Acknowledgment of receipt of notice of privacy practices: this notice is effective on colon April 14, 2003

Please sign your name and print your name on this acknowledgment form. Return your signed acknowledgment to the receptionist.

Signature________________________________________

Printed Name_____________________________________

Date_____________________________________________

This notice is effective on April 14, 2003

William R. McKenna, MD PA

PROVIDER NOTICE

OF PRIVACY PRACTICE

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.

Uses and disclosures of health information

We use health information about you for treatment, to obtain for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Continually of care is part of treatment and your records may be shared with other providers to whom you are referred information may be shared by paper mail, electronic mail, fax, or other methods.

We may use or disclose identifiable health information about you without your authorization for several reasons. Subject to certain requirements, we may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We may provide information when otherwise required by law, such as for law enforcement and specific circumstances. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that are authorization to stop future uses and disclosures.

We may change our policies at any time. Before we make a significant change to our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time. Fore more information about our privacy practices, contact the person listed below.

Individual rights

In most cases, you have the right to look at or get a copy of health information about your that we use to make decisions about you. If you request copies, we will charge you only normal photocopy fees. You also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment, or related administrative purposes and other than when you explicitly authorize it. If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add missing information.

Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you the appropriate address upon request.

Our legal duty

We are required by law to protect the privacy of your information, provide this notice about our information practices, follow the information practices that are described in this notice, and obtain you acknowledgment of receipt of this notice

If you have any questions or complaint, please contact:

Office Manager: Barbara Paris

Address: 1713 Treasure Hills Blvd., Ste 1-B

Harlingen, Texas 78550

Phone: (956) 425-9240