Notice of Privacy Practices

Rejuvent Medical Spa & Surgery Privacy Policy

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 our Privacy Practices, including your rights and ability to voice your concerns, please call Ruth Hernandez

at (480) 889-8880.

Dear Patient:

The confidentiality of your personal health information is important to us. As physicians, we rely on you to provide us with complete and accurate information about your

condition, symptoms and health history, which helps us make a diagnosis and provide you care and treatment. We appreciate how you trust us with this personal information.

We want you to know about the privacy practices in our office that are intended to safeguard the proper use and disclosure of your Protected Health Information.

Please sign the Acknowledgment, so we know you received a copy of our Notice of Privacy Policies.

Let’s Start With Some Important HIPAA Terms:

 “HIPAA” means the Health Insurance Portability and Accountability Act. On August 14, 2002, the Department of Health and Human Services issued the HIPAA Privacy Rule,

which describes how Protected Health Information may be properly Used and Disclosed.

 “Protected Health Information” means information about your past, present and future medical condition, treatment of your medical condition, and payment for your treatment.

 “Disclose” means how we (physicians and staff) properly release, transfer, divulge or provide access to Protected Health Information to an outside person or entity, such as

another doctor, hospital or nursing home.

 “Treatment” means the provision of medical care by physicians and staff within our office as well as the management and coordination of care and services between our office

and other health care providers, such as doctors, hospitals, nursing homes, home health agencies, and the information and records related to that treatment and care.

 “Payment” means our activities to obtain payment or reimbursement from a Health Plan for Treatment that we have provided. Payment includes billing and claims management,

collection activities and related health care data processing.

 “Health Plan” means a group insured or self-insured plan, HMO, PPO or other plan offered by your employer or by Medicare or Medicaid that provides for the Payment of

Treatment for eligible persons and their dependents (spouses and children).

 “Health Care Operations” means certain internal functions, business management and administrative activities we perform in our office, such as quality assessment and

improvement, evaluating our employees, performing risk management and compliance activities, and arranging for legal and accounting services. Some of these services are

performed by Business Associates.

 “Business Associate” means a person who, when performing certain services (including specified Health Care Operations) on our behalf, may have access or Use of Protected

We have entered into agreements with our Business Associates to assure that they safeguard your Protected Health Information according to HIPAA’s

Health Information. Privacy Rule.

 “Authorization” means the written permission you give us to Use or Disclose your Protected Health Information to persons and for purposes other than for Treatment, Payment

and for Health Care Operations. An Authorization form is attached to this Notice of Privacy Practices.

 “Non-Covered Person or Entity” means a person or entity that is not required to comply with HIPAA’s Privacy Rule for the Use or Disclosure of Protected Health Information.

For example, your employer (in its capacity as employer) is a Non-Covered Entity. Health information in your employee record is not considered Protected Health Information

under HIPAA’s Privacy Rule.

 “Privacy Officer” means the person in our office who is in charge of assuring that we follow our privacy practices to safeguard your Protected Health Information. Our Privacy

Officer also is in charge of our Patient Concern and Complaint Resolution Procedure (described below and in the attachment). If you have a question about this Notice, or our

privacy practices, or your rights, or if you have a concern or complaint, please contact our Privacy Officer

How We Use and Disclose Protected Health Information for Treatment, Payment, and Health Care Operations:

As permitted by HIPAA’s Privacy Rule, we will use and Disclose Protected Health Information for Treatment, Payment, and Health Care Operations. There is no need for you

to sign a Consent for us to Use and Disclose Protected Health Information for these purposes.

For example, our physicians and staff will use Protected Health Information to provide you Treatment in our office. We also will Disclose Protected Health Information to other

physicians, health care providers, hospitals and facilities that are involved in providing or coordinating your Treatment. We will take reasonable precautions to protect against

someone accidentally seeing confidential materials or overhearing confidential conversations.

An example of our Use and Disclosure of Protected Health Information for Payment is when we check with your Health Plan about eligibility, coverage and pre-certification

requirements, as well as when we submit a claim to your Health Plan for Payment of Treatment we provided to you.

An example of how we Use Protected Health Information for Health Care Operations is when we monitor our own performance quality in providing you Treatment.

Our Use and Disclosure of Protected Health Information According to Your Written Authorization and Your Right to Revoke in Writing that Authorization:

We will not Use or Disclose your Protected Health Information for purposes other than Treatment, Payment or Health Care Operations (unless we are required to do so by law—

1see next section below) without your signed, written Authorization.

For example, we will not release records to your employer for employment purposes without obtaining your written Authorization. We will not Disclose Protected Health

Information to a third party for marketing purposes without your written Authorization. Once information is obtained by a Non-Covered Entity, it no longer is considered Protected

Health Information and is not covered under HIPAA’s Privacy Rule.

It also is necessary for you to sign an Authorization before we can Use or Disclose Protected Health Information for medical research.

You may revoke the Authorization in writing at any time. Once we receive your written revocation, we will stop the Use or Disclosure of Protected Health Information according

to the Authorization. However, we cannot be held responsible for any previous Use or Disclosure of Protected Health Information, as permitted by the Authorization, before we

receive your written revocation.

USES AND DISCLOSURES

 We may contact you to provide appointment reminders or information about your treatment, tests or other health related information.

 We will use and disclose your protected heath information when we are required to do so by federal, state and local law.

 We may disclose your protected heath information to public health authorities that are authorized by law including but not limited to: response to a health oversight agency

for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding, response to a

discovery request, subpoena ,or other lawful process by another party involved in the dispute, but only after we have made an effort to inform you of the request or to obtain

an order protecting the information the party requested.

 We will release your protected health information if requested to a law enforcement official for any circumstance required by law.

 We may release your protected health information to a medical examiner or coroner to identify a deceased individual or to identify the cause of death.

 We may release your protected health information to organizations that handle organ, eye or tissue procurement or transplantation, including organ banks as necessary to

facilitate organ or tissue nation and transplantation if you are an organ donor.

 We may use and disclose your protected health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another

individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

 We may disclose your protected health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

 We may disclose your protected health information to federal officials for intelligence and national security activities authorized by law.

 We may disclose protected health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

 We may disclose your protected health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement

official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or

(c) to protect your health and safety or the health and safety of other individuals or the public.

 We may release your protected health information for workers’ compensation and similar programs.

We Want You to Know Your Rights under the Privacy Rule and Our Privacy Practices

 You have the right to request and receive from us confidential communications of Protected Health Information by alternative means or at alternative locations.

Our general policy is to contact you by mail or by telephone at your home address or telephone number. You have the right to request that we communicate with you confidentially

by alternative means or at alternative locations. Our policy is to honor all reasonable requests. If we cannot honor your request, we will inform you of that.

For example, if you do not want us to contact you by telephone or at your home telephone, please fill out the written request that appears in the new patient form or in the

separate request form (see attached). You also may request that we send a bill to a certain address. We will not require an explanation for why you are making this request.

 You have the right to request restrictions on certain Uses and Disclosures of Protected Health Information.

You may request that we restrict certain Uses or Disclosures of your Protected Health Information by completing the Request for Restriction form (identical or similar to the one

attached for your review). You may present or mail the completed form to us.

This request may involve certain restrictions in connection with Treatment, Payment or Health Care Operations. It also may involve a request that we do not discuss Protected

Health Information with family members, friends or others who are involved in caring for you.

HIPAA’s Privacy Rule gives all physicians the right to deny patient requests for restricted Use or Disclosure of Protected Health Information.

While we will consider reasonable requests, it is our general policy and practice not to restrict the Use or Disclosure of Protected Health Information that is necessary for providing

good Treatment or important for protecting the health and safety of others providing Treatment or taking care of you. For example, information that you provide when giving us

your medical history or certain test results may necessarily be shared with another physician or provider of care. Restricting Disclosure could adversely affect the ability of that

physician or provider to give you proper Treatment.

It also is our general policy and practice not to restrict the Use or Disclosure of Protected Health Information when submitting a claim to a Health Plan for reimbursement.

If you are a Minor (less than 18 years old), you may request us not to Disclose Protected Health Information to your parents. We will consider this request in connection with

our obligations under Arizona law.

We will consider all other requests for restricted Use or Disclosure of Protected Health Information on a case-by-case basis, taking into account risks and benefits to you and

others. If we cannot honor your request, we will let you know.

 You have a right to access, inspect and copy your own Protected Health Information that we maintain in a Designated Record Set.

You have the right generally to access, inspect and copy your own Protected Health Information that our office maintains in a Designated Record Set (see Definition above).

There are some exceptions under the Privacy Rule. For example, you do not have the right to inspect of copy psychotherapy notes or information compiled in anticipation of (or

use in) civil, criminal or administrative proceedings. Your right also may not extend to information covered by other laws or information obtained from someone other than

another health care provider, based on a promise of confidentiality.

We may also deny access if, in our judgment, it could endanger the life or safety of you or another.

2You may request access to your Protected Health information by completing the Request for Access form (identical or similar to the model form attached for your review) and

presenting or sending it to us.

Our practice will consider all requests according to our legal responsibilities under the Privacy Rule. We generally will act on your request within 30 days from the time we

receive the competed form (if the form is incomplete, we will ask you to complete it). In some circumstances, it may take more than 30 days, in which case we will notify you

and will act on your request as soon thereafter as reasonably possible.

If we are able to grant your request, we will contact you to set up an appointment for you to inspect your Protected Health Information and request a copy of that information.

You may not make changes in the original record.

Alternatively, with your permission, we may provide you with a summary or explanation of the Protected Health Information in lieu of having you inspect the record.

Under the Privacy Rule, we may charge you copying costs (supplies and labor) and postage.

If we are unable to grant your request, because of the reasons listed above, or because the information is not part of a Designated Record Set, we will notify you in writing of the

basis for the denial and your rights for review of our denial.

 You have the right to amend incorrect or incomplete facts in your Protected Health Information maintained in a Designated Record Set.

You may make a request to amend your Protected Health Information by completing the Request form (identical or similar to the form attached for your review) and presenting

or mailing it to us.

We will respond to your request within 60 days from the time we receive your completed form (if your form is not complete, we will notify you of that).

We will honor your request if Protected Health Information is incorrect or incomplete. We may not, under the HIPAA Privacy Rule, amend your Protected Health Information if it

is not part of a Designated Record Set, if it would not be available for you to inspect (see Right to Inspect, above), or if the information is accurate and complete.

For example, if your record mistakenly indicates that you received Treatment for a fracture of the right arm when, in fact, your Treatment was for a sprain of your left leg, clearly

that information should be amended. If, however, you want to delete a reference contained in the history that you told the doctor you were feeling “depressed,” it would not be

appropriate to delete that reference from the Protected Health Information, because it accurately reflected the information you gave the doctor.

If we accept the requested amendment, we will amend the Protected Health Information in the Designated Record Set, inform you that we have made the amendment, and notify

persons who have received and may have relied on Protected Health Information that has been amended.

If we deny your request to amend Protected Health Information, we will: (1) notify you in writing of the basis for that denial; (2) inform you of your right to submit a written

statement of disagreement and provide you with a form to submit your statement of disagreement, which we will maintain with your record and will include with future Disclosures,

if requested; and (3) inform you of your right to file a complaint.

If you file a statement of disagreement, we may prepare a written rebuttal statement.

If you have any questions about this right, please ask our Privacy Officer Ruth Hernandez.

 You have a right to receive an Accounting of Disclosures of Protected Health Information.

You have a right to receive an Accounting of Disclosures that we have made to others of your Protected Health Information. This right is limited and does not require us to

provide you with an Accounting of Disclosures made for: (1) Treatment, Payment and Health Care Operations purposes; (2) Disclosures made to you or your legal representative

on your behalf; (3) Disclosures made in accordance with a written Authorization that you signed