Name: Preferred name:____________________ Date:DOB: _________________________ Age: Home Phone:______________ ___ Mobile Phone: ___________ ____

Email address: ________________________________ Receive email announcements/newsletters/updates/offers?* Y NReceive Text messages for appointment information/office announcements/offers?* Y N (*LHHP will never sell, lease, or otherwise disclose your email address/personal information.)

Address:___________________________________________________________________________________________

Emergency Contact Info: ________________________ Relationship: ___________Phone Number:_________________ _ What medical concerns bring you to our office? ___________________________________________________________

Marital Status: (circle) S M D W Occupation: (if retired, previous occupation)_ ______________________________ If disabled, check here: Nature of disability _________________________________ Birthplace:________________

Do you exercise routinely? (circle) No Yes If Yes, what exercise/how often?______ _____________________________ Have you ever smoked? (circle) No Yes Cigar Pipe Cigarettes If Yes: #cigarettes/day______#yrs.______

If you have never smoked, skip this question: Do you still smoke now? (circle) No Yes If No, when did you quit? _________ How did you hear about LHHP and our Wellness Services? Referred by: _____________________________

___ Internet search ___ Friend/Family Member ___ Previous LHHP Client ___ Other: __________________

Health Questionnaire for Non-Member Wellness Services

Ha ve you ever had or been diagnosed to have: (check box by all that apply)

POTS/Dysautonomia Heart Disease Eczema/Psoriasis Anemia Depression/Anxiety

Glaucoma Heart Murmur Digestive Disorder Bleeding Disorders Frequent Infections

Asthma High Blood Pressure Lyme Disease/Co-Infections Bone or Cancer (type)

Allergies Pneumonia Kidney Disease Joint Disease

Stroke TB/Lung Disease Kidney Stone(s) Chronic Fatigue Syndrome ADD/ADHD

Seizures/Epilepsy SIBO Diabetes or Migraines Neuropathy

Heart Attack or Jaundice or PreDiabetes Chronic EBV/HHV-6

Angina Liver Disease Thyroid Disease Detox Problems

Loudoun Holistic Health Partners, PLLC 1 of 4

Mold/Biotoxin Illness

AutoImmune Disorder

Allergies: Are you allergic to any drugs?(circle) No Yes Please list: Allergies: Are you allergic to any foods?(circle) No Yes Please list:

Medications (list all medications you are taking regularly. Include over the counter, herbal or natural remedies.)

Which LHHP Wellness Service(s) Are You Interested in Receiving:IV ImmunoBoost ___ IV Magnesium ___IV Phosphatidycholine ___

IV Vitamin C* ___ IV Enhance* ___ IV Chelation ___

Far Infrared Sauna ___ InBody Body Comp Scan ___

IV Myers' Cocktail ___ IV Glutathione ___ IV Iron ___ Home Sleep Study ___ Home 24HR BP Monitor ___ HALO Pap Breast Cancer Risk ___ *High-dose Vitamin C infusions may require pre-infusion testing for G6PD deficiency. Your practitioner can order through Quest/LabCorp. Or, you can order throughWalk-In-Lab (http://bit.ly/G6PD_Test) and provide LHHP with a copy of the results.

Medical Information

Operations: Hospitalizations: Please list any surgery and approximate year Other than operationsYear Surgery Year Reason Hospital ______

______

______

______

______

______

______

Family Medical History Age Health

(list significant illness) Age atDeath

If deceased, cause Comments

Father Mother Brothers or Sisters

Spouse Children

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Transfusions: Have you ever had a blood or plasma transfusion (circle) No Yes

Weight: What is your weight now? _______ One year ago? _______ Maximum? _______ When? ________

Females Only: Are you pregnant, planning a pregnancy or nursing a child? (circle) No Yes

Date of last menstrual period?_______________________

Have you previously received any of the following treatments or therapies? (Mark all that apply.) If so, please explain any side effects, or other difficulties, you experienced related to the treatment or therapy.

IV Vitamin Therapy: _________________________________________________________________ IV Chelation Therapy: ________________________________________________________________ Far-Infrared Sauna Therapy: ___________________________________________________________ Hyperbaric Oxygen Therapy: __________________________________________________________ Massage Therapy: ___________________________________________________________________ Acupuncture: _______________________________________________________________________ Hormone Replacement Therapy: ________________________________________________________Other: _____________________________________________________________________________

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New Patient Health Questionnaire

Name: ___________________________________________ DOB/ID: Systems Review: Please indicate those items that have been a recurrent or a recent significant change.

Yes No Constitutional Symptoms Good health lately Recent significant weight change Unusual fatigue or weakness

Frequent headaches

Eyes Change in vision Blurred or double vision Eye disease or injury Wear glasses/contact lenses?

Ears/Nose/Mouth/Throat/Neck Do you wear hearing aids? Hearing loss or ringing in ears? Earaches or drainage? Chronic sinus problems or runny nose

Nose bleeds Mouth sores Bleeding gums

Sore throat/hoarseness or voice change Lumps or swollen glands in neck

Difficulty swallowing Neck pain or stiffness

Cardiovascular Heart trouble

Chest pain or angina pectoris Palpitations

Shortness of breath with walking or lying flat Swelling feet, ankles or hands Waking at night with shortness of breath

Respiratory Chronic or frequent cough Coughing or spitting up blood Shortness of breath Asthma or recurrent wheezing

Gastrointestinal Loss of appetite Change in bowel movements Nausea or vomiting Painful bowel movements or constipation

Frequent diarrhea Rectal bleeding or blood in stool Stomach/abdominal pains or heartburn Black or tarry stools

Comments:

Yes No Genitourinary Frequent urination

Burning or pain on urination Blood in urine Change in force or strain when urinating Incontinence or dribbling of urine

Sexual difficulties Men: Testicular pain Women: Painful periods

Irregular periods Recurrent vaginal discharge

Number of pregnancies (including miscarriages):

# Deliveries _______ #Miscarriages

Method of birth control (if applicable)

Menopausal, since when:

Date of last menstrual period:

Date of last pap smear:

Date of last mammogram:

Yes No Musculoskeletal Joint pain(s)

Joint stiffness/swelling or warmth Weakness of muscles or joints Muscle pain or recurrent cramps

Back pain Cold hands or feet Difficulty in walking

Integumentary (Skin/Breast) Rashes or itching Change in skin color or moles Change in hair or nails

Varicose veins Breast pain Breast lump

Breast discharge or rash

Neurological Frequent, recurring or increasing headaches Light-headedness or dizziness Convulsions, seizures or spasms Numbness or tingling sensations

Tremors Paralysis Stroke Head injury

Loudoun Holistic Health Partners, PLLC

Yes No Psychiatric Memory loss or confusion

Nervousness Insomnia Depression

Endocrine Glandular or hormone problem Heat or cold intolerance Excessive skin dryness Excessive thirst or urination Change in hand or glove size

Hematologic / Lymphatic Slow to heal after cuts or wounds Bleeding or bruising tendency

Recurrent anemia Swelling, warmth or tenderness of veins

or history of phlebitis

Yes No Allergic / Immunologic History of skin reaction or other adverse reaction to: Penicillin or other antibiotic: describe

reaction: Morphine, Demerol or other narcotics

reaction: Novocain or other anesthetics

reaction: Aspirin or other pain remedies

reaction: Tetanus antitoxin or other serums Iodine, methiolate or other antiseptic

Other medications: Other known food allergies

Comments:

Reviewed by:

Date:

Physician Signature: Date:

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I certify that the information provided by me on this form is, to the best of my knowledge, accurate and complete. I acknowledge that withholding any medical information may increase the risk of harm from any treatment I receive.

Patient Signature:

Date:

Physician Review:

Loudoun Holistic Health Partners, 2019

LHHP Financial Policy Please read through carefully and sign the bottom to acknowledge understanding of our financial policies.

1. In order to provide comprehensive care and extended office visits, we do not participate with insurance. We are happy to provide the receipt necessary for you to file the claim for reimbursement but submission of the claim is the patient’s responsibility. It should be pointed out that we cannot assure a patient that any insurance company will reimburse for our services. Caseload demands do not allow time for this office to respond to insurance company requests for information. We will provide you a copy of medical records that you can forward to your insurance company. We are not obligated to take action on your behalf against an insurance carrier for collection of negotiating your insurance claim. We will not contact your insurance company unless there has been an error by this office.2. Please note the following LHHP policies:

A) Unless included as part of Concierge Membership benefits package, payment for any LHHP service is due at the time of service.B) In-Office and phone consults are billed in 15-minute increments (rounded up to next increment).C) Fees for laboratory testing vary depending on cost of panel selected. Please consult with your insurance company regarding your lab testing benefits. (See LHHP Lab Testing Policy for more info.)D) In-house labs (i.e. urinalysis, strep) are charged to patient at time of visit.E) Kindly provide 48-hours notice if you are not able to make your scheduled appointment.F) Appointments for IV Infusion Services must be canceled at least 24 hours prior to appointmentOR WILL BE CHARGED AT FULL PRICE.

3. We accept all major credit cards (a 3.5% processing fee will be added), cash, or check. A $35 fee will be collected for any failed credit card payment (for any reason).

4. Payment is expected in full at time of visit.

5. Phone consults are to the credit card on file after the consultation is finished. We will then mail you the receipt and treatment plan that Dr. Stewart makes for you. If you have any questions please feel free to contact our front office staff.

6. We accept ACH payments. A $35 fee will be collected for any failed ACH payment (for any reason).

7. Accounts are considered past due after the date of service. After 90 days, past due accounts will automatically be turned over for collection. Please be aware that in the event that your account is referred to an attorney for collection, you will be responsible for and must pay our bill, all court costs, private processing fees, and other costs of collection, as well as attorney’s fees in the amount of 33 1/3% of the bill, which sum you agree is reasonable. We also reserve the right to charge interest (up to 18%) on past due accounts.8. Opened supplements cannot be refunded or exchanged.

I acknowledge that I have read the financial policy and I agree to abide by its terms.

___________________________ _________________________ Signature Name (printed)

__________________ Date

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Office Etiquette for LHHP Patients

Everyone at LHHP strives to ensure that your visit with us is as productive and effective as it can possibly be. For that reason, it is important for you, as well as for other patients visiting at the same time you are, to adhere to the following policies.

1. Silence ALL electronic devices while in our office.a. If you must take a call, please notify the receptionist and step out of the office.

2. Please leave your children at home, unless they are the scheduled patient.a. They may distract you and/or your LHHP provider and make your visit less productive.b. If you must bring them to the office:

i. They must not be left unattended. An adult must be present with them at all times.ii. If your children must be left unattended, LHHP reserves the right to reschedule your appointment.

iii. If your children are left unattended, LHHP will hold you responsible for any damages they cause to the officefurniture, equipment, etc.

3. Please do not ask the receptionist or the nurse questions about your medical care.a. They are NOT (except in certain circumstances) authorized to give medical advice of ANY kind.b. They are not aware of your care plan. This may lead to misinformation which may cause harm.

4. Please do not wear any perfumes, colognes, or other scented cosmetics or skincare products.a. Many LHHP patients have multiple sensitivities to odors.

5. LHHP will not provide medical advice to ANY person who is not an established LHHP patient.a. It is illegal for us to do so. It is unsafe for us to do so because we do not know the entire case.b. This includes your family members, best friends, etc.

6. LHHP expects its staff and its patients to extend the utmost respect and patience to one another.a. From Dr. Dave and Dr. Anne:

i. We, and our staff, will provide you with the best care possible. However, we are not perfect. We promiseto extend to you the utmost grace and patience possible (in accordance with our established officepolicies). In return, we expect the same from you. We will not tolerate rudeness or disrespectful behavior(including taking anangry/disrespectful tone or using disrespectful language) to our staff under ANY circumstance. Also, wepromise not to tolerate rudeness from our staff to you under ANY circumstance.

ii. It will be at the discretion of the LHHP Officers (David Stewart, MD, Anne Stewart, MD, and other LHHPAdministrators) to determine if any behavior is inappropriate. Violations of this policy will be handled asfollows:

1. First violation: A warning will be issued both verbally and in writing (by certified mail).2. Second violation: Immediate dismissal from LHHP. Notification will be provided both verbally and

in writing (by certified mail).iii. If you feel you have been treated inappropriately by anyone at LHHP, please contact David Stewart, MD to

discuss the matter.

I acknowledge that I have read the office policy and I agree to abide by its terms.

________________________________________ Print Name

________________________________________ Signature

__________________ Date

Patient Acknowledgment of LHHP Privacy Policy

I understand that, under the Health Insurance Portability & Accountability Act (HIPPA), I have certain rights to privacy regarding my protected health information.

I have been informed by you of your Notice of Privacy Practices (Copy attached). I have been given the right to review such Notice of Privacy Practices prior to signing this consent form. I understand this practice has the

right to change its Notice of Privacy Practices from time to time and that I may contact this practice at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to

my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name:__________________________________________________________________

Signature:_____________________________________________________________________

Relationship to Patient:___________________________________________________________

Date:_________________________________________________________________________

I authorize the staff of Loudoun Holistic Health Partners to disclose medical information (i.e. lab results) by phone and/or in person to the following people (please provide names and phone number).

1.____________________________________________________________________________

2. ____________________________________________________________________________

3.____________________________________________________________________________

Loudoun Holistic Health Partners, 2019

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 - THIS IS YOUR COPY - KEEP FOR YOUR RECORDS

If you have any questions about this Notice, please contact our Privacy Officer at

209 Old Waterford Rd, NW Leesburg, VA 20176 or (703) 779-2801

1. Purpose.

We understand that medical information about you and your health is personal and we are committed to protecting that information. We create a record of the care and services you receive at Loudoun Holistic Health Partners, in order to provide you with quality care and to comply with certain legal requirements.

This Notice of Privacy Practices describes how we may use and disclose medical information about you, including demographic information, that may identify you and your related health care services to carry out your treatment, obtain payment for our services, to perform the daily health care operations of this practice and for other purposes that are permitted or required by law. This notice also describes your rights to access and control your medical information. For the purpose of this document, "you" refers to the patient.

We are required to abide by the terms of this Notice of Privacy Practices.

2. Written Acknowledgement.

You will be asked to sign a written statement acknowledging that you have received and reviewed a copy of this notice. The acknowledgement only serves to create a record that you have received a copy of the notice.

3. Changes 1D this Notice.

We may change the terms of our Notice, at any time. The new Notice will be effective for all medical information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. To request a revised copy, you may call our office and request that a' revised copy be sent to you in the mail or you may ask for one at the time of your next appointment.

4. How We May Use and Disclose MedicallnfOl'IDation about You.

The following categories describe the different ways that Loudoun Holistic Health Partners may use and disclose your medical information and a few examples of what we mean. These examples are not meant to describe every circumstance, but to give you an idea of the types of uses and disclosures that may be made by our office. Other uses and disclosures of your medical information that are not listed or described below will be made only with your written anthorization. You may revoke this authorimtion, at any time, in writing, but it will not apply to any actions we have already taken.

Please keep in mind that these examples pertain to medical information for your child, or yourself, if you are a patient who is of legal age.

✓ For your Treatment: Your medical informationmay be used and disclosed by us for the purpose of providing medical treatment to you or for another health care provider providing medical treatment toyou. For example, a nurse obtains treatment

information about you and documents it in your medical reoord and the physician has access to that information. .In addition, your medical information may be provided to a physician to whom you have been referred or are otherwise seeing to ensure that the physician has the necessary information to diagnose or treat you.

✓ For your Emergency Treatment: Your medical and certain demographic information may be used in order for us to provide emergency treatment to you. This information may be transmitted via pager, cell phone, or email. For example, if you need to speak tothe physician on-call at night, your natne, phonenumber, and nature of the emergency may becommunicated to the doctor via an alpha-numeric pager. This will allow for the quickest response toyour emergencies.

✓ To Obtain Payment for onr Services: Your medical information ritay be used and disclosed by us to obtain payment for your health care bills or to assist another health care provider in obtaining pll)'ffiCIII for their health care bills. For example, we may submit requests for payment to your health insurance company for the medical services that you received. We may also disclose your medical information as required byyour health insurance plan before it approves or paysfor the health care services we recommend for you.

✓ For our Health Care Operations: Your medicalinformation may be used and disclosed by us to support our daily operations. These health careoperation activities include, but are not limited to, quality assessment activities, employee rei,;iew activities, training of medical students, licensing, fundraising activities, and conducting or arranging forother business activities. For example, we maydisclose your medical information to medical school students that see patients at our office. We may also use the medical information we have to determine where we can make improvements in the services and care we offilr.

✓ For the Health Care Operation• of Other HealthCare Providers: We may also use your medical information to assist another health care provider treating you with its quality improvement activities, evaluation of the health care professionals or for ftaud and abuse detection or compliance. For exatnple, we may disclose your medical information to another physician to assist in its efforts to make sure it iscomplying with all rules related to o�ting a medical Pract!ce.

✓ For Appointment Reminders and Scheduling: We may use or disclose your medical information to contact you to remind you of your appointment, by mail, telephone, or email. Our message will include the. name of our practice or the name of our physician as well as the date and time for your appointment or areminder that an appointment needs to be scheduled.

✓ For Lah Result Notification: We may use or disclose your medical information to contact youregarding lab test results, by mail, telephone, or email. Our message will include the name of our practice or

the name of our physician as well as whether the lab test was positive or negative.

✓ For Referral Notification: We may leave youinformation regarding referral appointments/testing and referral numbers via mail, telephone, or email.

✓ To Provide you with Treatment Alternatives: Wemay use or disclose your medical information to provide you with information about treatment alternatives or other health-related benefits and services that may be ofinterest to you. For example, we may contact several home health agencies or physical therapy providers to discuss the services they provide when we have a patient who needs those services.

✓ To our Bnsiness Associates: We will share yourmedical information with third party "businessassociates" that perform various activities (e.g., billing,transcription services) for the practice. Whenever anarrangement between our office and a business associate involves the use or disclosure of your medical information, we will have a written agreement that contains terms that will protect the privacy of your medical information. For example, Loudoun HolisticHealth Partners may hire a billing company to submitclaims to your health care insurer. Your medicalinformation will be disclosed to this billing company,but a written agreement between our office and thebilling company will prohibit the billing company fromusing your medical information in any way other thanwhat we allow.

✓ For Education/Networking/FundraisingActivities: We may use or disclose your demographicinformation and the dates that you received treatmentfrom us in order to contact you regarding educational orfundraising opportunities supported by our office. Anexample of this would l!e inviting patients diagnosedwith fibromyalgia to a presentation on that topic. If you do not want to receive these materials, please contactthe Privacy Officer and request that these fundraisingmaterials not be sent to you.

✓ Others Involved in your Health Care: Unless youobject, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your medical information that directly relates to that person's involvement in your health care. If you areunable to agree or object to such a disclosure, we maydisclose such information as necessary if we determine that it is in your best interest based on our professionaljudgment We may use or disclose your medical information to notify a family member or any otherperson that is responsible for your care of your location and general health condition. Finally, we may use or disclose your medical information to an authorm:d public or private entity to assist in (I) disaster reliefefforts and (2) to coorljinate uses and disclosures tofamily or other individuals involved in your health care.

✓ A. Required by Law: We may use or disclose your medical information to the extent that the use or disclosure is required by law. The use or disclosure willbe made in compliance with the law and will be

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limited to the relevant requirements of the.laws. You will be notified, as required by law, of any such uses or disclosures.

✓ For Public Health Activities: We may discloseyour medical information for public health activitiesand purposes to a public health authority that is permitted by law to collect or receive the information.The disclosure will be made for the purpose ofcontrolling disease, injury or disability. We may alsodisclose your medical information, if directed by thepublic health authority, to any other governmentagency that is collaborating with the public healthauthority.

✓ As Required by the Food and DrugAdministration: We may disclose your medicalinformation to a person or company required by the

• Food and Drug Administration to report adverseevents, product defects or problems, biologic product deviations, or to track products; to enable product recalls; to make repairs or replacements; or to conduct post marketing surveillance, as required.

✓ For Communicable Disease Exposure: We maydisclose your medical Information, If authorized bylaw, to a person who may have been exposed to acommunicable disease or may otherwise be at risk ofcontracting or spreading the disease or condition.

✓ To your Employer: We may disclose yourmedical information concerning a work related injuryor illness to your employer if you are covered underyour employer's policy in order to conduct anevaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-relatedinjury, in accordance with the law.

✓ For Abuse or Neglect:· We may disclose your.medical information to a public health authority that isauthorized by law to receive reports of child or adultabuse or neglect In addition, we may disclose yourmedical information if we believe that you have been avictim of abuse, neglect or domestic violence as maybe required or permitted by Virginia and/or federallaw.

✓ For Health Oversight: We may disclose yourmedical information to a health oversight agency foractivities authorized by law. Oversight agenciesseeking this information include government agenciesthat oversee the health care system, government benefitprograms (such as Medicare or Medicaid), othergovernment regulatory programs, and civil rights laws.

✓ In Legal Proceedings: We may disclose yourmedical information in the course of any judicial oradministrative proceeding, in response to an order of acourt or administrative tribunal (to the extent suchdisclosure is expressly authorized), and in certainconditions in response to a subpoena or other lawfulrequest.

✓ For'l,aw Enforcement: We may also discloseyour medical information, so long as all legalrequirements are met, for law enforcement purposes.Examples of these law enforcement purposes include(I) information requests for identification and locationpurposes, (2) pertaining to victims of a crime, (3)suspicion that death has occurred as a result of criminalconduct, (4) in the event that a crime occurs on thepremises of the Practice, and (S) in a medicalemergency where it is likely that a crime has occurred.

✓ To Coroners, to Fuueral Directors, aud forOrgan Donation: We may disclose your medicalinformation to a coroner or medical examiner foridentification purposes, determining cause of death orfor the coroner or medical examiner to perform otherduties authorized by law. We may also disclose

medical information to a funeral director in order to permit the fimeral director to carry out its duties. We may disclose such information in reasonable anticipation of death. Your medical information may be used and disclosed for cadaveric organ, eye, or tissue donation purpose.

✓ For Research: We may disclose your medicalinformation to researchcfs when their research hasbeen established as required by federal and state law.

✓ Due to Criminal Activity: Consistent withapplicable federal and state laws, we may disclose yourmedical information if we believe that the use ordisclosure is necessary to prevent or lessen a seriousand imminent threat to the health or safety of a personor the public. We may also disclose your medicalinformation if it is necessary for law enforcementauthorities to identify or apprehend an individual.

✓ For Military Activity and National Security:When the appropriate conditions apply, we may use ordisclose medical information of individuals who areArmed Forces personnel (I) for activities deemednecessary by appropriate military commandauthorities; (2) for 1he purpose of a determination bythe Department of Veterans Affairs of your eligibilityfor benefits; or (3) to foreign military authority if youare a member of that foreign military services. Wemay also disclose your medical inrormation toauthorized federal officials for conducting nationalsecurity and intelligence activities, including for theprovision of protective services to the President orothers legally authorized.

✓ For Workers' Compensation: Your medicalinfomtation may be disclosed by us as authorized tocomply with workers' compensation laws and othersimilar legally established programs.

✓ Regarding Inmates: We may use or disclose yourmedical information if you are an inmate of acorrectional facility and your physician created orreceived your medical information in the course ofproviding care to you.

✓ For Required Uses and Disclosures: Under thelaw, we must make disclosures to you and, whenrequired by the Secretary of the Department of healthand Hmnan Services, to investigate or determine ourcompliance with the requirements of the HealthInsurance Portability and Accountability Act and itsregulations.

5. Your Rights.

Following is a statement of your rights with respect to your medical information and a brief description of how you may exercise these rights.

You have the right to inspect and ropy your medical informatio1L You may inspect and obtain a copy of your medical information that we maintain. The information may contain medical and billing records and any other records that we use for making decisions about you. However, under federal law, you may not inspect or copy the following records: psychotherapy notes; information compiled related to a civi� crlmlnal, or administrative action; and medical information that is subject to law that prohibits access to medical information in certain circumstances. We may deny your request to inspect your medical information. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

You have the right to request a restriction of your medleal Information. This means you may ask us not to use or disclose any part of your medical information

for the purposes of treatment, payment or health care operations. You may also request that any part of your medical information not be disclosed to family members or friends wbo may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply.

We are not required to agree to your request. If we agree to the requested restriction, we may not use or disclose your medical information in violation of that restriction unless it is needed to provide emergency treatment or Wlless we otherwise notify you that we can no longer honor your request. With lhis in mind, please discuss any restriction you with to request.with you physician. Please request all restrictions in writing to our Privacy Officer.

You have the right to request that we acrommodate you in communicating roofidentlal medical information. We will accommodate reasonable requests, but we may condition this accommodation by asking you for information as to how payment will be handled or other information necessary to honor your request. Please make this request in writing to our Privacy Officer.

You may have the right to ask us to amend your medical information. You may request an amendment of your medical information as long as we maintain this information. In certain cases, we may deny your request for amendment If we deny your request for an amendment, you have the right to file a disagreement with us and we may respond in writing to you. Please contact our Privacy Officer if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your medical informatio1L This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made pursuant to your authorization (permission), made directly to you, to family members or friends involved in your care, or for appointment notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2006. You may request a shorter time ftame. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper ropy of this notice from us. If you would like a paper copy of this notice, please request one from our Privacy Officer or request one when you are in our offices.

6. Complaints.

You may complain to us if yon believe your privacy rights have been violated by us. To file a complaint, please contact our Privacy Officer who will be happy to assist you. You may file a complaint with us by notifying our Privacy Officer of your complaint We will not retaliate against you for filing a complaint. If you do not wish to file a complaint with us, you may contact the Secretary of Health and Human Services.

7. Privacy Contact.

If you have any questions about this Notice or require additionfll information, please contact our Privacy Officer, at (703) 779-2801 or at 209 Old Waterford Rd, NW,Leesburg, Virginia 20176. Our Privacy Officer is available during normal business hours to discuss your privacy questions, concerns or complaints.

8. Effective Date. This notice was published andbecomes effective on April 14, 2006.

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