Notice of Privacy Practices & Releases

“Mindful Urgent Care”

NOTICE OF PRIVACY PRACTICES

Notice of Privacy Practices

Effective: May 7, 2018

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.

• If you have any questions about this Notice of Privacy Practices, please contact our Privacy Officer, TBD at TBD

• This Notice of Privacy Practices describes how our practice (TBD PLLC, and Mindful Urgent Care”) may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including, but not limited to, demographic information, that may identify you and that relates to your past, present or future physical or mental health or conditions and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of this Notice at any time. Any revised Notice of Privacy Practices would be effective for all protected health information that we maintain at that time and any protected health information we maintain in the future. Upon your request, we will provide you with any revised Notice by calling the office and requesting that a revised copy be sent to you in the mail. A copy of the current Notice of Privacy Practices will be prominently displayed in our offices at all times and posted on our website at www.mindfulurgentcare.com

1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Uses and Disclosures of Protected Health Information

Prior to disclosing your protected health information to outside health care providers or to obtain payment, Mindful Urgent Care will obtain your general consent, usually at your first visit to our facility, on our general consent form.

Treatment: We will use and disclose your protected health information to provide, coordinate or manage your healthcare and any related treatment. This includes sharing your protected health information with outside providers who may be involved in your care and with networks such as IPAs or ACOs that may coordinate care with outside providers.

Prior to disclosing your protected health information to outside health care providers or to obtain payment, Mindful Urgent Care will obtain your general consent, usually at your first visit to our facility, on our general consent form.

Treatment: We will use and disclose your protected health information to provide, coordinate or manage your healthcare and any related treatment. This includes sharing your protected health information with outside providers who may be involved in your care and with networks such as IPAs or ACOs that may coordinate care with outside providers.

We may participate in one or more Organized Health Care Arrangements (“OHCA”) with other providers in the community. Through the OHCA, Mindful Urgent Care is better able to provide coordinated medical care. Mindful Urgent Care may share your health information with the OHCA or other providers within the OHCA for purposes of care coordination or population health initiatives.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we provide for you, determining your eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity and undertaking utilization review activities.

Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of our practice. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to an insurer or accreditation agency that performs chart audits.

We will share your protected health information with third
party “business associates” that perform various activities

We will share your protected health information with third

party “business associates” that perform various activities

for our practice (e.g., computer consulting company, law firm or other consultants).

We may use or disclose your protected health information,

as necessary, to contact you to remind you of follow-up care or appointments. We may also use or disclose your protected health information to provide you with information about treatment alternatives or other health- related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.

Special Protections: We will not disclose confidential HIV-related information, alcohol or substance abuse treatment information without your prior consent or as authorized or allowed by law.

Uses and Disclosures of Protected Health Information

Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke your authorization at any time, in writing, except to the extent that Mindful Urgent Care has taken an action in reliance on the use or disclosure indicated in the authorization.

The following uses and disclosures will be made only with your authorization:

• Uses and disclosures for marketing purposes;

• Uses and disclosures that constitute the sale of PHI;

and

• Other uses and disclosures not described in this notice.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Permission or Opportunity to Object

Others Involved in Your Health Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care or payment for your care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based upon our professional judgment. Additionally, unless prior preference is expressed to Mindful Urgent Care, we may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person who is responsible for your care, of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and coordinate uses and disclosures to family or other individuals involved in your health care.

Immunization Disclosure to Schools and Agencies: Upon your agreement, which may be oral or in writing, Mindful Urgent Care may disclose proof of immunization to a school where a state or other law requires the school to have such information

prior to admitting the student. Mindful Urgent Care also may disclose your immunization history with health oversight agencies/registries for syndromic surveillance.

Other Permitted and Required Uses and Disclosures that may be Made without your Consent or Authorization

Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law.

Public Health: We may disclose your protected health information for public health activities to a public health authority that is permitted by law to collect or receive the information, such as for the purpose of controlling disease injury or disability, or for disaster relief. We also may disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose your protected health information to a governmental agency for activities authorized or required by law, such as audits, investigations, and inspections.

Abuse or Neglect: With your consent or where required by law, we may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse, neglect or domestic violence. .

Product Monitoring and Recalls: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, and biologic product deviations; to track products; to enable product recalls; to make repairs or replacements, or in connection with post- marketing surveillance, as required by law.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of Mindful Urgent Care, and (6) medical emergency (not on Mindful Urgent Care’s premises) and it is likely that a crime has occurred.
Decedents: Health information may be disclosed to medical examiners, funeral directors or coroners to enable them to carry out their lawful duties. Protected health information does not include health information of a person who has been deceased for more than 50 years.

Organ/Tissue Donation: If you are an organ donor, your health information may be used or disclosed for cadaver organ, eye or tissue donation purposes.

Criminal Activity: We may disclose your protected health information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We also may disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel for authorized military purposes, as required by law.

Workers’ Compensation: Your protected health
information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally- established programs.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the federal privacy regulations.

2. YOUR RIGHTS

You have the right to inspect and receive a copy your protected health information. This means that, except in very limited circumstances, you may inspect and obtain a copy of protected health information about you that is contained in a medical record maintained by Mindful Urgent Care
for as long as we maintain the protected health information. We may charge you our standard fee for the costs of copying, mailing or other supplies we use to fulfill your request. You have the right to electronic copies of your protected health information when requested. Where information is not readily producible in the form and format requested, the information must be provided in an alternative readable electronic format as agreed to by you, and Mindful Urgent Care may charge a reasonable cost-based fee.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You also may request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply.

In most circumstances, your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. However, if you request us to restrict disclosures to health plans that we would normally make as part of payment or health care operations, we must agree to that restriction if the protected health information relates to health care which you have paid out of pocket in full. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction using the form for requests for restrictions on protected health information from the Privacy Officer, or you may provide us your request, in writing. Your request must include (a) the information you wish restricted; (b) whether you are requesting to limit Mindful Urgent Care’s use, disclosure, or both; and (c) to whom you want the limits to apply.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. For example, you may ask us to contact you by mail, rather than by phone at home. You do not have to provide us a reason for this request. We will accommodate reasonable requests. We also may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. Please make this request in writing to our Privacy Officer.

You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you that we maintain. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. 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 protected
health information. This right applies generally to

disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. However, you do have the right to an accounting of disclosures for treatment, payment or health care operations if the disclosures were made from an electronic health record.

Your right to an accounting of disclosures excludes disclosures we may have made to you, to family members or friends involved in your care, for notification purposes, or made pursuant to your authorization.

You have the right to receive specific information regarding other disclosures that occurred up to six years from the date of your request (three years in the case of

disclosures from an electronic health record made for treatment, payment or health care operations). You may request a shorter timeframe. The first list you request within a 12-month period is free of charge, but there is a charge involved with any additional lists within the same
12-month period. We will inform you of any costs involved with additional requests, and you may withdraw your request before you incur any costs.

You have the right to obtain a paper copy of this Notice from us.

You have the right to receive notice in the event of a breach of unsecured protected health information. This means that, if a breach of your unsecured protected health information is discovered, you will receive notice within 60 days of discovery.

3. COMPLAINTS

You may complain to us or the Security of Health and Human Services if you believe your privacy rights have been violated by us. We will provide you with contact information for HHS. 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.

You may contact our Privacy Officer, TBD, at TBD, TBD @ Mindful Urgent Care.net for further information about the complaint process.