Notices of Privacy Practices

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 of Privacy Practices (“Notice”) is provided to you pursuant to the Health Insurance Portability and Accountability Act of 1996, as amended, and its implementing regulations (“HIPAA”). This Notice is designed to inform you of how we may, under federal law, use or disclose your health information.

1. OUR PLEDGE TO PROTECT YOUR PRIVACY

We understand that health information about you is personal, and we are committed to protecting the privacy of your information. As a patient of INPRESENT Psychiatry, P.C., dba Rappore (“Rappore”), the care and treatment you receive is recorded in a healthcare record. We maintain this record so that we may provide you with quality care and to comply with various legal requirements. This Notice applies to the records of your care provided by Rappore’s health care providers.

We are required by law to:

• Maintain the privacy of your health information;
• Give you this Notice of our legal duties and privacy practices with respect to your health information;
• Notify you if you are affected by a breach of unsecured health information; and
• Follow the terms of the Notice that is currently in effect.

2. WHO WILL FOLLOW THIS NOTICE

The following people or groups will comply with this Notice:

• Any health care professional authorized to enter information into your healthcare records maintained by Rappore.
• All employees, staff, workforce members and other Rappore personnel.

3. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

• For Treatment: we may use or disclose your health information to provide you with medical treatment or services. Example: Your health information may be used by our health care providers that are involved in your care.
• For Payment: we may use or disclose your health information to obtain payment for our services. Example: Your health information may be released to an insurance company to get pre-approval of or payment for services.
• For Health Care Operations: we may use your health information for uses necessary to run our healthcare businesses, such as to conduct quality assessment activities, train, or arrange for legal services. Example: we may use your health information to conduct internal audits to verify proper billing procedures.
• To Business Associates: we may share your health information with “Business Associates,” as defined by HIPAA, who provide services to or on behalf of us.
• Appointment Reminders, Test Results, Treatment Alternatives, etc.: we may use your health information to contact you to remind you about appointments, to inform you about test results or to advise you of treatment alternatives.
• Health-Related Benefits and Services: we may use your health information to advise you of health-related benefits and services provided by us that may be of interest to you, including educational lectures, special events and support groups. Example: we may sponsor annual health care events that may be of interest to our patients, such as health fairs.
• Individuals Involved in Your Care or Payment for Your Care: unless you tell us you object, we may use or disclose your health information to notify a friend, family member, or legal guardian who is involved in your care or who helps pay for your care.
• Organ and Tissue Donation: if you are an organ donor, we may release health information to organ donation banks or organizations that handle organ or tissue procurement or transplantation.
• [Fundraising Activities: we may use your health information to contact you about our fundraising efforts. Any materials received will contain information on how to remove yourself from fundraising lists.]
• As Required by Law: we will disclose your health information where required by law. Example: federal law may require your health information to be released to an appropriate health oversight agency, public health authority or attorney.
• Public Health and Safety: we may use and disclose your health information to prevent or control a serious threat to the health and safety of you, others, or the public and for public health activities, such as to prevent injury. Example: California law requires us to report birth defects and cases of communicable disease.
• Food & Drug Administration (FDA) and Health Oversight Agencies: we may disclose health information about incidents related to food, supplements, product defects, or post-marketing surveillance to the FDA and manufactures to enable product recalls, repairs, or replacements; and to health oversight agencies for activities authorized by law, such as audits.
• Lawsuits/Disputes: if you are involved in a lawsuit/dispute and have not waived the physician-patient privilege, we may disclose your health information under a court/administrative order, subpoena, or discovery request after attempting to inform you of the request.
• Victims of Abuse, Neglect or Domestic Violence: if we reasonably believe you are a victim of abuse, neglect or domestic violence, we may use and disclose your health information to a governmental authority, including social service or protective services agency, authorized by law to receive reports of such abuse, neglect or domestic violence.
• Research: we may use and share your health information for research purposes.
• Coroners, Medical Examiners, and Funeral Directors: we may release your health information to coroners, medical examiners, or funeral directors to enable them to carry out their duties.
• National Security/Intelligence Activities and Protective Services: we may release your health information to authorized local or national security or other law enforcement agencies for the protection of certain persons or to conduct special investigation.
• Workers’ Compensation: we may use or disclose medical information about you for workers’ compensation or similar programs as authorized or required by lay. These programs provide benefits for work-related injuries or illnesses.
• Military/Veterans: we may disclose your health information to military authorities if you are an armed force or reserve member.
• Inmates: if you are an inmate of a correctional facility or are in the custody of law enforcement, we may release your health information to a correctional facility or law enforcement official so they may provide your health care or protect the health and safety of you or other. We may also include information related to mental health and communicable diseases.

4. OTHER USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Other uses and disclosures of your health information not described in this Notice will be made only with your authorization. We will obtain your written authorization for: (i) most uses and disclosures of psychotherapy notes; (ii) most uses and disclosures of health information for marketing purposes, as defined by HIPAA; and (iii) disclosures that constitute a sale of PHI, as defined by HIPAA. If you authorize us to use or disclose your health information for another purpose, you may revoke your authorization, in writing, at any time. Your revocation will be effective upon receipt, but will not be effective to the extent that we or others have acted in reliance upon the authorization.

5. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the rights described below in regard to the health information that we maintain about you. You must submit a written request to exercise any of these rights. You may obtain forms for any of these purposes by contacting the Privacy Officer at the number or address below.

• Right to Inspect/Obtain a Copy: you have the right to inspect and get a copy of health information maintained by us and used in decisions about your care. This right does not apply to psychotherapy notes and certain other information. We may charge you a reasonable cost-based fee to cover copying, postage and/or preparation of a summary. We may deny your request in certain circumstances. You may request a licensed health care professional chosen by us to review a denial based on medical reasons; we will comply with this decision.
• Right to Amend: if you believe the health information we created for you is inaccurate or incomplete, you may ask us to amend it in writing. We cannot delete or destroy any information already included in your medical record. You must provide a reason for your request. We may deny your request if you ask to amend information that: (i) we did not create (unless the person or entity that created the information is not available to make the amendment); (ii) is not part of the health information we maintain; (iii) is not part of the information you are permitted by law to inspect and copy; or (iv) is accurate and complete.
• Right to Accounting of Disclosures: you have the right to ask for a list or “accounting” of disclosures we have made of your health information. We are not required to list all disclosures, such as those you authorized or disclosures made for treatment, payment, health care operations and certain other purposes. You must state a time period, which may not be longer than 6 years. You may obtain one accounting in a 12-month period for free; we may charge you a reasonable fee for additional accountings of disclosures.
• Right to Request Restrictions: you have the right to request a restriction or limit on how we use or disclose your health information. You must be specific in your request for restriction. We are not required to comply with your request, except when you request that we restrict disclosure of your health information to a health plan for a health care item or service for which you have paid out-of-pocket in full and the disclosure is for the purpose of carrying out payment or health care operations, and not otherwise required by law.
• Right to Request Confidential Communications: you have the right to request, in writing, that we contact you about medical issues in a certain way, such as by mail, or at alternative locations. You must specify how or where you wish to be contacted; we will try to accommodate reasonable requests.
• Right to a Copy of This Notice: you have the right to a paper or electronic copy of this Notice, which is posted and available at each location where medical services are provided and is on our website.

6. CHANGES TO OUR PRIVACY PRACTICES

We reserve the right to change our privacy practices and update this Notice accordingly. We reserve the right to make the revised or changed Notice effective for all your health information, even if it was created prior to the change in the Notice. Revised Notices will be posted and available at each location where medical services are provided and on our website.

7. COMPLAINTS