1 of 3 — TeleHealth Notice of Privacy Practices

Form 1 of 3

DISCLAIMER*

I AGREE — These conversations do not replace medical or legal advice but provide a wealth of experience and information to help families transition into their new roles in caring for loved ones with dementia, as well as elder care professionals assisting families. A Dr Liz Geriatrics Educator will address your questions and offer their extensive experience to provide solutions.

30-minute Session Fee: $495

Patient's Name*

First NameLast Name

Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient's Date of Birth (to access medical records)

Date

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.

We are Required by Law to Protect Medical Information About You

We are required by law to protect the privacy of medical information about you and that identifies you. This medical information may be information about health care we provide to you or payment for health care provided to you. It may also be information about your past, present, or future medical condition.

We are also required by law to provide you with this Notice of Privacy Practices explaining our legal duties and privacy practices with respect to medical information. We are legally required to follow the terms of this Notice. In other words, we are only allowed to use and disclose medical information in the manner that we have described in this Notice.

We may change the terms of this Notice in the future. We reserve the right to make changes and to make the new Notice effective for all medical information that we maintain.

If, at any time, you have questions about information in this Notice or about our privacy policies, procedures or practices, you can contact our Privacy Officer at 650-357-8834.

If confidential information is requested or needed from individuals not mentioned above, written permission to release specific information will be requested from the participant at that time.

Reports will be sent to the primary doctor. In rare cases of imminent harm, or patient threats of harm to self, we will need to contact the local aging authorities.

If you sign a written authorization allowing us to disclose medical information about you, you may later revoke (or cancel) your authorization in writing (except in very limited circumstances related to obtaining insurance coverage). If you would like to revoke your authorization, you may write us a letter revoking your authorization or fill out an Authorization Revocation Form. Authorization Revocation Forms are available from our Privacy Officer. If you revoke your authorization, we will follow your instructions except to the extent that we have already relied upon your authorizationand taken some action.

You may file a complaint about our privacy practices.

If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a written complaint either with us or with the federal government.

We will not take any action against you or change our treatment of you in any way if you file a complaint.

If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a written complaint either with us or with the federal government.

We will not take any action against you or change our treatment of you in any way if you file a complaint.

To File a Written Complaint with the Federal Government—

Please use the following contact information:

Office for Civil Rights, U.S. Department of Health and Human Services

200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201

Toll-Free Phone: 800-368-1019

TDD Toll-Free: 800-537-7697

Website: hhs.gov

Email: OCRMail@hhs.gov

Responsible Party's Name*

First NameLast Name

Responsible Party's Email*

example@example.com

Date*

Date

Responsible Party's Signature — Use your curser to sign in the box below*

Clear

Please Verify That You are Human*

FOR QUESTIONS CALL 650.357.8834 EXT 1