SILVER LAKE DIRECT PRIMARY CARE NOTICE OF PRIVACY PRACTICES This notice describes how health information about you may be used and disclosed and how you can gain access to your individually identifiable health information. A. OUR COMMITMENT TO YOUR PRIVACY: We, at Silver Lake Direct Primary Care, PLLC (the Practice, Our, or We), are dedicated to maintaining the privacy of your (and your child’s) personally identifiable, protected health information (PHI). In conducting our business, We will create records regarding you and the treatment and services We provide to you. We strive to maintain the confidentiality of health information that identifies you. This notice explains the privacy practices that we maintain concerning your PHI. The terms of this notice apply to all records containing your PHI that are created or retained by the Practice. We reserve the right to revise or amend this Notice of Privacy Practices at any time. If we change/update this notice, We will provide you with the updated notice by posting it on Our website. Any revision or amendment to this notice will affect all of your records that our Practice has created or maintained in the past and any records of yours that we may create or maintain in the future. You may request a copy of our most current notice at any time. B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Silver Lake Direct Primary Care Attn: Privacy Officer 102 A Court Street Middlebury, Vermont 05753 Email: info@silverlakedpc.com C. WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS: This notice describes the rights you have concerning your own medical information. It also describes how we may use your medical information within the Practice and how we may disclose your medical information to others outside the Practice. Uses and disclosures not described in this notice will be made only with the Patient’s authorization. The following describes the different ways in which we may use and disclose your PHI unless you object: Treatment. Our Practice may use your PHI in the course of your treatment. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI to a pharmacy when writing a prescription for you; or disclose your PHI to an imaging center to order studies. We may also disclose your medical information to others, such as health care providers or emergency medical personnel who need that information for your treatment and follow-up medical care. Payment. Our Practice may use and disclose your PHI to bill and collect payment for the services and products you may receive from us. We do not participate with or bill insurance, so we do not disclose your information to insurance companies for the purpose of being reimbursed. However, we may use and disclose your PHI to obtain payment from those who may be responsible for such costs, such as family members. Health Care Operations. The Practice may use and disclose your PHI to operate our business. For example, we may use and disclose your information to operate our business. For example, the Practice may use your PHI to evaluate the quality of care you received from us, to develop protocols and clinical guidelines, or to aid in credentialing and medical review. We may also use your medical information to obtain audit, accounting, or legal services, or to conduct business management and planning. We may employ the services of business associates who may assist us in one or more tasks and who may use, change, or create medical information. Appointment Reminders. The Practice may use and disclose your PHI to contact you and remind you of an appointment. Release of Information to Family/Friends. The Practice may release your PHI, when necessary, to a friend or family member involved in your care. Disclosures Required by Law. The Practice will use and disclose your PHI when we are required to do so by federal, state, or local law or regulation. COMMUNICATION - please refer to our practice agreement and our SMS privacy policy in regards to email and text messaging use. WE DO NOT SHARE OR SELL SMS OPT-IN OR PHONE NUMBERS FOR THE PURPOSE OF SMS. If you OPT IN for text messaging,messaging frequency may vary; message and data rates may apply; you can opt out at any time by texting STOP; for assistance, reach out to us at info@silverlakedpc.com D. USE AND DISCLOSURE OF YOUR PHI UNDER CERTAIN, SPECIAL CIRCUMSTANCES: The following categories describe unique scenarios in which we may be allowed or even be required by law to collect and disclose information for the purposes of: Health Oversight Activities. The Practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions and other activities necessary for the government to monitor its programs, compliance with civil rights laws, and the health care system in general. Lawsuits and Similar Proceedings. The Practice may use and disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process, by another party involved in the dispute. But we shall only disclose PHI after we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. Law Enforcement. We may release PHI if required to do so by a law enforcement official: regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement; concerning a death we believe has resulted from criminal conduct; regarding criminal conduct at our offices; in response to a warrant, summons, court order, subpoena, or similar legal process; to identify or locate a suspect, material witness, fugitive or missing person; Suspected child abuse; In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity, or location of the perpetrator). Deceased Patients. The Practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information to funeral directors as necessary to perform their jobs. Organ and Tissue Donation. If you are an organ donor, the Practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation. Serious Threats to Health or Safety. The Practice may use and disclose your PHI, when necessary, to reduce or prevent a serious threat to your health and safety or that of another individual or the public. But we will only make such disclosures to a person or organization able to help prevent the threat. Military. The Practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. Workers’ Compensation. The Practice may release your PHI if required for workers’ compensation and similar programs. Information with Additional Protection. Certain types of medical information have additional protection under state and federal law. For instance: Restrictions on disclosure of PHI to health plans: We must abide by a request to restrict disclosure of PHI to a health plan if the disclosure is for payment or health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full. Medical information about communicable disease and HIV/AIDS, drug and alcohol abuse treatment, genetic testing, and evaluation and treatment for a serious mental illness is treated differently than other types of medical information. In most circumstances, We are required to get your permission before disclosing information with special protections such as those listed above. Other Uses and Disclosures. If We wish to use or disclose your medical information for a purpose that is not discussed in this notice, We will seek your authorization. E. YOUR RIGHTS REGARDING YOUR PHI: The health and billing records we maintain are the physical property of Practice. The information in it, however, belongs to you. You have the right to: Confidential Communications. You have the right to request that our Practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than at work. To request a specific type of confidential communication, you must make a written request to the Privacy Officer, identifying the requested method of contact, or location where you wish to be contacted. Our Practice will accommodate reasonable requests. You do not need to give a reason for your request. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. To request a restriction in our use or disclosure of your PHI, you must make your request in writing to the Privacy Officer. Your request must describe in a clear and concise fashion: (A) the information you wish restricted; whether you are requesting to limit our Practice’s use, disclosure, or both; and to whom you wish the limits to apply. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you and your care, including your billing and medical records, but not your psychotherapy notes. In order to inspect and/or obtain a copy of your PHI, You must submit your request in writing to the Privacy Officer. We may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. The review shall be conducted by different licensed health care professional of our choosing. Right to be Notified Following a Breach of Unsecured PHI. You have the right to be notified if your medical information has been breached. Our Compliance Office will notify you in any event where your medical information has been breached. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our Practice. To request an amendment, your request must be made in writing and submitted to the Privacy Officer. You must provide us with a reason that supports your request for amendment. Our Practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion ─ accurate and complete; not PHI kept by or for the Practice; PHI which you would be permitted to inspect and copy; or, not created by our Practice, unless the individual or entity that created is not available to amend the information. Paper Copy of this Notice. You have a right to receive a paper copy of our notice of privacy practices upon request. Right to File a Complaint. Please tell us about any problems or uncertainty you have in regard to your Privacy Rights or the manner in which Practice uses or discloses your medical information. To report concerns please contact Our Compliance / Privacy Officer at the address written above. If for some reason We cannot resolve your concerns, you may also file a complaint in writing, with the federal government at: The Department of Health & Human Services, Office of Civil Rights 50 United Nations Plaza, Room 322 San Francisco, California 94102 We will not penalize or retaliate against you in any way for filing a complaint with Us or the federal government. Right to Revoke an Authorization. Our Practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. You have the right, at any time, to revoke your authorization to disclose your PHI. Simply send a written notice of revocation to the Privacy Officer at the address provided above. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care. Electronic Signature. Your electronic signature, if contained within this Notice of Privacy Practices shall have the same legal effect as a handwritten signature, including for the purposes of validity, enforceability, and admissibility. You have the option of signing with handwritten signature on request. Acknowledgement By checking the box below where indicated, and/or by hand signing in the place provided, I hereby acknowledge that I have received and read this Notice of Privacy. I understand that I may request additional copies of this notice at any time. I have received and read this notice _______________________ Signature Date ____________________________________ ___________________________ Printed Name Relationship to Patient