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NOTICEOF PHI
YC
1 PHCTICE8
PHY L|TOV|T, M.L.,H.L.
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 notice takes effect on April 14, Z00oand remains in effect until we replace it.
1. OUR PLEDGE REGARDING MEDICAL INFORMATION
The privacy of your medical information i s i mportant to us. We understand that your medical information is personal
and we are committed to protecti ng it. We create a record of the care and services you receive at our practice. We
need thi s record to provide you with quality care and to comply with cerain legal requirements. This notice will tell you
about the ways we may use and share medical information about you. We also describe your ri ghts and cerain duties
we have regardi ng the use and disclosure of medical information.
Z. OUR LEGAL DUTY
Law Reuires Us to:
T. Keep your medical information private.
Z. Give you this notice descri bi ng our legal duties, privacy practices, and your rights regardi ng your medical
i nformation.
o. Follow the terms of the notice that is now in effect.
We Have the Right to:
1. Change our privacy practices and the terms of this notice at any ti me, provided that the changes are permitted
by law.
Z. Make the changes i n our privacy practices and the new terms of our notice effective for all medical information
that we keep, i ncl udi ng information previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before we make an important change i n our privacy practices, we will change this notice and make the new
notice availabl e upon request.
o. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways that we use and disclose medical information. Not every use or
disclosure will be listed. Your specific written authorization will be requested for use or disclosure purposes not fisted.
Any specific written authorization you provide may be revoked at any ti me b

writing to us.
"
FOH THbATMbNT! We may use medical i nformation about you to provide you with medical treatment or
s
ervices.
We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who
are taking care of you. We may also share medical information about you to your other health care providers to assist
them in treati ng you.
FOHHbALTHCAHbOPbHAT|ONb. We may use and disclose your medical i nformation for our health care
operations. This might include measuring and improving quality, eval uating the performance of employees, conducting
training programs, and getting the accreditati on, cerificates, licenses and credentials we need to serve you.
AUUT|ONAL Ubbb ANUU|bCLObUHbb. In addition to usi ng and disclosing your medical i nformation for treatment,
payment, and health care operations, we may use and disclose medical i nformation for the following purposes:
Notification: Medical i nformation to notify or help notify: a fami l y member, your personal representative or another
person responsible for your care. We will share information about your location, general condition, or death. We may
share information that directly relates to that person's involvement i n your health care. If you are present, we will get
your permission if possi bl e before we share, or give you the opportunity to refuse permission. I n case of emergency,
and if you are not abl e to give or refuse permission, we will share only the health i nformation that is directly necessary
tor your heal th care, according to our professional judgement. We will also use our professional judgement to make
decision
s
i n your best i nterest about allowing someone to pick up medicine, medical supplies, x-ray or medical
information for you.
Disaster Relief: Medical information with a publ ic or private organization or person who can legally assist i n disaster
relief effors.
Research In Limited Circumstances: Medical i nformation for research purposes in li mited circumstances where the
research has been approved by a review board that has reviewed the research proposal and established protocols to
ensure the privacy of medical information.
NOTICEOF
PHIVC1 PHCTICE8
Funeral Dictor, Coroner, Medical Examiner: To hel p them
carry' out their duties, we may share the medical
information of a person who has died with a coroner, medical examiner, funeral di rector, or an organ procurement
organizati on.
Specialzed Goverment Functions: Subject to certain requi rements, we may disclose or use health information for
mi l itary personnel and veterans, for national security and intelligence activities, for protective services for the President
and others, for medical suitability determinations for the Deparment of State, for correctional i nstitutions and other law
enforcement custodial situations, and for goverment programs arovidi ng public benefits.
Court Orders and Judicial and Administative Proceedings: We may disclose medical information in response to
a court or admi nistrative order, subpoena, discovery request, or other lawful process, under certain ci rcumstances.
Under l i mited ci rcumstances, such as a court order, warrant, or grand j ury subpoena, we may share your medical
information with law enforcement officials. We may share li mited information with a law enforcement official
concerni ng the medical information of an i nmate or other person in lawful custody with a law enforcement official or
correctional institution under cerain circumstances.
Public Health Activities: As required by law, we may disclose your medical information to public health or legal
authorities charged with preventing or control l ing disease, injury, or di sabi l ity, i ncludi ng chi l d abuse or neglect. We
may also di sclose your medical information to persons subject to j urisdiction of the Food and Drug Admini stration for
purposes of repori ng adverse events associated with product defects or problems, to enable product recal l s, repairs or
replacements, to track products, or to conduct activities required by the Food and Drug Acministration. We may also,
when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or
otherwise be at risk of contracti ng or spreading a disease or condition.
Victims of Abuse, Neglect, or Domestic Violence: We may disclose medical information to appropriate authorities if
we reasonably bel i eve that you are a possi ble victim of abuse, neglect, or domestic violence or the possible victim of
other cri mes. We may share your medical information if it is necessary to prevent a serious threat to your health or
safety or the health or safety of others. We may share medi cal information when necessary to hel p law enforcement
officials capture a person who has admitted to bei ng part of a crime or has escaped from legal custody.
Workers Compensation: We may disclose health information when authorized and necessary to compl y with laws
relating to workers compensation or other si mi lar programs.
Health Oversight Activities: We may disclose medical information t o an agency providing heal th oversi ght for
oversight activities authorized by law, i ncl udi ng audits, ci vi l , administrative, or criminal investigations or proceedi ngs,
inspections, licensure or discipl inary.actions, or other authorized activities.
Law Enforcement: Under cerain circumstances, we may disclose health information to law enforcement officials.
These ci rcumstances i ncl ude reporting required by certain laws (such as the reporting of certain types of wounds),
pursuant to cerain subpoenas or court orders, reporting l i mited information concerni ng identification and location at
the request of law enforcement official, reports regarding suspected victi ms of crimes at the request of a law
enforcement official, reporing death, crimes on our premises, and crimes i n emergencies.
4. YOUR INDIVIDUAL RIGHTS
You Have a Right to:
T . Look at or get copies of your medical information. Thi s right does not apply to psychotherapy notes. You must
make a request i n writing and there is a charge for copying and mai l i ng records. Please ask for a full explanation
of our fee structure.
Z. Receive a list of al l the times we shared your medical information for purposes other than treatment, payment, and
health care operations and other specified exceptions.
o Request that we pl ace additional restrictions on our use or disclosure of your medical information. We are not
requi red to agree to these additional restrictions, but if we do so, we wi l l abide by our agreement (except in the
case of an emergency).
4. Request that we communicate with you about your medical information by different means or to different locations.
Your request that we communicate your medi cal information to you by different means or at different locations
must be made in writing to your doctor.
b. Request that we change your medical information. We may deny your request if we did not create the information
you want changed or for certain other reasons. I f we deny your request, we wi l l provide you a written explanation.
You may respond with a statement of disagreement that will be added to the information you want changed. If we
accept your request to change the information, we wi l l make reasonabl e efforts to tel l others, i ncl udi ng people you
name, of the change and to i nclude the changes i n any future shari ng OI that information.
QUESTIONS AND COMPLAINTS
If you have any questions about thi s notice or if you thi nk that we may have vi olated your privacy rights, please contact
us. You may also submi t a written complaint to the U. S. Department of Health and Human Services. We will not
retaliate if you choose to fi l e a compl aint.
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LEX I NGTON , K Y 405 1 2-4 1 1 2
202-484- 1 650 1 -800-848-9766
TDD NUMBER 202-479-3546
WWW . CAREF I RST . COM
EXPLANATI ON OF BENEFITS AT A GLANCE
|
|
| dIl L t0LIuL I D Number : R59450499
001 4702580F
0 1 /25/20 1 0
0 1 / 1 4/20 1 0
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| C l a i m Number :
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l C l a i m Rece i ved On :
| 0 of Si ce: 12

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Check Number : 1 00872
' rov i der : GARY L L I TOV I TZ Da tes of Serv i ce : 1 2/07/2009 - 1 2/07/2009
rype : NON-PART I C I PAT I NG PROV I DER
rype of Serv i ce Subm i tted l P l an ! Remark ! Deduct l Co i nsurance l Med i care/ l
What ! You Owe the
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EXPLANATI ON OF REMARK CODES
J9J.JbJ 3.9
62 1 - -ALLOWABLE CHARGES FOR COVERED SERV I CES BY NON-PART I C I PAT I NG P ROFESS I ONAL
PROV I DERS ARE PA I D BASED UPON THE NON-PART I C I PAT I NG PROV I DER ALLOWANCE .
P LEASE REFER TO YOUR BLUE CROSS AND BLUE SH I ELD SERV I CE BENEF I T PLAN
BROCHURE . YOU ARE RESPONS I BLE FOR THESE CHARGES , EXCEPT WHEN ANOTHER CARR I ER
HAS PA I D FOR THE SERV I CE ( S ) I N F ULL .
YOUR RESPONS I B I L I TY TO THE PROV I DER ( S ) I S $380 . 00 . WE PA I D $ 1 0 1 . 1 6 .
THE PROV I DER CAN COLLECT $380 . 00 FROM YOU FOR THESE SERV I CES .
WE ARE PAY I NG YOU D I RECTLY FOR THESE SERV I CES BECAUSE YOUR P ROV I DER DOES NOT
PART I C I PATE I N OUR LOCAL PROV I DER NETWORK . YOU ARE RESPONS I BLE FOR THE TOTAL
PROV I DER ' S CHARGE , I NCLUD I NG ANY D I F FERENCE BETWEEN OUR PAYMENT AND THE
AMOUNT B I LLED . CONTACT YOUR PROV I DER TO D I SCUSS WHAT YOU OWE .
OUTPAT I ENT V I S I TS FOR THE TREATMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE BY
PREF ERRED AND NON-PREFERRED PROV I DERS ACCUMULATE TOWARD THE NON-PREFERRED V I S I T
L I M I T OF UP TO 25 V I S I TS . W I TH TH I S CLA I M YOU HAVE ACCUMULATED 1 1 V I S I TS TOWARDS
TH I S MAX I MUM FOR 2009 . WHEN YOU USE A PREFERRED PROV I DER AND FOLLOW AN APPROVED
TREATMENT PLAN TH I S MAX I MUM MAY BE WA I VED .
Cont i nued On Next Page
THANK YOU FOR ALLOWING US TO SERVE YOU
Usted below are defnitions to help describe this Explanation of Benefts.
PROVIDER: The hospi tal , heal th care fci l i ty, physi cian or other health care professi onal who
provided services to you.
PROVIDER TYPE: Each l ocal Blue Cross and Bl ue Shield Pl an can contract with providers
i n its service area. There are two types of professional contracti ng providers, Preferred and
Partici pati ng, and two types of contracting faci liti es, Prefened or Member. If providers do not
contract with the Plan, they ae considered to be non-partici pati ng or non-member.
DATE 1SERVICE: The month, day and year you actually received servi ces.
TYPE OF SERVICE: This i s a general description of the service or s upply provided.
SUB. MITTED CHARGES: Thi s iS the amount the provider has billed.
PLAN ALLOWANCE: The amount used to determi ne Upayment and your coinsurance for
covered services or the umCuuI we use I0CulLu8I0 oU payment for covered services.
REMARK CODES: An explanation of the payment determi nation fr a particul ar service.
DEDUCTIBLE: The fixed amount of covered expenses you must i ncur each cal endar year for
certain covered services and supplies befre we start paying benefi ts.
COINSURANCE: The percentage of the Pl an Allowance that you must pay for your care.
COPY: The fxed amount of money you pay to the physician. faci lity, pharmacy, etc. when you
receive certai n services.
MEDICARE/OTHER INS.: The amount pai d by another health insurance carrier when you or
covered frj l y members have coverage with Medicare or another health benefit pl an.
NON-COVERED CHARGES: Ydi d not pay for these services. The Bl ue Cross and Bl ue
Shiel d Servi ce Benefit JIuu does not consider these charges as a covered beneft. You are
responsi bl e for these charges.
PRECERTIFICATION PENALTY: \Ve v! reduce your benefit by S00if no one (you, your
physician or the hospi tal ) contacts us to obtain precertification of i npatient hospital servi ces,
when requi rPd.
CATSTROPHIC PROTECTION: \ Service Beneft Pl an coverage !ImII your out-of
pocket c\|tuSts , coi nsurance, copayrents and deductibles you pay per calendar year. If you
reach you tuluS|I|1t !oUl!n l imi t vI!|I a calendar year, we wil l pay l percent of certain
covered out-of-pocket expenses for the remainder 0Jthe year. Pl ease note that not all of your
out-of-pocket expenses will count toward meeting your catastrophic protection li mit. See your
Service Benefit Pl an brochure for more info1mation.
If you have any questions, please refer to your Blue Cross and Blue Shield Service Beneft Plan
brochure (RI 71-005), or call us at the telephone number shown on the font of this HI.
HELP STOP :FRAUD AND ABUSE!
IF YOU SUSPECT FRAUD OR ABUSE
CALL THE FEP ANTIFRAUD HOTLINE:
1-800-FEP-8440 (337-8440)
SM
BlueCross.
BlueShield, r
Federal Employee Program
WWW.0bluc.uty
LYNNAE D W I LL I AMS
70 EYE ST SE APT 1 2 1 0
WASH I NGTON D C 20003 - 3323
00006087495737001560001 5600003l0003
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PAGE 02
Cl aim Number : 00147025 80F ( continued) :
YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY
DUE TO THE I MPORTANCE OF HAV I NG EVERYONE I N THE R I SK GROUPS I DENT I F I ED BY THE
CDC RECE I VE THE H l N l FLU VACC I NE , I N ADD I T I ON TO THE SEASONAL FLU VACC I NE ,
YOUR SERV I CE BENEF I T PLAN COVERAGE W I LL PROV I DE BENEF I TS FOR THE
ADM I N I STRAT I ON OF THE H l N l VACC I NE , BASED ON THE CDC GU I DEL I NES . FOR MORE
I NFORMAT I ON PLEASE V I S I T OUR WEBS I TE AT WWW . F EPBLUE . ORG, CALL OUR 24/7 NURSE
ADV I CE L I NE ( 1 -888-258-3432 , OPT I ON 1 ) REGARD I NG TREATMENT FOR THE FLU OR
CALL US AT THE NUMBER ABOVE/BELOW FOR QUEST I ONS ON YOUR BENEF I T COVERAGE .
YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY
NEW WELLNESS I NCENT I VE COM I NG I N 20 1 0 : BEG I NN I NG 1 / 1 /20 1 0 , WHEN YOU COMPLETE
YOUR BLUE HEALTH ASSESSMENT QUEST I ONNA I RE , YOU W I LL RECE I VE A CERT I F I CATE OF
COMPLET I ON . PRESENT TH I S CERT I F I CATE WHEN YOU USE A PREFERRED PROV I DER FOR
YOUR ANNUAL ROUT I NE P HYS I CAL EXAM I NATI ON AND YOU CAN RECE I VE YOUR PREVENT I VE
EXAM I NAT I ON W I THOUT PAY I NG THE OFF I CE V I S I T COPAY . SEE YOUR 20 1 0 BROCHURE OR
V I S I T WWW . FEPBLUE . ORG, FOR MORE I NFORMAT I ON .
Hea l th T i ps
New for 20 1 0-your Per sona l Hea l th Record . You now have a secure , on l i ne l oca t i on to s tore i mportant
hea l th-re l ated i nforma t i on for you a nd your fam i l y i n one p l ace . Access the new Person a l Hea l th Record
on www . fepb l ue . or g today .
Have you taken the B l ue Hea l th Assessment yet? Spend a few m i nutes on l i ne to a nswer s i mp l e ques t i ons
a bout yourse l f , l ea r n how to take charge of your hea l th w i th an act i on p l an just for you and rece i ve a
9iI iIi\ LerIiJiQte upn cl etio. Visi t ww .fepl ue.org [N,
5 of O-o- Pock Es ) I
hat You Have P a i d
I nd i v i dua l
F am i l y
nnua l Max i mum
I nd i v i dua l
Li IN
I l Catastroph i c Protect i on I
! Ca l endar Yea r ! P r eferred I
Non-Preferred/ I
I Deduct i b l e | I Preferred Tota l I
I I I I
| $300 . 00 1 $ 1 , 1 1 3 1 $ 1 , 1 1 3 1
I $0 .00I $0I $0 I
I I l I
I $300 . 00 I $5 , 000 I $1 , 000 1
J .J J |
Your Out-of-Pocket Expenses I
| |
! Ca l endar Year Deduct i b l e $0 . 00 1
! Per Adm i ss i on Copay $0 . 00 I
I Co i nsurance $67 . 43 I
I Copayment $0 . 00 I
! Non-covered Charges $21 1 . 41 1
I Precer t i f i ca t i on Pena l ty $0 . 00 I
I I
! T: .b|
you have ques t i ons , p l ea s e ca l | a customer serv i ce representat i ve a t your l oc a l B l ueCross B l ueSh i e l d
an . I f you d i s a gree w i th the dec i s i on o n your c l i ms o r reques t for serv i ces , and w i s h to have the
c i s i on recons i dered , you must not i fy your P l an i n wr i t i ng w i th i n 6 months from the date of th i s dec i s i on ,
g . 07/25/201 0 . Your P l a n w i I I not accept unauthor i zed recons i der a t i ons from prov i ders . See the D i s puted
a i ms Sect i on of your Serv i ce Benef i t P l an Brochure .
CON002015 (|ev. f|03}
THANK YOU FOR ALLOWING US TO SERVE YOU
Listed below are definitions to help describe this Explanation of Benefits.
PROVIDER: The hospi tal , health care faci li ty, physician or other health care professional who
provided servi ces to you.
PROVIDER TYPE: Each local Bl ue \rs; and Bl ue Shi el d Plan can contract with providers
in its service area. There are two types of professi onal contracting provi ders, Preferred and
Partici pati ng, and two types of contracting faci l i ti es, Preferred or Member. If provi ders do not
contract wi th the Plan, they are consi dered to be non-parti ci pating or non-member.
DATE OF SERVICE: The month, day and year you actual l y received services.
TYPE lJ1 SERVICE: Jhi - is U general descripti on of the service or supply provided.
SUBMITTED CHARGES: This is the amounr the provi der has bil l ed.
PLAN ^1lYXl1 Jc a11 1ount used to determine our p.yment and yol coi n-urance for
covered S.I\It or lhC amount we use to calculate our payment for covered services.
RE:ARK CODES: An explanation of the payment determi nati on for a parti cul ar service.
DEDUCTIBLE: The fixed amount of covered expenses you must i ncur each cal endar year for
cert ai n covered services and suppl i es before we start payi ng benefi ts.
COINSURANCE: The percentage of the Plan Al l owance that you must pay fr your care.
COPAY: The fxed amount of money you pay to the physi ci an, faci lity, pharmacy, etc. when you
receive certai n services.
MEDICARE/OTHER INS.: The aniount paid by another health i nsurance carrier when you or
covered fmi l y members have coverage with Medicare or another heal th benefit pJ an.
NON-COVERED CHARGES: We did not pay for these services. The Blue Cross and Bl ue
Shiel d Servi ce Benefi t Plan does not consider these charges as a covered benefit. You are
responsi bl e H these charges.
PRECERTIFICATION PENALY: We wi l reduce your benefi t by !3UU i f no one (you, your
physician or the hospital ) contacts us to obtai n precertifcation of i npatient hospital services,
Wucu IcquIIud.
CATASTROPHIC PROTECTION: Your Service Benefi t Plan coverage l imits your om-of
pocket expenses ; coinsurance, copayments and deductibl es you pay per cal endar year. Hyou
reach your catastrophic protection limit withi n a calendar year. we wi l l pay ! UU percent of certai n
covered out-of-pocket tXch-C- for t he remainder of the year. Please note that not al l of your
out-of-pocket expenses W| count toward meeti ng your catastrophic protection l imit. See your
Service Beneft Plan brochure for more i nfrmati on.
If you have any questions, please refr to your Blue Cross and Blue Shield Service Benefit Plan
brochure (RI 71-005), or call U at the telephone number shown on the font of this form.
HELP STOP FRAUD AND ABUSE!
IF YOU SUSPECT FRAUD OR ABUSE
CALL THE FEP ANTIFRAUD HOTLINE:
1-800-FEP-8440 (337-8440)
YL
BlueCross.
BlueShield

Federal Employee Program
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21 10-D GALLOWS ROAD
VIENNA, VA 22182
TEL: (703) 883-2942
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21 10-D GALLOWS ROAD
VIENNA, VA 22182
TEL: (703) 883-2942
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