing homes, foster care homes, home health agencies and/or referral to other providers for treatment. Payment examples include, but are not limited to, insurance companies for claims including coordination of benefits with other insurers; collection agencies. Healthcare operations include, but is not limited to, internal quality control and assurance including audition of records.

2. Seven Hills Urology Center, Inc. is permitted or required to use or disclose protected health information without the individuals' written consent or authorization in certain circumstances. Two examples of such are for public health requirements or court orders.

3. Seven Hills Urology Center, Inc., will not make any other use or disclosure of a patient's protected health information without the individual's written authorization. Such authorization may be revoked at any time. Revocation must be written.

4. Seven Hills Urology Center, Inc., may at times contact the patient to provide appointment reminders or information regarding treatment alternatives or other health-related benefits and services that may be of interest to the individual patient.

5. Seven Hills Urology Center, Inc., will abide by the terms of this notice currently in effect at the time of the disclosure.

6. Seven Hills Urology Center, Inc., reserves the right to change the terms of its notice and to make new notice provisions effective for all protected health information that it maintains.

7. Seven Hills Urology Center, Inc., will provide each patient with a copy of any revisions of its Notice of Information Practice at the time of their next visit, or at their last known address if there is a need to use or disclose any protected health information of the patient. Copies may also be obtained at any time at our offices.

8. Any person/patient may file a complaint to the Practice and to the Secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with the practice, please contact the Privacy Officer at the following address and/or phone number: Judy Berryman, 434-947-5297

All complaints will be addressed and the results will be reported to the Privacy Officer.

9. It is Seven Hills Urology's Center, Inc.'s policy that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance of the privacy standards.

10. Full Privacy document available in Waiting room or individually by request.

11. Acknowledgment of having read Privacy Notice document:

Patient's Name (please print) ___________________________________

Date:__________________________