New You Medical Weight Loss & Testosterone HRT
Effective Date: [Insert Date]

This Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.

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

You may ask to see or obtain an electronic or paper copy of your medical record and other health information we maintain about you. We will provide a copy or a summary, typically within 30 days of your request. We may charge a reasonable, cost-based fee.

If you believe that information in your medical record is incorrect or incomplete, you may request a correction. We may deny your request, but we will explain the reason in writing within 60 days.

You may ask us to contact you in a specific way (for example, at home or work) or to send mail to a different address. We will accommodate all reasonable requests.

You may request that we not use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may deny it if it would affect your care.

If you pay for a service or health care item out-of-pocket in full, you may request that we not share that information with your health insurer for purposes of payment or operations. We will honor this request unless the law requires otherwise.

You may request a list (accounting) of certain disclosures of your health information for the six years prior to your request, including who we shared it with and why. One accounting per year is provided free of charge. We may charge a reasonable fee for additional requests within a 12-month period.

You may request a paper copy of this Notice at any time, even if you have agreed to receive it electronically.

If you have given someone medical power of attorney or if someone is your legal guardian, that person may exercise your rights and make choices about your health information. We will verify that this person has authority to act for you.

You may file a complaint if you believe your privacy rights have been violated. You may contact us using the information below or file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.

For certain health information, you can tell us your preferences about what we share.

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

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a directory
• Contact you for fundraising efforts

If you are unable to express your preference (for example, if you are unconscious), we may share your information if we believe it is in your best interest. We may also share information when necessary to reduce a serious and imminent threat to health or safety.

We will never share your information without your written permission for:

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

If we contact you for fundraising, you may opt out at any time.

We may use your health information and share it with other professionals who are involved in your care.

We may use and share your health information to operate our practice, improve your care, and contact you when necessary.

We may use and share your health information to bill and receive payment from health plans or other entities.

We are permitted or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and safety.

These may include:

• Helping with public health and safety issues
• Preventing disease
• Assisting 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
• Conducting research
• Complying with the law
• Responding to organ and tissue donation requests
• Working with a medical examiner or funeral director
• Addressing workers’ compensation, law enforcement, and other government requests
• Responding to lawsuits and legal actions

We must meet many conditions in the law before we can share your information for these purposes.

We are required by law to:

• Maintain the privacy and security of your protected health information
• Notify you promptly if a breach occurs that may have compromised the privacy or security of your information
• Follow the duties and privacy practices described in this Notice
• Provide you with a copy of this Notice

We will not use or share your information other than as described here unless you tell us we may do so in writing. If you tell us we may, you may change your mind at any time by notifying us in writing.

We may change the terms of this Notice at any time. The changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.

If you have questions about this Notice or wish to exercise your rights, please contact:

New You Medical
5038 Cemetery Rd. Suite D.
Hilliard, OH 43026
Phone: 614-454-3083
Email: help@newyou-medical.com

You may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:

200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
Website: www.hhs.gov/ocr/privacy/hipaa/complaints/

You will not be penalized or retaliated against for filing a complaint.