HIPAA NOTICE OF PRIVACY PRACTICES The Notice of Privacy Practices attached to this Summary provides important information to you about how the physician, his staff and others may use and disclose your personal health information. The Notice describes those uses and disclosures that they may make. The Notice also describes your privacy rights and how you mayexercise them. Finally, the Notice tells you how to get more information or file a complaint. When we refer to “information”, “medical information” or “protected health information” in the notice, we mean information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health and related healthcare services. Protected health information may be transmitted or shared in any form or medium(oral, written, or electronic).The protected health information we receive may vary by patient; therefore, the examples that follow may not apply to all patients, but are designed to represent the general categories of information that may be received and maintained by the doctor. _________________________________________________________________ -Information provided by you on applications, forms and surveys, such as your name, address and date of birth-Information from other physicians, hospitals or other health care providers, clinics, pharmacies, medical groups or health care service plans-Information provided by your employer, benefits plan sponsor or association, regarding any group product that you may have-Information about your transactions and experiences with us, such as medications or services purchased, account balances, payment history, claims history and policy coverage-Information form consumer or medical reporting agencies or other third parties, including medical and demographic information _________________________________________________________________ The Notice of Privacy Practices describes our policies on how your health information may be used. Forexample:-Treatment, payment and health care operations-To coordinate treatment-For disclosure to business associates-Relatives, close friends and other caregivers-Use or disclosure with your authorizationWe do not need to obtain your written permission to use your protected health information for the followingpurposes:Treatment:We use and disclose your protected health information to provide health care services to you. This includes uses and disclosures to: treat your illness or injury, or contact you to provide appointment reminders, or give you information about new treatments, treatment alternatives or other health related benefits and services that mayinterest you.To Coordinate Treatment:We may use and disclose health information about you to coordinate and manage medical treatment or services you receive. For example, we may use health information to coordinate your treatment between health care providers or help plan for you to receive follow-up care or therapy. The doctor may also contact health care providers to discuss treatment.Payment:We may use and disclose your protected health information to obtain payment for health care services that we or others provide to you. This includes uses and disclosures to submit and obtain payment from your health insurer, HMO, or other company that pays the cost of some or all of your health care (payor), - Verify that your payor will pay for your health care, or - Pursue or appeal claims that are not paid or are denied - Health Care Operations: to evaluate the quality and competence of our health care providers, nurses, and other health care workers or to train new employees Right to Request Access to Your Health Information: 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. All requests for access must be made in writing.Right to Request Amendments to Your Health Information: You have the right to request that we amend your health information maintained in your medical record file or billing records. If you wish to amend your records, please obtain an amendment request form from our staffRight to Revoke Your Authorization: You may revoke (take back) any written authorization obtained by us for use and disclosure of your protected health information, except to the extent that we have taken action in reliance upon itPlease sign and date below to indicate that you have received a copy of this notice. Your signature simply acknowledges that you have received a copy of the Doctor's Privacy Practices.My signature below constitutes that I have read, understood, and agreed to the information contained in this form. I understand and consent to treatments as recommended by Health Watchers 360 and its designated representatives and agree to accept financial responsibility for services rendered. I further understand that it is my responsibility to advise Health Watchers 360 of any updates or changes to my health, medical conditions, as well as insurance coverage.