This notice describes:

• HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

• YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

• HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR HEALTH INFORMATION, OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION

YOU HAVE A RIGHT TO A COPY OF THIS NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH FHP. Please use the contact information at the bottom of this form IF YOU HAVE ANY QUESTIONS.