RELAX YOUR MIND SERVICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") requires that all medical records and other individually identifiable health information must be kept properly confidential. This Notice explains the ways in which I may use and disclose your health information, and your related rights as a patient. I am required by law to follow the terms of this Notice so long as it remains in effect. Feel free to ask questions about this Notice at any time.

WHAT IS PROTECTED HEALTH INFORMATION ("PHI")

PHI is information that individually identifies you. It includes records that I create or obtain from you or from another health care provider, health plan, your employer, or a health care clearinghouse regarding: Your past, present, or future physical or mental health or conditions, The provision of health care to you, or The past, present, or future payment for your health care.

HOW I MAY USE AND DISCLOSE YOUR PHI

I may use and disclose your PHI in the following circumstances: Treatment. I may use or disclose your PHI to give you medical treatment or services and to manage and coordinate your medical care. For example, your PHI may be provided to a physician or other health care provider (e.g., a specialist or laboratory) to whom you have been referred to ensure that the physician or other health care provider has the necessary information to diagnose or treat you or provide you with a service. Payment. I may use and disclose your PHI in order to bill for the treatment and services you receive from me and to collect payment from you, a health plan, or a third party. This use and disclosure may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services I recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, I may need to give your health plan information about your treatment in order for your health plan to agree to pay for that treatment. Health Care Operations. I may use and disclose PHI for my health care operations. For example, I may use your PHI to internally review the quality of the treatment and services you receive and to evaluate my own performance. I may also disclose information to my professional associates for educational and learning purposes. Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services. I may use and disclose PHI to contact you to remind you that you have an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you. Minors. I may disclose the PHI of minors to their parents or guardians unless otherwise prohibited by law. Business Associates. I may disclose PHI to my business associates who perform functions on my behalf or provide me with services if the PHI is necessary for those functions or services. For example, I may use another company to do my billing, or to provide transcription or consulting services. All of my business associates are obligated, under contract with me, to protect the privacy and ensure the security of your PHI. To Avert a Serious Threat to Health or Safety. I may use and disclose PHI when necessary to prevent a serious threat to your health or safety or to the health or safety of others. Public Health Risks. I may disclose PHI for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products. Health Oversight Activities. I may disclose PHI to a health oversight agency for audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Workers' Compensation. I may use or disclose PHI for workers' compensation or similar programs that provide benefits for work- related injuries or illness. Coroners, Medical Examiners and Funeral Directors. I may disclose PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. Law Enforcement. I may disclose PHI for law enforcement purposes, if all applicable legal requirements are met.

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Military, Veterans, National Security and Intelligence. If you are or were a member of the armed forces or national security or intelligence communities, I may be required by military command or government authorities to disclose PHI. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, I may disclose PHI in response to a court or administrative order, subpoena, discovery request, or other legal process initiated by someone involved in the dispute. I may also use or disclose your PHI to defend myself in the event of a lawsuit. As Required by Law. I will disclose PHI when required to do so by international, federal, state, or local law. Family and Friends. I may disclose PHI to your family or friends if I obtain your verbal permission. I may also disclose PHI to your family or friends if, given the circumstances, your permission is clearly implied. For example, I may assume that you agree to disclosure of PHI to your spouse if you bring your spouse with you into your appointment. In situations where you are not capable of giving consent (because you are not present, or due to your incapacity or medical emergency), I may, using my professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, I will disclose only PHI relevant to the person's involvement in your care.

YOUR RIGHTS REGARDING YOUR PHI

Inspect and copy. You have the right to inspect and copy your PHI. I have up to 30 days to make your PHI available to you from the time of your request, and I may charge a reasonable fee for this service. Request Amendments. If you feel that the PHI in my records is incorrect or incomplete, you have the right to request an amendment. Such a request must be submitted to me in writing, and must explain the reason for your request. In some cases, I may deny your request, in which case you have the right to file a statement of disagreement. Accounting of Disclosures. You have the right to request a list of the instances in which I have disclosed your PHI. Such a request must be submitted to me in writing, and I may charge a reasonable fee for this service. Receive Notice of a Breach. You have the right to be notified if your PHI is improperly disclosed. Request Restrictions. You have the right to request a restriction or limitation on the use and/or disclosure of your PHI for treatment, payment, health care operations, or other legal purposes described in this Notice. Such a request must be submitted to me in writing, and I am not required to agree to your request. If I do agree to your request, I will abide by it except as required by law, or to provide emergency treatment, or if you submit a written revocation of the restriction. Request Confidential Communications. You have the right to request that I communicate with you only in certain ways to protect your privacy. For example, you may request that I contact you by mail at a specific address or call you only at your work number. Such a request must be submitted to me in writing. Authorize Other Uses and Disclosures. Other uses and disclosures of PHI not covered by this Notice will be made only with your written authorization. If you provide an authorization, you may revoke it at any time by submitting a written revocation, and I will no longer disclose PHI under the authorization. Any disclosure made in reliance on your authorization before you revoked it will not be affected by the revocation. Copy of This Notice. You have the right to obtain a paper copy of this Notice from me upon request. Changes to This Notice. I reserve the right to change the terms of this Notice and to make the revised Notice effective for all PHI that I maintain. You may request a paper copy of the current Notice at any time. The current Notice is also posted online at frazeemd.com/policies. Complaints. If you believe your privacy rights have been violated, you may file a written complaint with the Office of Civil Rights at the Department of Health and Human Services. You will not be retaliated against for filing a complaint.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing below, you acknowledge that you have read and/or received a copy of the Notice of Privacy Practices of RELAX YOUR MIND SERVICES, LLC effective January 28, 2021.

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