Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES

Effective Date: 9/13/2023

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.

Our Commitment to Your Privacy

Premier Head and Neck Surgery, PC is required by law to maintain the privacy of your protected health information ("PHI"), to provide you with this notice of our legal duties and privacy practices with respect to your PHI, and to notify you following a breach of unsecured PHI. We are required to abide by the terms of this notice for as long as it remains in effect. We reserve the right to change the terms of this notice and to make the revised notice effective for all PHI we maintain. If we make a material change, an updated notice will be made available at our office and, if we maintain a website, posted there.

How We May Use and Disclose Your Health Information

We use and disclose health information about you for treatment, payment, and health care operations. Examples include:

• Treatment: Sharing information with physicians, nurses, technicians, or other personnel involved in your care, and with other providers involved in your treatment.
• Payment: Providing information to your insurance carrier, Medicare, Medicaid, or other payers so that we may bill and receive payment for services provided to you.
• Health Care Operations: Using information for quality assessment, staff training, licensing, audits, and other activities necessary to run our practice.

We may also use or disclose your information, without your written authorization, for the following purposes, as permitted or required by law:

• Appointment reminders, and information about treatment alternatives or other health-related benefits and services that may interest you.
• Individuals involved in your care (family members, friends, or others you identify) or for notification purposes, only with your consent and approval.
• Public health activities (e.g., reporting disease, injury, or vital events; FDA-regulated product monitoring).
• Health oversight activities, such as audits, investigations, and inspections by government agencies.
• Judicial and administrative proceedings, in response to a court or administrative order, subpoena, or discovery request.
• Law enforcement purposes, as required by law or in response to a valid legal process.
• To avert a serious threat to the health or safety of you or others.
• Workers' compensation, as authorized by and to the extent necessary to comply with workers' compensation laws.
• As required by law, including disclosures to the U.S. Department of Health and Human Services to investigate our compliance with federal privacy law.

Any use or disclosure not described in this notice — including most uses and disclosures of psychotherapy notes, marketing communications, and any sale of PHI — will be made only with your written authorization. You may revoke that authorization in writing at any time, except to the extent we have already relied on it.

Your Rights Regarding Your Health Information

Right to Request Restrictions. You may ask us not to use or disclose certain health information for treatment, payment, or health care operations. We are not required to agree, except where you paid for a service out-of-pocket in full and ask that we not disclose that information to your health plan.

Right to Request Confidential Communications. You may ask us to communicate with you about health matters in a certain way or at a certain location (for example, only at work or by mail).

Right to Inspect and Copy. You may inspect and obtain a copy of health information that may be used to make decisions about your care, with limited exceptions. We may charge a reasonable, cost-based fee for copies.

Right to Amend. You may ask us to amend your health information if you believe it is incorrect or incomplete. We may deny your request under certain circumstances.

Right to an Accounting of Disclosures. You may request a list of certain disclosures we have made of your health information, generally covering up to six years prior to the request date, excluding disclosures for treatment, payment, and health care operations, and certain other disclosures.

Right to a Paper Copy of This Notice. You may request a paper copy of this notice at any time, even if you agreed to receive it electronically.

Right to Be Notified of a Breach. You have the right to be notified if there is a breach of your unsecured protected health information.

Right to Choose Someone to Act for You. 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.

To exercise any of these rights, please submit a written request to our [Privacy Officer Name / Title] at the address above.

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 here unless you tell us, in writing, that we can. If you tell us we can, you may change your mind at any time by notifying us in writing.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our [Privacy Officer Name / Title] at the address and phone number listed above, or with the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be penalized or retaliated against for filing a complaint.

Office for Civil Rights, U.S. Department of Health and Human Services

200 Independence Avenue, S.W., Washington, D.C. 20201 | (877) 696-6775 | www.hhs.gov/ocr/privacy/hipaa/complaints/

Acknowledgment of Receipt

Your signature below acknowledges that you have received a copy of this Notice of Privacy Practices. Signing this acknowledgment is not a waiver or release of any of your rights under this notice.

Patient / Legal Representative Printed Name

Signature (and Relationship to patient, if not the patient)

If acknowledgment could not be obtained, document the good-faith effort made and the reason below (per 45 CFR 164.520(c)(2)(ii)):