Effective Date: September 20, 2024

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

You may be asked to provide your health information to us. Any health information you provide to us is subject to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). HIPAA requires us to ask each of our patients to acknowledge receipt of our Notice of HIPAA Privacy Practices (“this Notice”).

You acknowledge receipt of this Notice by clicking on the “I Acknowledge Receipt of the Notice of HIPAA Privacy Practices” button on our website.

This Notice applies to the following organizations:

Extreme Weight Loss & Wellness LLC, has established a professional companies to comply with state laws concerning the provision of professional medical services:

For information concerning this Notice or our privacy practices, please contact [email protected].

Your Rights. You have the right to:

– Get a copy of your medical record
– Correct your medical record
– Request confidential communications
– Ask us to limit the health information we share
– Get a list of those with whom we’ve shared your health information
– Get a copy of this Notice
– Choose someone to act for you
– File a complaint if you believe your privacy rights have been violated

Your Choices. You have some choices in the way that we use and share information as we:

– Answer questions from your family and friends
– Provide disaster relief
– Market our services or sell your health information

Our Uses and Disclosures. We may use a and share your information as we:

– Treat you
– Run our organization
– Bill for our services to you
– Help with public health and safety issues
– Do research
– Comply with the law
– Respond to organ and tissue donation requests
– Work with a medical examiner or funeral director
– Address workers’ compensation, law enforcement, and other government requests
– Respond to lawsuits and legal actions

Notice Summary:

1. Your Rights. When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

A. Get an electronic or paper copy of your medical record

i. You can ask to see or get an electronic copy of, or to get a paper copy of, your medical record and other health information we have about you. Please complete and submit this Medical Records Request Form. a third party requests these records on your behalf, they can complete and submit our form, or submit their completed form with your signed authorization to [email protected].

ii. We do not maintain physical clinical locations, so seeing or getting a copy of your medical records in-person is not possible.

iii. We will provide a copy or a summary of your health information, usually within thirty (30) days of your request. We may charge a reasonable, cost-based fee.

B. Ask us to correct your medical record

i. You can ask us to correct health information about you that you think is incorrect or incomplete. Please contact [email protected] or call us at (855) 511-2639.

ii. We may say “no” to your request, but we’ll tell you why in writing within sixty (60) days.

C. Request confidential communications

i. You can ask us to contact you in a specific way. For example, you can ask us to contact you by e-mail instead of by cell phone, or to send mail to a different address. Please contact [email protected] or call us at (855) 5111-2639.

ii. We will say “yes” to all reasonable requests.

D. Ask us to limit what we use or share

i. You can ask us not to use or share certain health information for treatment, payment, or our operations. Please contact [email protected] or call us at (855) 511-2639. We are not required to agree to your request, and we may say “no” if it would affect your care.

ii. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

E. Get a list of those with whom we’ve shared information

i. You can ask for a list (accounting) of the times we’ve shared your health information for six (6) years prior to the date you ask, who we shared it with, and why. Please contact [email protected] or call us at (855) 511-2639.

ii. We will include all the disclosures except for those about treatment, payment, and our operations, and certain other disclosures (such as any you asked us to make). We’ll provide one (1) accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within twelve (12) months.

F. Get a copy of this Notice

i. This Notice is available on our website. You can ask for a copy of this Notice at any time, even if you have agreed to receive this Notice electronically. Please contact [email protected] or call us at (855) 511-2639. We will promptly provide you with a copy in Adobe PDF or Microsoft Word format, assuming you provide us a valid email address. If instead you prefer a paper copy, we can have it mailed to you, assuming you provide us a valid mailing address.

ii. We do not maintain physical clinical locations, so asking for a paper copy of this Notice in-person is not possible.

G. Choose someone to act for you

i. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. Please contact [email protected] or call us at (855) 511-2639.

ii. We will make sure the person has this authority and can act for you before we take any action.

1. Your Choices. For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, please contact [email protected] or call us at (855) 511-2639.

2. . Tell us what you want us to do, and we will follow your instructions.

A. In the following cases, you have both the right and choice to tell us to: (i) share health information with your family, close friends, or others involved in your care; (ii) share health information in a disaster relief situation; and (iii) include your health information in a hospital or clinic directory.

B. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your health information if we believe it is in your best interest. We may also share your health information when needed to lessen a serious and imminent threat to health or safety.

C. In the following cases, we never share your health information unless you give us written permission: (i) sale of your health information; (ii) in the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again; (iii) most sharing of psychotherapy notes; and (iv) marketing purposes.

3. Our Uses and Disclosures

A. How do we typically use or share your health information? We typically use or share your health information in the following ways.

i. To treat you. We can use your health information and share it with other professionals who are treating you. Example: Your primary care provider asks our provider about your overall health condition.

ii. To run our organization. We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.

iii. To bill for our services to you. We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

B. How else can we use or share your health information? We are allowed or required to share your health information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html.

C. Help with public health and safety issues. We can share health information about you for certain situations such as: (i) preventing disease; (ii) helping with product recalls; (iii) reporting adverse reactions to medications; (iv) reporting suspected abuse, neglect, or domestic violence; and (v) preventing or reducing a serious threat to anyone’s health or safety. In addition:

i. We must report to government officials in charge of collecting specific information related to births, deaths, and certain diseases and infections.

ii. Where required by law we must report information about patients with certain conditions, such as HIV/AIDS and cancer, to central registries.

iii. We also are required to report information about immunizations to certain people exposed to communicable diseases and to employers in connection with occupational health and safety matters.

D. Do research. We can use or share your information for health research.

E. Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

F. Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.

G. Work with a medical examiner or funeral director. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

H. Address workers’ compensation, law enforcement, and other government requests. We can use or share health information about you: (i) for workers’ compensation claims; (ii) for law enforcement purposes or with a law enforcement official; (iii) with health oversight agencies for activities authorized by law; and (iv) for special government functions such as military, national security, and presidential protective services.

I. Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

4. Our Responsibilities. We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. In addition:

A. We must follow the duties and privacy practices described in this Notice and give you a copy of it.

1. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind by contacting [email protected].

5. Changes to the Terms of this Notice. We reserve the right to revise this Notice at any time. We will make the revised version of this Notice available on our website. The date this Notice was last revised is identified under the title above. By continuing to access our services for your treatment after revisions to this Notice are made available on our website, you accept the revised Notice unless we are required by law to obtain your acceptance some other way. To obtain a copy of the revised Notice, please refer to Section 1, Paragraph (f) above.