HIPAA Notice Of Privacy Practices

Introduction

This notice outlines your protected health information, how it may be used, and what your rights are.
Please review carefully and ask any questions prior to signing.

Questions about this notice can be directed to BETTER ME BARIATRICS (address: 30 N Gould St Ste.
R, Sheridan, WY 82801 ; phone: (281) 969-3993; email: care@bettermejourney.com)

Our Pledge Regarding Protected Health Information

Better Me Bariatrics understands that protected health information about you and your health is
personal. We are committed to protecting health information about you. This Notice applies to all the
records generated by Better Me Bariatrics, whether made by Better Me Bariatrics personnel or its
partnered doctors. This Notice will tell you about the ways in which we may use and disclose protected
health information about you. We also describe your rights and certain obligations we have regarding
the use and disclosure of protected health information.

The law requires us to: – Make sure that protected health information that identifies you is kept private. –
Notify you about how we protect protected health information about you. – Explain how, when and why
we use and disclose protected health information. – Follow the terms of the Notice that is currently in
effect.

We are required to follow the procedures in this Notice. We reserve the right to change the terms of this
Notice and to make new notice provisions effective for all protected health information that we maintain
by: – Making copies of the revised Notice available upon request. – Posting the revised Notice on our
website.

How We Communicate With You – Communication Policy

Better Me Bariatrics communicates with patients and prospective patients via several mediums. I wish
to be contacted via email, text (SMS), and the email address I provided for communication from Better
Me Bariatrics regarding my care and follow-up, even though these forms of communication may not be
secure.

– Email Communication – Text (SMS) Communication – Telephone Communication

These mediums of communications are not a secure way to communicate. However, we make every
attempt to limit the e-PHI and the communication to a minimum. Individuals seeking Better Me
Bariatrics scheduling services for obesity treatment must approve to be communicated via these forms.

How We May Use and Disclose Protected Health Information About You

The following categories describe different ways that we use and disclose protected health information
without your written authorization.

For Treatment: We may use protected health information about you to provide you with, coordinate or
manage your medical treatment or services. We may disclose protected health information about you to
doctors, nurses, technicians, medical students, affiliates, or other Better Me Bariatrics personnel who
are involved. Better Me Bariatrics staff may also share protected health information about you in order
to coordinate the different things you need, such as prescriptions, lab work, and x-rays. We may use
and disclose protected health information to remind you of an appointment or to recommend possible
treatment options, alternatives, or health-related benefits or services.

For Payment for Services: We may use and disclose protected health information about you so that the
treatment and services you receive at Better Me Bariatrics may be billed to and payment may be
collected from you, an insurance company or a third party.

For Health Care Operations: We may use and disclose protected health information about you for
Better Me Bariatrics’ health care operations, including quality assessment, case management,
coordination of care, business planning, customer services, and other activities. These uses are
necessary to run the facility and ensure quality care. We may also combine your information with that of
others to decide on services or treatments, or for learning and research, after removing identifying
details.

As Required by Law: We will disclose protected health information about you when required by federal,
state, or local law.

Research, Health Risks, and Public Health: We may disclose information for approved research, if
required by law to report abuse, neglect, or domestic violence, or for public health efforts to control
disease, injury, or disability.

Judicial and Administrative Proceedings: We may disclose information as required for lawsuits,
subpoenas, or lawful court orders.

Law Enforcement, National Security, and Other Government Functions: We may disclose information to
law enforcement, military authorities, or federal officials for lawful purposes including inmate care or
national security.

Organ Donation, Coroners, and Funeral Directors: If you are an organ donor, we may share your PHI
for donation and transplantation purposes. We may also share information with coroners or funeral
directors as required.

Worker’s Compensation and FDA: We may disclose your PHI to comply with workers’ compensation
laws or for FDA-related safety reporting.

To Avert a Serious Threat: We may disclose PHI if necessary to prevent a serious threat to your health
or safety or that of the public.

You Can Object to Certain Uses and Disclosures

Unless you object, we may use or disclose your information in the following cases:

– With a family member, relative, friend, or person identified by you, directly relevant to that person’s
involvement in your care or payment. – To notify others of your location or condition. – To disaster relief
agencies (like the Red Cross).

If you wish to object, please contact us using the contact information on page 1.

Your Rights Regarding Protected Health Information About You

You have the following rights regarding protected health information we maintain about you:

Right to Inspect and Copy: You may inspect and copy medical or billing records used to make
decisions about your care. Submit a written request to Better Me Bariatrics. We may charge a fee for
copies and must respond within 60 days. Some exceptions apply.

Right to Amend: If you believe your PHI is incorrect or incomplete, you may request an amendment in
writing with a reason. We may deny requests that are inaccurate, not part of our records, or not subject
to review. Denials will be provided in writing.

Right to an Accounting of Disclosures: You may request a list of disclosures we made (excluding those
for treatment, payment, and operations) for up to six years before your request. Submit the request in
writing. The first list is free; additional lists may incur a fee.

Right to Request Restrictions: You may request limits on our use or disclosure of your information. We
are not required to agree, but if we do, we will honor the restriction unless required for emergency
treatment.

Right to Request Confidential Communications: You may request we contact you in a specific way
(e.g., only by mail or at work). Requests must be in writing. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice: You may request a paper copy of this Notice at any time.

Other Uses and Disclosures

We will obtain your written authorization before using or disclosing your protected health information for
purposes not covered in this Notice or required by law. You may revoke authorization at any time in
writing. We will stop using or disclosing your information, except where action has already been taken
in reliance on your authorization.

You May File a Complaint About Our Privacy Practices

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

To file a complaint with Better Me Bariatrics, use the contact information on page 1. To file with the
Secretary, submit your complaint in writing within 180 days of the suspected violation.

We will not retaliate or take any action against you for filing a complaint.