WorkCare Medical Group, Inc.,

NOTICE OF PRIVACY PRACTICES

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

Effective Date: 04/14/03

Anyone has the right to ask for a paper copy of this Notice at any time.

Purpose of This Notice

This Notice applies to the information and records we have about your health, health status, and the healthcare and services administered by us. A new federal law, the Health Insurance Portability and Accountability Act (HIPAA), requires us to make sure that your Protected Health Information (PHI) is kept private. We must give you this Notice of our legal duties and Privacy Practices with respect to your PHI. We are also required to follow the terms of the Notice that is currently in effect. PHI includes information that we have created or received about your past, present, or future health or medical condition that could be used to identify you. We are required to tell you how, when, and why we use and/or share your PHI.

This Notice will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.

All personal health information supplied by you to WorkCare Medical Group, Inc., including the results of the medical examinations and services, will be kept confidential and in accordance with OSHA Regulations (Standards – 29 CFR, Access to Employee Exposure and Medical Records) and the HIPAA Privacy Rule. Your medical records cannot be released to an unauthorized party without your express written consent and authorization, except as described below.

The provisions of the OSHA law apply to the entity that serves as the custodian of records. In most cases, WorkCare Medical Group, Inc.’s, business associate, WorkCare, Inc. serves as the custodian of record for your employer or organization. In some cases, though, the employer or organization you work for serves as the custodian of record.

Purposes for which WorkCare Medical Group, Inc., May Use or Disclose Your Medical Information Without Your Consent or Authorization

WorkCare Medical Group, Inc., may use and/or disclose your PHI for treatment, payment or other healthcare operations carried out by its physicians, associates and staff.

As an occupational health provider, treatment provided consists of the coordination of healthcare, including health care management of the individual through medical surveillance review, case management, disability review and on-site medical evaluations.

WorkCare Medical Group, Inc., will use and/or disclose your PHI for the purposes of:

1. Treatment
In order to support your healthcare treatment needs, we may provide medical management services for incidents of workplace injury, illness or disability. Your health information may be disclosed to other health care professionals in the course of your treatment and recovery.

For example, WorkCare Medical Group, Inc., physicians and staff may use your health information supplied by another doctor in the state where you were treated. The WorkCare Medical Group, Inc., doctor and the treating physician who provided you healthcare service may discuss your health information to determine appropriate preventive measures and/or treatment related to occupational illnesses or injuries.

We will report to your employer or organization your work qualifications as it relates to your fitness for work and any work restrictions. If you are out of work due to illness/ injury, we may also report your ability to return to work with or without restrictions.

Also, your employer or organization may ask WorkCare Medical Group, Inc., to assist in ensuring that you receive appropriate preventive medical services and/or treatment related to potential hazards in the workplace.

We will release your health information to your employer or organization and/or other claims managers or processors in accordance with all applicable Workers’ Compensation laws and regulations.

2. Payment
We will disclose to your employer or organization or other payer, treatment services, including medical surveillance and disability review, case management, and on-site physical evaluations in order to obtain payment.

3. Operations
WorkCare Medical Group, Inc., may use or disclose your medical information to (i) to conduct quality assessment and improvement activities, (ii) to authorize business associates to perform data aggregation services, (iii) to engage in care coordination or case management. For instance, WorkCare Medical Group, Inc., may use your medical information in order to evaluate the performance of our staff personnel.

4. Health Evaluation
We may use health information about you for the purpose of determining your medical status for a specified purpose such as to determine a diagnosis, or to provide a second medical opinion, or as a qualified medical examiner or agreed medical examiner. We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in the process of your health evaluation.

Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your evaluation, such as phoning, scheduling lab work and ordering X-rays. We may disclose your medical information to other healthcare providers outside this office.

5. Healthcare Administration
We may use and disclose health information about you in order to administer healthcare operations and to ensure that you and other client employees receive quality care. For example, we may use your health information to evaluate the performance of our staff. We may also use health information about all or many of our client employees to help us become more efficient.

6. Health Promotion Services
We will provide you with a written summary of medical examination findings and results. We may refer you to your personal physician for treatment or management of health conditions that are not related to your employment such as for smoking cessation, high blood pressure, abnormal laboratory results or weight control.

Special Situations In Which WorkCare Medical Group, Inc., May Use or Disclose Your Medical Information Without Your Consent or Authorization

1. To Avert a Serious Threat to Health or Safety
We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

2. Required By Law
We will disclose health information about you when required to do so by federal, state or local law.

3. Military, Veterans, National Security and Intelligence
If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.

4. Workers’ Compensation
We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. We will release your health information to your employer or organization and/or other claims managers or processors in accordance with all applicable Workers’ Compensation laws and regulations.

5. Public Health Risks
We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

6. Health Oversight Activities
We may disclose health information to a health oversight agency for audits, investigations, inspections or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the healthcare system, government programs, and compliance with civil rights laws.

7. Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.

8. Law Enforcement
We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

9. Coroners, Medical Examiners and Funeral Directors
We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

10. Information Not Personally Identifiable
We may use or disclose health information about you in a way that does not personally identify you or reveal who you are for purposes of population health reporting or health promotion activities for your employer or organization.

Appointment Reminders

As your organization’s or employer’s occupational health provider, we conduct medical surveillance activities that often require us to schedule health exams. We may contact you as a reminder that you have an appointment or other scheduled medical services.

Uses And Disclosures with Your Permission

We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization (different than the Authorization and Consent mentioned above) from you. In order to disclose these types of records for purposes of treatment, payment or healthcare operations, we will have to have both your signed Consent and a special written Authorization that complies with the law governing HIV or substance abuse records.

Your Rights Regarding Health Information About You

For non-work related examinations, you have the following rights:

1. Request to Revoke Appointment Reminders and Consent
Please notify us if you do not wish to be contacted for appointment reminders. If you advise us in writing (at the address listed at the top of this Notice) that you do not wish to receive such communications, we will not use or disclose your information for these purposes.

You may revoke your Consent at any time by giving us written notice. Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures that occurred before that time.

If you revoke your Consent, we will not be permitted to use or disclose information for purposes of treatment, payment or healthcare operations. As a result, your employment with your employer or organization may be adversely affected.

2. Right to Inspect and Copy
As authorized by the OSHA Regulations (Standards – 29 CFR), you have the right to access, inspect and receive a copy of your medical and exposure records from the custodian of records, WorkCare, Inc. A copy of your medical records will be provided to you at no charge. We ask that you provide a written request for your medical records to WorkCare, Inc.

If your employer or organization serves as the custodian of record, you also have the right to access, inspect and receive a copy of your medical and exposure records at no cost.

3. Right to Request an Amendment
If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information if WorkCare, Inc., is serving as custodian of record. The WorkCare office is located at 300 S. Harbor Boulevard, Suite 600, Anaheim, CA 92805 or 1320 Harbor Bay Parkway, #115 , Alameda, CA 94502 .

a. To request an amendment, send a letter of request to Marsinah Trujillo, WorkCare Medical Group, Inc.’s designated privacy official, at the above address in Anaheim.

b. If your employer is serving as custodian of record, you will need to contact them to determine the process for requesting an amendment.

4. Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and healthcare operations, as described in the Special Situations section of this notice. To obtain this list, you must submit your request in writing to Marsinah Trujillo. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

5. Right to Request Restrictions
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. However, if we are limited from disclosing information regarding your physical qualifications for work, your employment may be adversely affected, based upon your employer’s or organization’s policy.

To request restrictions, you may send a letter to Marsinah Trujillo, WorkCare Medical Group, Inc.’s designated privacy official, at 300 S. Harbor Boulevard, Suite 600, Anaheim, CA 92805.

6. We are Not Required to Agree to Your Request Regarding Restriction of Health Information
If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

7. Right to Confidential Communications
To request confidential communications, you may send us a letter stating your request. The letter should state your Request For Restriction On Use/Disclosure of Medical Information And/Or Confidential. You may send the letter to WorkCare, Inc., Marsinah Trujillo at 300 S. Harbor Boulevard, Suite 600, Anaheim, CA 92805.

We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or when you wish to be contacted.

8. Right to a Paper Copy of this Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact Marsinah Trujillo.

Changes To This Notice
We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.

Complaints And Contact Information
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Marsinah Trujillo, Vice President, Corporate Communications, 714-978-7488. You will not be penalized for filing a complaint. If you have any questions about this notice, please contact Marsinah Trujillo, WorkCare Medical Group, Inc.’s designed privacy official of our office at 714-978-7488.

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I acknowledge receipt of the WorkCare Medical Group Notice of Privacy Practices with
an effective date of 4/14/03.

Sign:_________________________ Date:_________________________________

Print name of patient:__________________________________________________

If you are signing as the patient’s representative:____________________________

Print your name:______________________________________________________

Describe your authority:________________________________________________