Notice of Privacy Practices

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. This Notice will tell you about the ways we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding such medical information. We are required by law to make sure that medical information which identifies you is kept private; give you this Notice of our legal duties and privacy practices with respect to your medical information; and follow the terms of the Notice that is currently in effect. This Notice covers the healthcare provider practices of Ziphealthy, PLLC (collectively “Ziphealthy”, “we” or “us”), including its employed healthcare providers and other personnel. (If you are being treated by a Ziphealthy healthcare provider while in another institution you should refer to that other institution’s Notice of Privacy Practices for information about how your medical information may be used and disclosed and whom to contact to exercise your rights).

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical information.

Treatment.

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, social workers, psychologists, psychiatric nurse practitioners, licensed professional counselors, licensed marriage and family therapists, nurses, technicians, medical students, social work students, counseling students, marriage and family therapy students, and psychology students, or other Ziphealthy personnel or personnel of other institutions (collectively “our Affiliated Institutions”), who are involved in taking care of you. For example, a healthcare provider treating you for a depression may need to know if you have another health condition, because another health condition may hinder the therapuetic process. Different departments of Ziphealthy and our Affiliated Institutions also may share medical information about you, such as diagnosis, treatment history and prognosis notes, to coordinate your treatment. We also may disclose medical information about you to people outside Ziphealthy who may be involved in your medical care.

Payment.

We may use and disclose medical information about you so that we may bill for treatment and services you receive at Ziphealthy and can collect payment from you, an insurance company or another party. For example, we may need to give information about treatment you received or are going to receive to your health plan so that the plan will pay us or reimburse you for the treatment. In the event a bill is overdue, we may need to give information to a collection agency as necessary to help collect the bill or may disclose an outstanding debt to credit reporting agencies. We may also disclose information about you to our Affiliated Institutions and other healthcare facilities for purposes of payment as permitted by law.

Health Care Operations.

We may use and disclose medical information about you for operations of Ziphealthy and our joint operations with our Affiliated Institutions or Service Providers. These uses and disclosures are necessary to run Ziphealthy or such joint operations and make sure that all of our patients receive quality care. For example, we may use medical information to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, social workers, psychologists, psychiatric nurse practitioners, licensed professional counselors, licensed marriage and family therapists, nurses, technicians, medical students, social work students, counseling students, marriage and family therapy students, and psychology students, or other Ziphealthy personnel or personnel of other institutions and other Ziphealthy personnel for educational purposes. We may also disclose information about you to other healthcare facilities as permitted by law.

Appointment Reminders; Treatment Alternatives; Health-Related Benefits and Services.

We may use and disclose medical information to contact you to remind you that you have an appointment for treatment or medical care, or to contact you to tell you about possible treatment options and health-related benefits and services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care. We may also tell your family or friends your condition. If you do not wish us to share this information with your friends and family, please inform Ziphealthy personnel in writing. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

As Required By Law.

We will disclose medical information about you when required to do so by federal, state or local law.

Special Privacy Protections.

If your medical information includes HIV-related information, alcohol or substance abuse, mental health or genetic information, special protections may apply to such information, and you can contact the Privacy Officer if you have any questions. To Avert a Serious Threat to Health or Safety. of you, the public or another person, we may use or disclose medical information about you.

Organ and Tissue Donation.

If you are an organ or tissue donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank.

Military and Veterans.

If you are a member of the armed forces of the United States or another country, we may release medical information about you as required by military command authorities.

Workers’ Compensation.

We may release medical information about you for workers’ compensation or similar programs.

Public Health Risks.

We may disclose to authorized public health or government officials medical information about you for public health activities when required or authorized by law. These activities generally include the following: to a person subject to the jurisdiction of the Food and Drug Administration (FDA) for purposes related to the quality, safety or effectiveness of an FDA-regulated product or service; to prevent or control disease, injury or disability; to report disease or injury; to report births and deaths; to report reactions to medications and food or problems with products; to notify people of recalls or replacements of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence.

Health Oversight Activities.

We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.

Lawsuits and Disputes.

If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other legal demand by someone else involved in the dispute, but only if efforts have been made by us or someone else to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement/National Security/Protective Services.

We may release medical information if asked to do so by a law enforcement official: in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if, under certain circumstances, we are unable to obtain the person’s agreement; about a death we believe may be the result of criminal conduct; about criminal conduct on the premises of Ziphealthy; and in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime; to authorized federal officials so they may provide protection for the President and other authorized persons, or conduct special investigations, or for intelligence, counterintelligence, and any other national security activities authorized by law.

Coroners, Medical Examiners and Funeral Directors.

We may release medical information about deceased persons to a coroner, medical examiner or funeral director so they can carry out their duties.

Other Uses of Medical Information.

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made with your written authorization, on a Ziphealthy authorization form. You may revoke such an authorization by writing to the Privacy Officer, and such revocation will be effective to the extent that we have not already released the information pursuant to the authorization or otherwise taken action in reliance on the authorization.

Research.

Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of patients who received one treatment modality to those who received another, for the same condition. All research projects, however, are subject to a special approval process before your medical information may be used or disclosed. We may use or disclose medical information about you to researchers who are preparing to conduct a research study, for example, to help them look for patients with specific medical needs who might be asked to participate in this project. In this case, information they review will not leave Ziphealthy or our Affiliated Institutions. When legally required, we will ask for your specific written permission (authorization) if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at Ziphealthy or our Affiliated Institutions. Finally, we may permit a researcher to look at your medical information and use and disclose it for research purposes if, after going through an approval process, an evaluation is made that the proposed use and disclosure complies with legal and ethical requirements regarding the privacy of medical information.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

Right to Inspect and Copy.

You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. This right does not include: psychotherapy notes; information compiled for use in a legal proceeding; or certain information maintained by laboratories. In order to inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at the address listed at the end of this Notice. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to medical information, you may request in writing to the Privacy Officer that the denial be reviewed. A licensed healthcare professional who was not directly involved in the original decision to deny access will conduct the review. We will comply with the outcome of the review.

Right to Request Amendments.

If you think that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, your request must be made in writing and submitted to the Privacy Officer at the e-mail address listed at the end of this Notice. In addition, you must give a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: • was not created by us, unless the person or entity that created the information is no longer available to make the amendment; • is not part of the medical information kept by or for Ziphealthy; • is not part of the information you would be permitted to inspect and copy; or • is accurate and complete. We will provide you with written notice of action we take in response to your request for an amendment.

Right to an Accounting of Disclosures.

You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we have made of medical information about you. We are not required to account for any disclosures you specifically requested or for disclosures related to treatment, payment, or healthcare operations, made pursuant to an authorization signed by you, or and which fall into certain other limited categories of disclosures. To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer at the address listed at the end of this Notice. Your request must state a time period, which may not be longer than six years prior to the date of your request. You may request one accounting in any 12-month period free of charge, and we will charge you for any subsequent request in the same 12-month period. Such charge may include reasonable retrieval, list preparation, and mailing costs.

Right to Request Restrictions.

You have the right to request a restriction or limitation on the medical information we use or disclose about you. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. If you wish to request such a restriction, you must contact the Privacy Officer in writing at the address listed at the end of this Notice. We are not required to agree to your request. If we agree to your request, we will comply with your request unless the information is needed to provide you with emergency treatment.

Right to Request an Electronic Copy of your Medical Record.

You have a right to request that we provide you with an electronic copy of your medical record. Ziphealthy will try to provide the information in the format you request. However, if the format is not available, we are permitted to offer other electronic formats. If none for the offered formats are acceptable to you, Ziphealthy is permitted to provide you with a “hard copy”. You may also request that Ziphealthy transmit the electronic copy directly to a third party designated by you and we will comply.

Right to Request Confidential Communications.

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must contact the Privacy Officer in writing at the address listed at the end of this Notice. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will attempt to accommodate reasonable requests.

Right to Restrict Disclosures of your PHI to your Health Plan with Respect to Healthcare for which you have paid out of pocket and in full.

If you pay for a service out of pocket and in full, you may request that Ziphealthy not disclose information about that visit to your insurance plan and Ziphealthy must honor that request. However, if you want us to bill your insurance plan for any subsequent care, we may have to provide the original information to your carrier in order for us to be paid for the subsequent service.

Prohibition on Certain Disclosures or Sale of PHI Without Authorization.

Ziphealthy will not disclose your health information for the purpose of marketing non-Ziphealthy products or services without an authorization (which authorization would state whether Ziphealthy received any payment for such marketing). If your medical record contains psychotherapy notes, Ziphealthy will not use or disclose the psychotherapy notes except for your specific treatment or for our training programs, or in the event of a legal proceeding brought by you or your representative against us, unless you specifically grant permission (authorization). Lastly, any other uses or disclosures not specifically described in the Notice of Privacy Practices will not be made without your written authorization. And, in the event that you authorize one of more of the above mentioned uses or disclosures, you have the right to revoke your authorization at any time by writing to us at the e-mail address below. We will honor the revocation unless we have already used or disclosed the information. Revocation will in no case affect your care at Ziphealthy.

Right to be Notified in the Event of a Breach

In the event of a breach of your Protected Health Information as defined by the Department of Health and Human Services (HHS), you will be notified by us in a manner specified by HHS.

Right to a Paper Copy of This Notice.

You have the right to a paper copy of this Notice. You may obtain a copy by contacting the Privacy Officer. You may also obtain a copy of this Notice electronically at our website address noted below.

Changes To This Notice.

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information about you we already have as well as any information we receive in the future. The current Notice in effect at any time will be posted on our website address listed below and will be available from the Privacy Officer as well as at any of our practice locations.

Complaints.

If you believe your privacy rights have been violated, you may file a complaint with Ziphealthy or with the Secretary of the Department of Health and Human Services.

To file a complaint with Ziphealthy, please call or write to the Privacy Officer at the address listed at the end of this Notice. You will not be penalized or retaliated against for filing a complaint regarding your privacy rights.

Questions.

If you have a question about this Privacy Notice, please contact: Privacy Office Ziphealthy Phone: 914.768.3026  Email: privacy@ziphealthy.com.

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