WILCREST MEDICAL GROUP’S INFORMED CONSENT, TERMS AND CONDITIONS, AND HIPAA NOTICE OF PRIVACY PRACTICES

Effective Date: 02/08/2023

I, as the individual (or his or her legal representative) receiving services, agree to receive the services provided by Wilcrest Medical Group, PA, hereinafter referred to as (“we” “us” or “Wilcrest”) or its business services provider FPK Services, LLC. I agree that the services may include health care provider education sessions, physician consultations via telemedicine (“Consults”), any customer support or counseling, and any other related services provided by Wilcrest via telemedicine such as ordering laboratory tests (“Tests”), including, without limitation, physician oversight, for the ordering of Tests, the results of the Tests, the (“Results”)and any other related services provided by Wilcrest directly or through its business services provider, FPK Services, LLC, (the “Services”).

I acknowledge and agree to the following:

I have read, understand, and had the opportunity to ask questions about the information provided about Wilcrest’s Services.
My medical history is correct to the best of my knowledge. I will hold neither Wilcrest nor FPK Services, LLC, its physicians, nurse practitioners, or employees responsible for any errors or omissions that I may have made in providing such information.
(“Health Care Providers”) means Wilcrest, its physicians, nurse practitioners, and employees.
I authorize Wilcrest and third-party business services provider FPK Services, LLC, Health Care Providers, staff, and agents to view and use my health information, including any Test Results in furtherance of its healthcare operations.
Only Wilcrest physicians diagnose conditions, disease, or illness.
If I receive an abnormal Result on a Test I understand that a member of Wilcrest’s Care Coordination Team may attempt to call me to review the Results, offer education and explain the next steps I should take. Wilcrest’s Care Coordination Team may leave me a voice message at my designated telephone number. I also understand that if I am not able to be reached, Wilcrest’s Care Coordination Team may mail a follow-up letter to my designated address (the letter will not include my Test Results). If I receive an abnormal Result and have not connected with Wilcrest’s Care Coordination Team, I understand that I should not delay following up with my personal physician.
I understand that after receiving my Results for an STD Test, including HIV, I will have the opportunity for a telemedicine Consult. I understand that after receiving my Results for non-STD Tests, I will have the opportunity for either an education session with a member of Wilcrest’s Care Coordination Team, a Health Care Provider, or a telemedicine Consult with a Wilcrest physician, as appropriate under applicable law. If my Results show that I have Chlamydia, Gonorrhea, Herpes Simplex 2, or Trichomoniasis (the “Treatment Conditions”), the physician may be able to prescribe medication during the Consult, if appropriate. I understand that if my Results show that I have one of the Treatment Conditions, it is important to schedule a Consult as soon as possible or obtain other treatment.
I certify that throughout the duration of my Consult I will be physically present in the state of residence I provided or other state of which I have notified Wilcrest.
Wilcrest’s Health Care Providers are responsible for sharing information regarding any Consults and forwarding any Results to my primary care or other personal physician within 72 hours after providing such Consults or receiving such Results. I am responsible for initiating follow-up care with my physician. I will let Wilcrest’s Care Coordination Team know of my desire to have my information forwarded to my primary care or other personal physician, and I will fill out the required release form.
I will not make medical decisions without consulting a health care provider or disregard medical advice from my health care provider or delay seeking such advice based on information I receive as a result of my Consult.
If I receive an abnormal Result on certain STD Tests, my name and Result will be disclosed to my state health agency in accordance with applicable law.
If I receive an abnormal result on an STD Test, it is important that I notify my sexual and needle sharing partners and follow up with my personal physician to receive treatment.
I understand that Wilcrest Consults are delivered by physicians who are not in the same physical location as I am, using electronic communications, information technology or other means, including the electronic transmission of personal health information, and that they may not have the opportunity to perform an
in-person examination of me. I also understand that a physician will determine whether or not treatment is appropriate for me, based on information I provided.
For Consults, the scope of Services will be at the sole discretion of the physician treating me, with no guarantee of diagnosis, treatment, or prescription, and the standard of care will be the same as it would be if I were receiving such services in-person. The physician will determine whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter.
I have the right to withdraw my consent to use telemedicine in the course of my care at any time by contacting Wilcrest’s Care Coordination Team by calling 1 (888) 308-5889 or [email protected].
Any video feed from the Consult will not be retained or recorded by Wilcrest.
My health and wellness information pertaining to telemedicine services are governed by Wilcrest’s Notice of Privacy Practices.
I may need to see a health care provider in person for diagnosis, treatment and care.
There are potential risks associated with the use of technology that are beyond Wilcrest’s and any health care provider’s control, including disruptions, loss of data, and technical difficulties.
There are alternative services available to me if I experience medical symptoms that require immediate attention, such as visiting a primary care provider, an emergency room, or an urgent care facility; however, I voluntarily choose to proceed with Wilcrest’s Services at this time.
I have been provided with notice of how I may file a complaint with the Texas Medical Board relating to the provision of telemedicine services by Wilcrest Health Care Providers. I understand that I may contact the Texas Medical Board electronically by submitting an online complaint form at tmb.state.tx.us or print a copy of the complaint form and mail it in, or call the complaint hotline at 1-800-201-9353.

I understand that if I have any questions before or after my Test, I can contact Wilcrest’s Care Coordination Team by calling 1(888) 308-5889 or [email protected].

I authorize Wilcrest to use the email address and phone number I provided in connection with my account and to contact me in connection with my Consult including follow-up after the Consult. I am responsible for contacting Wilcrest’s Care Coordination Team by calling 1 (888) 308-5889 or [email protected] to notify them of any changes to my mailing address, email address, phone number, medical history or other information that I provided in connection with the Services.

I have read this Informed Consent carefully, and all my questions were answered to my satisfaction. I hereby consent to receive Services from Wilcrest pursuant to the terms, conditions, standards, and requirements set forth herein.

WILCREST MEDICAL GROUP’S TERMS AND CONDITIONS

Effective Date: 04/01/2021

WILCREST DOES NOT PROVIDE SERVICES FOR MEDICAL EMERGENCIES OR URGENT SITUATIONS. IF YOU BELIEVE YOU OR THE PERSON YOU ARE CONTACTING US FOR ARE EXPERIENCING A MEDICAL EMERGENCY, OR IF YOU OR THEY ARE IN NEED OF IMMEDIATE MEDICAL ASSISTANCE CALL 911 IMMEDIATELY. DO NOT RELY ON COMMUNICATION FROM WILCREST FOR ANY URGENT MEDICAL NEEDS.

PLEASE READ THESE TERMS OF USE CAREFULLY BEFORE USING OUR SERVICES.

These Terms of Use (“Terms”) govern your use of the services provided by Wilcrest Medical Group, PA. and certain affiliated professional entities (collectively, “Wilcrest”, “we” or “us”) relating to ordering laboratory tests (“Tests”), including, without limitation, physician oversight of Test requests, receipt of Test results (“Results”), education sessions (“Education Sessions”), telemedicine consultations with Wilcrest physicians (“Consults”), any customer support or counseling and any other related services provided by Wilcrest or its business services provider FPK Services, LLC (the “Services”). Wilcrest is not responsible for its Services, including, without limitation, the provision of the Test, the Results or other Services provided through or in connection with Wilcrest’s website. In these Terms, the terms “you” and “yours” refer to the person accessing and/or using the Services.

Your use of Wilcrest’s Services are subject to any additional terms and policies, such as our Notice of Privacy Practices below and any consents, of which we provide notice to you.

By using Wilcrest’s Services you acknowledge that you have read, understood and agree to be legally bound by and comply with these Terms, the Notice of Privacy Practices, and any and all additional terms and policies.

IF YOU DO NOT AGREE WITH THESE TERMS, DO NOT USE WILCREST’S SERVICES.

Changes to our Terms. We reserve the right to modify or amend these Terms, in whole or in part, at any time, and for any reason, in our sole discretion, with or without liability to you or any third party. All changes to these Terms will be effective immediately upon their posting to Wilcrest’s website. We will notify you of material changes to these Terms by posting the changes on Wilcrest’s website. Continued use of the Wilcrest website after the effective date of such modified Terms will indicate your acknowledgment and agreement to be bound by the modified Terms. You are expected to check this page from time to time so you are aware of any changes, as they are binding on you. Each version of our Terms will be prominently marked with an effective date at the top of this page. If any of the provisions of these Terms are not acceptable to you, your sole and exclusive remedy is to discontinue your use of Wilcrest’s Services and the Wilcrest website.
Medical Advice. Except for Consults, Wilcrest does not provide medical advice and the Services including, without limitation, Education Sessions are provided solely for informational purposes, and do not constitute treatment or diagnosis of any condition, disease or illness. Wilcrest does not and will not replace your existing primary care physician or other relationship with your physician. You should not make medical decisions without consulting with a physician. Do not disregard medical advice from your healthcare provider or delay seeking such advice based on the information obtained as a result of your use of Wilcrest’s Services. Wilcrest’s Services are not intended to make a medical necessity determination. You are solely responsible for initiating follow up care with your primary care physician or other such physician: for care, diagnosis, and medical treatment.
Medical Records. To get a copy of your health record including any Results please contact us at 1 (888) 308-5889 or email us at [email protected].
Messaging. By accepting the Terms, you understand that Wilcrest may send you messages, reports and emails regarding the Services, Tests, Results, and/or any personal or health information you have provided in connection with the Services. You further understand and agree that it is your responsibility to monitor and respond to these messages, reports, and emails.
Eligibility. Wilcrest Services are not intended or designed for individuals under the age of 18. By using Wilcrest’s Services you confirm that you are age 18 or over.
United States Residents. The Services are intended for individuals located and residing in the United States. However, Wilcrest Services may not be available in certain U.S. states. You will be notified if Wilcrest Services are not available in the state in which you are located. You agree that any and all data you provide or make available shall relate only to users located in the United States. By using Wilcrest’s Services you confirm that you are located in the United States when you use either Wilcrest’s website or Wilcrest’s Services. You shall not use Wilcrest Services or access the Wilcrest website outside of the United States and Wilcrest disclaims any responsibility for any attempt by you to do so.
You agree that any data submitted or provided by you or on your behalf in connection with the Services is truthful, accurate, and appropriate. You agree that the Services that you request are for your own personal use and that you will not order a Test for another person.
You may be ineligible for a Test based on the information that you provided (e.g., certain Tests may only be intended for women) or otherwise. You will be notified if it is determined that you are not eligible for a Test.
Payment. Wilcrest will collect your payment via its business services provider’s website. Its business services provider, FPK Services, LLC will be acting as its collection agent. You will be notified of the fees for Wilcrest’s Services on the business services provider’s website. Wilcrest reserves the right to change prices at our sole discretion at any time; however, the business services provider’s website will reflect then-current prices. Wilcrest Services are paid for by you and are not intended to be reimbursed by any health plan. Wilcrest does not submit or process insurance paperwork or claims. You understand that Wilcrest Services are solely your financial responsibility and that you will not submit any invoice or claim for reimbursement to any insurer or health plan (including, but not limited to, Medicare, Medicaid or any private health insurer or plan). Medications prescribed during Consults may not be reimbursable through Medicaid.
Physician Oversight. Wilcrest’s independent physicians provide clinical oversight of Test requests. Test requests and the information you provide are evaluated and if appropriate, a physician will order the Test requested by you. If you receive an abnormal result on a Test that Wilcrest determines warrants an alert call, you understand that a member of Wilcrest’s Care Coordination Team will attempt to call you to review the results, offer education and explain the next steps you should take. If you receive an abnormal result and have not connected with Wilcrest’s Care Coordination Team, you should not delay following up with your personal physician. Wilcrest Consults are provided by physicians. As part of Wilcrest’s Services, after you receive your Results, you will have the opportunity to receive either a telemedicine Consult or an Education Session, as described below.
You acknowledge that the ordering physician may be required by statute to report your Results (e.g., a positive STD test) to the local health department.
Consults. You understand that after receiving your Results for an STD Test, including HIV, you will have the opportunity for a telemedicine Consult with a Wilcrest physician.
Consults must be arranged through Wilcrest’s Care Coordination Team. If you elect to receive a Consult, you will be asked to complete a brief intake survey to collect necessary health information prior to scheduling your Consult. You may speak with the physician by phone or video, depending on your state’s regulations. If the physician does not reach you after three attempts, you can contact Wilcrest’s Care Coordination Team at the “Contact Us” number below to reschedule.

If your results show that you have Chlamydia, Gonorrhea, Herpes Simplex 2, or Trichomoniasis, if you elect to have a Consult, the physician may be able to prescribe medication for your condition. The physician will speak with you to assess your eligibility for treatment and, if appropriate, based on the Consult and your health information, send a prescription to the pharmacy of your choice. The scope of Services will be at the sole discretion of the physician, with no guarantee of diagnosis, treatment, or prescription.

If you are eligible for a Consult but don’t have one of the above conditions, the physician can discuss your specific test results and symptoms and talk about plans for managing your health. However, no diagnosis, treatment or prescriptions will be provided other than for the conditions listed above. You will need to follow up with your personal physician for diagnosis, treatment or prescriptions.
Education Session. If you are eligible for an Education Session, you may arrange for one with a Wilcrest Health Care Provider. Education Sessions are educational sessions providing general information about a test or condition, not your specific results or symptoms. They are provided solely for informational purposes and do not constitute treatment or diagnosis of any condition, disease or illness, or otherwise constitute the practice of medicine. Physicians will not prescribe or order any drugs or medication in connection with Education Sessions. You may be instructed to follow up with your local healthcare provider for care.
Privacy. Please review our Notice of Privacy Practices, which describes Wilcrest’s practices regarding the information that Wilcrest may collect from users of Wilcrest’s Services and which is available below. By accessing and using Wilcrest’s Services, you hereby consent to all actions we may take with respect to your information consistent with these Terms and our Notice of Privacy Practices.
Limitation of Liability.
IN NO EVENT WILL WILCREST, ITS BUSINESS SERVICES PROVIDER FPK SERVICES, LLC, OR THEIR RESPECTIVE OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, PARTNERS, LICENSORS, PHYSICIANS, HEALTHCARE PROVIDERS OR SERVICE PROVIDERS BE LIABLE TO YOU OR TO ANY PARTY FOR ANY CLAIMS, LIABILITIES, LOSSES, COSTS OR DAMAGES UNDER ANY LEGAL OR EQUITABLE THEORY, WHETHER IN TORT (INCLUDING NEGLIGENCE), CONTRACT, STRICT LIABILITY OR OTHERWISE, INCLUDING, BUT NOT LIMITED TO, ANY INDIRECT, PUNITIVE, INCIDENTAL, SPECIAL, OR CONSEQUENTIAL, DAMAGES, INCLUDING LOST PROFITS, LOSS OF DATA OR LOSS OF GOODWILL, SERVICE INTERRUPTION, MOBILE PHONE DAMAGE, SYSTEM FAILURE OR THE COST OF SUBSTITUTE PRODUCTS OR SERVICES, OR FOR ANY DAMAGES FOR PERSONAL OR BODILY INJURY OR EMOTIONAL DISTRESS, INCLUDING DEATH, ARISING OUT OF OR IN ANY WAY CONNECTED WITH ANY ACCESS TO OR USE OF (OR INABILITY TO USE) ANY WILCREST SERVICES. THE PRECEDING DISCLAIMERS AND LIMITATIONS SHALL APPLY EVEN IF WILCREST OR FPK SERVICES, LLC AND THEIR RESPECTIVE OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, PARTNERS, LICENSORS, PHYSICIANS, HEALTHCARE PROVIDERS OR BUSINESS SERVICES PROVIDERS HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES OR LOSSES.

IN NO EVENT SHALL THE TOTAL LIABILITY OF WILCREST, FPK SERVICES, LLC AND THEIR RESPECTIVE OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, PARTNERS, LICENSORS, PHYSICIANS, HEALTHCARE PROVIDERS AND SERVICE PROVIDERS ARISING IN CONNECTION WITH OR UNDER THESE TERMS EXCEED U.S. ONE HUNDRED DOLLARS ($100 USD). YOU AGREE THAT ANY CLAIM OR CAUSE OF ACTION ARISING UNDER THESE TERMS OR THE PERFORMANCE OR

NON-PERFORMANCE OF WILCREST IN RELATION TO THE SERVICES MUST BE BROUGHT WITHIN ONE (1) YEAR AFTER SUCH CLAIM OR CAUSE OF ACTION ARISES, OR BE FOREVER BARRED.
Disclaimers.
BOTH WILCREST SERVICES AND THE WILCREST WEBSITE, INCLUDING ANY RELATED CONTENT, IS PROVIDED WITHOUT WARRANTY OF ANY KIND, EXPRESS OR IMPLIED. MOREOVER, WILCREST AND FPK SERVICES, LLC AND THEIR RESPECTIVE OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, PARTNERS, LICENSORS, PHYSICIANS, HEALTHCARE PROVIDERS HEREBY EXPRESSLY DISCLAIM ALL WARRANTIES OF ANY KIND, WHETHER EXPRESSED OR IMPLIED, AND ALL CONDITIONS WITH REGARD TO WILCREST’S SERVICES, INCLUDING, BUT NOT LIMITED TO, ALL IMPLIED WARRANTIES AND CONDITIONS OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, NON-INFRINGEMENT, AND ANY OTHER WARRANTY, WHETHER ORAL OR WRITTEN, WITH RESPECT TO WILCREST’S SERVICES.

YOUR USE OF WILCREST’S WEBSITE OR WILCREST’S SERVICES IS AT YOUR OWN RISK. WILCREST AND FPK SERVICES, LLC AND THEIR RESPECTIVE OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, PARTNERS, LICENSORS, PHYSICIANS, HEALTHCARE PROVIDERS, SHALL NOT BE HELD RESPONSIBLE FOR ANY ACTION TAKEN BY YOU OR OTHERS THAT IS BASED ON THE CONTENT PRESENTED THROUGH WILCREST’S SERVICES OR WILCREST’S WEBSITE. WILCREST MAKES NO REPRESENTATIONS OR WARRANTIES THAT: (I) WILCREST’S WEBSITE AND OR WILCREST’S SERVICES, AND/OR THEIR RELATED CONTENT WILL BE UNINTERRUPTED, TIMELY, SECURE, ERROR-FREE OR FREE FROM VIRUSES, “TROJAN HORSES” OR OTHER MALICIOUS CODE OR DISABLING DEVICES; (II) THE CONTENT RELATED TO WILCREST’S SERVICES IS ACCURATE, COMPLETE, RELIABLE OR CURRENT; AND (III) THERE WILL BE NO DELAY, FAILURE OR CORRUPTION OF DATA TRANSMITTED THROUGH WILCREST’S WEBSITE (WHICH SHALL INCLUDE THE WEBSITES AND SYSTEMS OF THEIR BUSINESS SERVICES PROVIDER). IN NO EVENT SHALL WILCREST BE LIABLE FOR ANY DAMAGES OR HARM CAUSED FROM OR BY YOUR USE OF WILCREST’S SERVICES, OR ANY RELATED CONTENT, INCLUDING IF SUCH USE VIOLATES THESE TERMS.

WILCREST DOES NOT MAKE ANY REPRESENTATIONS, WARRANTIES OR ENDORSEMENTS REGARDING ANY WILCREST SERVICES PROVIDED BY THIRD PARTIES INCLUDING, WITHOUT LIMITATION, SERVICES PROVIDED BY QUEST DIAGNOSTICS, AND/OR OTHER PROVIDERS OF LABORATORY SERVICES.
Indemnification. You agree to defend, indemnify and hold harmless Wilcrest and FPK Services, LLC, and their respective officers, directors, employees, agents, partners, licensors, physicians, healthcare providers, from and against any and all claims, actions, demands, liabilities, settlements, costs, or expenses, including, without limitation, reasonable legal fees, legal costs and accounting fees, arising out of, or alleged to arise out of: (i) your violation of these Terms, other policies or any and all applicable laws, rules or regulations; or (ii) your use of Wilcrest’s Services, Wilcrest’s website, or Wilcrest’s business services provider’s website or system in an unauthorized manner.
Ownership; Intellectual Property and Proprietary Rights. Certain names, logos, brands and other materials displayed in connection with Wilcrest’s Services and through its business services provider’s websites, may constitute trademarks, trade names, services marks or logos (“Marks”) of either Wilcrest or its business services provider, FPK Services, LLC. You are not authorized to use any such Marks without the express written permission of Wilcrest or FPK Services, LLC. Ownership of all such Marks and the goodwill associated therewith remains with us or FPK Services, LLC, as the case may be. All intellectual property rights in Wilcrest’s services, and any suggestions, ideas or other feedback provided by you, are the sole and exclusive property of Wilcrest or our business services provider or content providers and are protected by United States and foreign intellectual property laws.
Term; Termination. The Terms, as may be amended from time to time, will remain in full force and effect as long as you continue to access or use Wilcrest’s Services, or until terminated in accordance with the provisions of these Terms. We, in our sole discretion, with or without notice to you, at any time and for any reason, may terminate, suspend or modify: (i) any of the rights granted by these Terms; (ii) the permission granted to you to access and/or use Wilcrest’s Services. You may terminate the Terms at any time by discontinuing use of Wilcrest’s Services. Your permission to use Wilcrest’s Services automatically terminates if you violate these Terms. Wilcrest shall not be liable if, for any reason, all or any part of Wilcrest’s Services is unavailable. Upon termination of these Terms, any provision that by its nature or express terms should survive will survive such termination.
Equitable Relief. You acknowledge and agree that breach of these Terms will result in irreparable harm that would be difficult to measure; and, therefore, that upon any such breach or threat of such breach, Wilcrest shall be entitled to seek injunctive and other appropriate equitable relief from any court of competent jurisdiction (without the necessity of proving actual damages or of posting a bond), in addition to whatever remedies it may have at law, under these Terms, or otherwise.
General. These Terms, Wilcrest Medical Group’s Notice of Privacy Practices, consents and any other agreements incorporated by reference herein constitute the entire agreement between you and Wilcrest with respect to access to and use of Wilcrest’s Services. These Terms and your use of Wilcrest’s Services are governed by the laws of the State of Texas, without respect to its conflict of law principles. In the event a dispute arises between the parties under these Terms or that in any way relates to your use of Wilcrest’s Services, or Wilcrest’s website, or Wilcrest’s business services provider’s website or system, the parties hereby agree to binding arbitration, which will be conducted in Houston, Texas, in accordance with the Commercial Arbitration Rules of the American Arbitration Association. If any provision of these Terms is found to be invalid or unenforceable by any court having competent jurisdiction, the invalidity of such provision shall not affect the validity of the remaining provisions of these Terms, which shall remain in full force and effect. No waiver of any of these Terms shall be deemed a further or continuing waiver of such term or condition, or of any other term or condition. You may not assign or transfer your rights or obligations under these Terms without our prior written consent, and any assignment or transfer in violation of this provision shall be null and void. There are no third-party beneficiaries to these Terms. Wilcrest may freely assign or transfer these Terms without restriction. Subject to the foregoing, these Terms will bind and inure to the benefit of the parties, their successors and permitted assigns.
Contact Us.
Should you have questions about Wilcrest’s Services, you may contact us at:
Phone Number: 1 (888) 308-5889
Address: Wilcrest Medical Group, PA.
11150 S. Wilcrest Dr, Suite 200
Houston, TX 77099
Online Form: Contact Us.

WILCREST MEDICAL GROUP’S HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Wilcrest Medical Group, P.A.

Online Form: Contact Us

Effective date: April 1, 2021

Summary

This is a summary of how we may use and disclose your protected health information and your rights and choices when it comes to your information. We will explain these in more detail on the following pages.

Purpose

Wilcrest Medical Group partners with certain Health Professionals and Labs (collectively “Health Care Providers” or “we”) that are independent third-parties that work together to provide you with services. We are legally required to maintain the privacy of your protected health information (“PHI”) under the Health Insurance Portability and Accountability Act (“HIPAA”) and other federal and state laws.

As part of our commitment and legal compliance, we are providing you with this Notice of Privacy Practices (“Notice”). This Notice describes:

Our legal duties and privacy practices regarding your PHI, including our duty to notify you following a data breach of your unsecured PHI.
Our permitted uses and disclosures of your PHI.
Your rights regarding your PHI.

Contact

If you have any questions about this Notice, please contact us at 1-888-308-5889.

Our Uses and Disclosures

We may use and disclose your PHI for health care operations as we:

Treat you.
Bill for services.
Run our organization.
Comply with the law.
Address law enforcement, or other government requests.
Respond to lawsuits and legal actions.
Help with public health and safety issues.
Do internal research for product enhancement.
Work with a medical examiner or funeral director.

Your Choices

You may limit how we use and disclose your PHI as we:

Communicate with you.
Share information about your condition with family and friends at your direction.
Market our products and services.

For these purposes, you can tell us what elements of your PHI we can share. If you have a clear preference for how we share your PHI in the situations described below, please contact us at [email protected] and we will make reasonable efforts to follow your instructions.

You have both the right and the choice to tell us whether and how to:

Share information, such as your PHI, general condition, or location, with your family, close friends, or others involved in your care.
Share information in a disaster relief situation.

We may share your PHI if we believe it is in your best medical interest, according to our best judgment, and:

If you are unable to tell us your preference, for example, if you are unconscious.
When needed to lessen a serious and imminent threat to health or safety.

We never share your PHI for marketing purposes unless you authorize us to do so in writing.

Other than a custodian transfer in the context of a merger, acquisition or other corporate reorganization, we do not sell your PHI.

PHI Defined

Your PHI:

Is health information about you:
- which someone may use to identify you; and
- which we keep or transmit in electronic, oral, or written form.
Includes information such as your:
- name;
- contact information;
- past, present, or future physical or medical conditions;
- payment for health care products or services; or
- prescriptions.

Scope

We create a record of the care and health services you receive, to provide your care and to comply with certain legal requirements. This Notice applies to all the PHI that we generate or receive.

We and our employees and other workforce members follow the duties and privacy practices that this Notice describes and any changes to this Notice once they take effect.

Changes to this Notice

We can change the terms of this Notice, and the changes will apply to all PHI we have about you. The new Notice will be available on request and on our website.

Data Breach Notification

We will promptly notify you if a data breach occurs that may have compromised the privacy or security of your PHI. We will notify you within the legally required timeframe but no later than 60 days after we discover the breach. Generally, we will notify you in writing, by mail or email if you have provided us with your current email address and you have previously agreed to receive notices electronically. In some circumstances, our business associates may provide the notification. In limited circumstances when we have insufficient or out-of-date contact information, we may provide notice of a breach in a legally acceptable alternative form.

Uses and Disclosures of Your PHI

Applicable law permits or requires us to use or disclose your PHI for various reasons, which we explain in this Notice. We have included some examples, but we have not listed every permissible use or disclosure. When using or disclosing PHI, or requesting your PHI from another source, we will make reasonable efforts to limit our use, disclosure, or request to the minimum amount of your PHI we need to accomplish our intended purpose.

Uses and Disclosures for Treatment, Payment, or Health Care Operations

Treatment. We may use or disclose your PHI and share it with other health professionals who are treating you, including doctors, nurses, technicians, medical students, or hospital personnel involved in your care. For example, we might disclose information about your overall health condition with physicians who are treating you for a specific injury or condition.
Payment. We may use and disclose your PHI to bill and receive payment for services we provide to you.
Health Care Operations. We may use and disclose your PHI to run our practice and improve your care. For example, we may use your PHI to manage the services you receive or to monitor the quality of our health care services.

Other Uses and Disclosures

We may share your PHI in other ways, usually for public health or research purposes or to contribute to the public good. For more information on permitted uses and disclosures, see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. For example, these other uses and disclosures may involve:

Our Business Associates. We may use and disclose your PHI to outside persons or entities that perform services on our behalf, such as auditing, legal, or transcription (Business Associates). HIPAA requires our business associates and their subcontractors to protect your PHI in the same way we do. We also contractually require these parties to use and disclose your PHI only as permitted under this Notice and HIPAA and to appropriately safeguard your PHI.
Legal Compliance. For example, we will share your PHI if the U.S. Department of Health and Human Services requires it when investigating our compliance with HIPAA privacy requirements.
Public Health and Safety Activities. For example, we may share your PHI to:
- prevent disease;
- report suspected child neglect or abuse or domestic violence; or
- avert a serious threat to public health or safety.
Responding to Legal Actions. For example, we may be required to disclose your PHI to respond to:
- a court or administrative order or subpoena
- discovery request; or
- another lawful process.
Law Enforcement, or Other Government Requests. For example, we may be required to disclose your PHI for:
- health oversight activities by federal or state agencies
- law enforcement purposes; or
- specialized government functions, such as military and veterans’ activities, national security and intelligence, presidential protective services, or medical suitability.

Uses and Disclosures that Require Authorization

In the following cases we will only share your PHI if you give us written authorization:

Marketing third-party services.
Use or share your information with a third-party for research purposes
Other uses and disclosures not described in this Notice.

You may revoke your authorization at any time, but it will not affect PHI that we already used and disclosed prior to receiving your revocation.

Your Rights

When it comes to your PHI, you have certain rights, in addition to your right to receive a copy of this Notice. This section explains your rights and some of our responsibilities to help you.

You have the right to:

Inspect and Obtain a Copy of Your PHI. You have the right to see or obtain an electronic or paper copy of the PHI that we maintain about you (right to request access).

Some clarifications about your access rights:

we require you to request access in writing by submitting a request to the address above;
we may charge a reasonable, cost-based fee for the costs of copying, mailing, or other supplies associated with responding to your request. This fee complies with state/federal laws;
you may request that we direct a copy of your PHI to a third party of your choice on a standing, regular basis. We require that you submit these requests in writing to the address above; and
if you request a copy of your PHI, we will generally decide to provide or deny access within 30 days, however, if we cannot act within 30 days, we will give you a reason for the denial or delay in writing.
Make Amendments. You may ask us to correct or amend PHI that we maintain about you that you think is incorrect or inaccurate.
Request Additional Restrictions. You have the right to ask us to limit the PHI we use or share (right to request restrictions). You can contact us and request us not to use or share certain PHI for treatment, payment, or operations or with certain persons involved in your care. We require that you submit this request in writing to the address listed above.
Request an Accounting of Disclosures. You have the right to request an accounting of certain PHI disclosures that we have made. For these requests:
- we will respond no later than 60 days after receiving the request. We may ask for an additional 30 days during this 60-day period, but if we do, we will only do it once, provide a written statement of why, and indicate the date by which we intend to send the response;
- we will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures, such as any you authorized us to make; and
- we will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. We will notify you about the costs in advance and you may choose to withdraw or modify your request at that time.
Choose Someone to Act for You. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI. We will confirm the person has this authority and can act for you before we take any action.
Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or at a specific address. In addition, you may consent to us communicate with you by e-mail or SMS messaging regarding various aspects of your care, such as test results, prescriptions, appointment reminders, and billing. For these requests:
- we will not ask for the reason;
- you must specify how or where you wish to be contacted; and
- we will accommodate reasonable requests.
Make Complaints. You have the right to complain if you feel we have violated your rights. We will not retaliate against you for filing a complaint. You may file a complaint either:
- directly with us by contacting us at [email protected].
  All complaints directed to us must be submitted in writing; or
- with the Office for Civil Rights at the US Department of Health and Human Services. Send a letter to 200 Independence Avenue, S.W. Washington,
  D.C. 20201; call 1-800-537-7697; or visit
  www.hhs.gov/ocr/privacy/hipaa/complaints/.

Acknowledgment of Receipt

I acknowledge that I received a copy of this Notice of Privacy Practices and that I read and understood it. I understand that:

I have certain rights regarding the use and disclosure of my PHI, which are listed in the Notice.
My Health Care Provider, directly or through its business associates and or their third-party providers, can and will use my PHI for purposes of my treatment, payment, and health care operations.
The Notice explains in more detail how my Health Care Provider may use and share my PHI for other purposes.

The Notice may be changed from time to time, and I can obtain a current copy of the Notice by visiting my Health Care Provider’s website or contacting [email protected].

By checking the “I agree” checkbox above, I certify that I have read and understand my Health Care Provider’s Notice of Privacy Practices.