NOTICE OF PRIVACY PRACTICES

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we've shared your information
• Get a copy of this privacy 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:

• Tell family and friends about your condition
• Provide disaster relief
• Provide mental health care
• Market our services or sell your information
• Raise funds

Our Uses and Disclosures

We may use and share your information as we:

• Treat you
• Run our organization
• Process payments for your membership and services
• Help with public health and safety issues
• Do research
• Comply with the law
• Work with a medical examiner or funeral director
• Address workers' compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
• Share your records through a health information exchange (with your consent)

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

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.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. You may request access through our electronic health record patient portal (Elation) or by submitting a written request to our office.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. You also have access rights under the Colorado Revised Statutes, § 25-1-802.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home, office, or cell phone) or to send mail to a different address.
• We will say "yes" to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no," for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.
• 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. Because this Practice is a cash-pay, membership-based practice and does not bill any health insurer or third-party payor, this right is unlikely to be implicated in our practice, but we will honor any such request.

Get a list of those with whom we've shared information

• You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting our Privacy Officer, Patrick M. Long, MD, at info@originalmd.com or 1601 E. 19th Ave, STE 6450, Denver, CO 80218.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html.
• We will not retaliate against you for filing a complaint.

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

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care or payment for your care
• Share information in a disaster relief situation
• Share your mental health treatment records, which we disclose only with your written consent except as Colorado law permits or requires (see Special Protections Under Colorado and Federal Law below)
• Participate in our health information exchange — we ask for your written consent on a separate form before sharing your records through the exchange, and you may decline or withdraw your consent at any time (see Health Information Exchange under Our Uses and Disclosures below)

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

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again. The Practice does not currently engage in fundraising activities using patient health information.

If we have your substance use disorder patient records, subject to 42 CFR part 2, we will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A specialist to whom Dr. Long refers you may need information about your overall health condition to provide appropriate care.

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, coordinate your care, and for quality improvement.

Business Associates

We may share your information with business associates that perform services for us, such as our electronic health record, secure communications, and payment vendors, under written contracts that require them to protect your information.

Payment

We can use and share your health information as necessary to process payments for your membership fees and any services rendered. This Practice is a cash-pay, membership-based direct primary care practice and does not bill health insurance plans, Medicare, Medicaid, or other third-party payors. We do not share your health information with health insurers for billing purposes.

Example: We use your information to process your membership fee payment through our payment platform.

Genetic information

Genetic testing and the information it produces receive special protection under Colorado law, which declares genetic information the unique property of the person tested and treats it as confidential and privileged. We use your genetic information only for your diagnosis, treatment, and care. We will not release it for any other purpose without your specific written consent, except in the narrow circumstances Colorado law permits or requires. We do not disclose your genetic information to insurers or employers. Federal law (the Genetic Information Nondiscrimination Act) separately prohibits health insurers and most employers from using genetic information against you.

Health information exchange

OriginalMD participates in a national health information exchange network. Through it, we can request your records from hospitals, laboratories, and other practices that have cared for you, so that your chart is complete. The same network allows another health care provider who has a current treating relationship with you to request a summary of your OriginalMD record for their treatment of you. The summary we share includes your problem list, medications, allergies, immunizations, vital signs, laboratory results, procedures, social history, and plan of care, including any genetic diagnoses recorded in your chart. It does not include records we have marked confidential. Because the summary may include genetic diagnoses, we obtain your specific written consent on a separate Health Information Exchange Notice and Consent form before activating your exchange participation. You may decline exchange participation or withdraw your consent at any time by contacting our office at (720) 575-0267; declining will not affect your membership, your appointments, or how Dr. Long cares for you.

How else can we use or share your health information?

We are allowed or required to share your 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.

In all cases, including those listed below, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your written consent or (2) a court order issued after notice and an opportunity to be heard, accompanied by a subpoena.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone's health or safety

Do research

We can use or share your information for health research.

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.

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.

Address workers' compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers' compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

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.

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.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described in this notice 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.
• Information we disclose to others may be redisclosed by the recipient and may no longer be protected by federal privacy law.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, through our patient portal, and on our website.

Special Protections Under Colorado and Federal Law

Colorado and federal law give certain categories of health information stronger protection than the general HIPAA rules described in this notice. Where a stricter law applies, we follow the stricter rule. This section summarizes those special protections.

Mental health records. Colorado law (C.R.S. § 27-65-123) provides additional protections for mental health treatment records that are stricter than general HIPAA rules. We will not disclose your mental health treatment records without your written consent except where Colorado law specifically permits or requires disclosure, such as for treatment purposes, where there is a duty to warn of a serious threat, or as otherwise required by law. This state-law protection limits certain disclosures that might otherwise be permitted under the general HIPAA treatment, payment, and healthcare operations framework.

HIV and STI records. Colorado law (C.R.S. § 25-4-406) makes provider-held records and information identifying a person tested for or diagnosed with HIV or another sexually transmitted infection strictly confidential, subject to narrow exceptions. We will not disclose this information except as that law permits or requires.

Genetic information. Your genetic information receives the protections described in the Genetic Information paragraph under Our Uses and Disclosures above, including the requirement of your specific written consent before release for any purpose other than your diagnosis, treatment, and care. If you consent to participate in the health information exchange, genetic diagnoses recorded in your chart may be included in summaries shared with treating providers; this occurs only with your specific written consent on the separate Health Information Exchange Notice and Consent form.

Substance use disorder records. If we have substance use disorder patient records subject to 42 CFR Part 2, the statements in this notice about those records apply, including the limits on their use in investigations and proceedings against you and the advance-notice requirement for fundraising communications.

Other Uses and Disclosures

Any use or disclosure of your health information not described in this Notice will be made only with your written authorization. You may revoke any authorization you provide to us at any time by submitting a written revocation to our Privacy Officer. Your revocation will not affect any uses or disclosures we made in reliance on your authorization before we received your revocation.