YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR ALL OTHER USES OR DISCLOSURES OF YOUR HEALTH INFORMATION

Other uses and disclosures of medical information other than those described above will be made only with your written permission (“Authorization”). If you provide us with an Authorization to use or disclose medical 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 medical information about you for the reasons covered by your written Authorization. You understand that we are unable to take back any disclosure we have already made with your permission, and that we are required to retain our records of the care that we provided to you. You also will be unable to revoke written Authorization to disclose medical information that you gave as a condition of obtaining insurance coverage where the law allows the insurer to contest a claim under the policy or the policy itself.

YOUR INDIVIDUAL RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights regarding your health information:

Right to Request Restrictions. You may request restrictions on our use and disclosure of your medical information for a particular reason related to service, payment and health care operations, or that we not disclose medical information to a family member or other specific relative or close friend involved in your care. All requests for such restrictions must be made in writing. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. If you wish to request additional restrictions, please obtain a request form from your Executive Director and submit the completed form to the Executive Director. We will send you a written response.

Right to Request Confidential Communications . You have the right to request that we communicate with you about medical matters in a confidential manner or at a specific location. For example, you may ask that we contact you via mail to a post office box.

If you wish to request alternative locations, please obtain a request form from your Executive Director and submit the completed form to the Executive Director.

Right to Inspect and Copy. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. If you desire access to your records, please contact a record request form from the Director of Business Administration.

• Right to Amend Your Records. You have the right to request that we amend your health information . We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply. If you desire to amend your records, please obtain an amendment request form from the Executive Director and submit the completed form to the Executive Director. All requests for amendments must be in writing

• Right to Receive An Accounting of Disclosures . You may request that we provide you with a written accounting of certain disclosures made by us during a certain time period. This is a list of certain disclosures we made of your medical information. It will not include certain disclosures such as those made for treatment, payment or healthcare operations purposes. You must submit your request in writing to your Executive Director. Your request must state a time period, which may not be longer than 6 years from the date the request is submitted and may not include dates before April 14, 2003.

• Right to Receive Paper Copy of this Notice . You have the right to obtain a paper copy of this Notice, even if you agreed to receive such notice electronically. You may obtain a copy of this notice from your Executive Director.

SPECIAL REGULATIONS REGARDING DISCLOSURE OF SUBSTANCE ABUSE OF PSYCHIATRIC AND HIV-RELATED INFORMATION

For disclosures concerning certain health information such as HIV-related information or records regarding psychiatric care or substance abuse that have been sent to us by another provider, special restrictions apply. Generally, we will disclose such information only with an Authorization, or as otherwise required by law.

TO REPORT A CONCERN REGARDING OUR PRIVACY PRACTICES

If you believe your privacy rights have been violated, you may file a complaint with Benchmark or with the Secretary of the Department of Health and Human Services. To file a complaint with Benchmark, contact Benchmark’s Privacy Officer Designee, Barbara Devereux, at the following telephone number (781) 489-7153 or Office of Civil Rights in the U. Department of Health and Human Services at 200 Independence Avenue, W., Room 509F, HHH Building, Washington D.C. 20201. All complaints must be submitted in writing. There will be no retaliation for filing a complaint.