A new federal regulation, known as the "Health Insurance Portability & Accountability Act (HIPAA)", requires that we provide notice in writing of our privacy practices. These privacy practices are in place to maintain the privacy of your protected health information (PHI).

John J. Basile, M.D. and Sunil V. Patel, M.D., may disclose PHI for the purposes of treatment, payment, and to operate the practice. The following are some examples. and do not imply an exclusive list.

Examples of uses and disclosures for treatment:

• If the doctor refers you to another physician for continuation of treatment, the doctor may give your name and the reason for your referral to the doctor's office.
• The doctor or his staff may call you to advise you of treatment alternatives or recommendations for treatment.

Examples of uses and disclosures to obtain payment:

• Our billing office may submit a claim form that contains your name, address, social security number, diagnosis, and procedure(s) performed by our physicians to your insurance company.

Examples of uses and disclosures to operate the practice:

• Our staff' may call with reminders about upcoming appointments.
• Our staff may leave messages for you on your telephone and ask you to return the call.
• The physicians may audit (read and comment upon) your chart to track and improve our performance in assuring that we perform screening test on time.

John J Basile, M.D. and/or Sunil V. Patel, M.D., are permitted or required to use or disclose PHI without the individual's written consent or authorization in certain circumstances. Two examples of such are for public health requirements and court orders.

John J Basile, M.D. and/or Sunil V. Patel, M.D., will not make any other disclosure of your PHI, other than for the aforementioned purposes of treatment, payment, or practice operation, without the individual's written authorization. Such authorization may be revoked by you at any time. Revocation must be in writing.

You have the following rights regarding your Pm, and the practice must act on your request within 60 days:

• You may request restrictions on certain uses and disclosures of PHI, but we are not required to agree to a requested restriction.
• You may request to inspect and copy your own PHI.
• You may request that your information be amended.
• You may request a paper copy of this notice.

Requested copies of your medical records will be available to you within 15 days of written request, as per Virginia State Law. The law requires the practice to abide by the terns of this notice and to provide individuals with notice revisions. Copies of this notice are available at any time during normal business hours and on our website.

THIS HIPPA FORM WILL ALLOW SPOUSE, FAMILY MEMBERS, OR FRIENDS TO OBTAIN YOUR INFORMATION WHEN THEY CALL ON YOUR BEHALF. PLEASE WRITE IN PERSON OR PERSONS NAME BELOW. IF NO ONE, MARK ON LINE BELOW.

__________________________________________________________
WRITE PERSON(S) NAME HERE

___ IF NO ONE - PUT A CHECK HERE

__________________________
TODAY'S DATE

__________________________
YOUR SIGNATURE HERE

Privacy Officer c/o John J. Basile, M.D. & Sunil V. Patel, M.D. 3020 Hamaker Court Suite B-l11 Fairfax, VA 22031 Phone 703.876.9288 I Fax 703.876.0290

Commonwealth Urology
JOHN J. BASILE, MD, PC
SUNIL V. PATEL, MD
3020 Hamaker Court, Suite B-111
Fairfax, Virginia 22031-2220
Tel: 703.876.0288
Fax: 703.876.0290
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