Understanding Your Health Record/Information

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.

When you receive care at The Longevity Clinic LLC (“The Longevity Clinic”), we create a record of the services you receive. This record contains your symptoms, examination and test results, diagnoses, treatment, plan for future care or treatment, and billing-related information. This Notice applies to all of the records of your care generated by The Longevity Clinic.

Our Responsibilities

The Longevity Clinic is required by law to:

• Maintain the privacy of your protected health information
• Provide you with this Notice of our legal duties and privacy practices with respect to information we collect and maintain about you
• Abide by the terms of this Notice
• Notify you if we are unable to agree to a requested restriction
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
• Notify affected individuals following a breach of unsecured protected health information

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will post the revised Notice on our website and at our office. You may request a copy of our Notice at any time.

How We May Use and Disclose Your Health Information

The following categories describe different ways that we may use and disclose your health information. Not every use or disclosure in a category will be listed.

For Treatment

We may use your health information to provide you with medical treatment or services. We may disclose your health information to doctors, nurses, technicians, or other personnel who are involved in taking care of you. For example, a doctor treating you for hormone optimization may need to know if you have certain medical conditions that could impact your treatment plan.

For Payment

We may use and disclose your health information so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about treatment you received so your health plan will pay us or reimburse you for the treatment.

For Healthcare Operations

We may use and disclose your health information for healthcare operations. These uses and disclosures are necessary to run our practice, improve your care, and contact you when necessary. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you.

As Required By Law

We will disclose your health information when required to do so by federal, state, or local law. For example, disclosure may be required by Workers’ Compensation statutes and various public health statutes in connection with required reporting of certain diseases, child abuse and neglect, domestic violence, adverse drug reactions, etc.

To Avert a Serious Threat to Health or Safety

We may use and disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Health Oversight Activities

We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes

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

Law Enforcement

We may release health 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 limited circumstances, we are unable to obtain the person’s agreement
• About a death we believe may be the result of criminal conduct
• 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

Special Situations

Military and Veterans

If you are a member of the armed forces, we may release your health information as required by military command authorities.

National Security and Intelligence Activities

We may release your health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Coroners, Medical Examiners, and Funeral Directors

We may release health information to a coroner, medical examiner, or funeral director. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Organ and Tissue Donation

If you are an organ donor, we may release your health information to organizations that handle organ procurement or organ, eye, or tissue transplantation, or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

Research

Under certain circumstances, we may use and disclose your health information for research purposes. All research projects are subject to a special approval process. We will ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are.

Inmates

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your health information to the correctional institution or law enforcement official as necessary for your health and the health and safety of others.

Your Rights Regarding Your Health Information

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

Right to Inspect and Copy

You have the right to inspect and obtain a copy of your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect it or get a copy of it. We may charge a fee for the costs of copying, mailing, or other associated supplies. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

Right to Amend

If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to our Privacy Official. You must provide 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 health information kept by or for our practice
• Is not part of the information which you would be permitted to inspect and copy
• Is accurate and complete

Right to an Accounting of Disclosures

You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of your health information for purposes other than treatment, payment, healthcare operations, and certain other activities. To request this list, you must submit your request in writing to our Privacy Official. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to our Privacy Official. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply.

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 make your request in writing to our Privacy Official. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice at our website, www.thelongevityclinic.net. To obtain a paper copy of this Notice, contact our Privacy Official.

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 health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice at our office and on our website. The Notice will contain the effective date on the first page.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our Privacy Official at the address and phone number listed at the end of this Notice. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Health Information

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

Privacy Official Contact Information

Privacy Official: Dr. Silvana Kalakech, MD, Chief Medical Officer
Address: The Longevity Clinic LLC, 30 N Gould St Ste R, Sheridan, WY 82801
Phone: (321) 380-1075
Email: info@thelongevityclinic.net