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 Responsibilities:

UMI Clinic is required by federal law (Health Insurance Portability and Accountability Act - HIPAA) and California state law to maintain the privacy of your protected health information (PHI). PHI includes any information about you that can be used to identify you and that relates to your past, present, or future physical health or condition and related healthcare services. We are obligated to provide you with this notice of our privacy practices, our legal duties, and your rights concerning your PHI. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect on [Date] and will remain effective until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. Before we make a significant change in our privacy practices, we will revise this notice and make the new notice available upon request.

Uses and Disclosures of Protected Health Information:

• Treatment: We may use or disclose your PHI to physicians or other healthcare providers providing treatment to you.

• Payment: We may use and disclose your PHI to obtain payment for the healthcare services provided to you.

• Healthcare Operations: We may use and disclose your PHI for essential operational purposes, such as quality assessment, audits, and administrative activities.

Your Rights:

• Access: You have the right to see and obtain a copy of your PHI that we maintain, with limited exceptions. Requests must be made in writing and may involve a fee.

• Amendment: You may ask us to amend your health information if you believe it is incorrect or incomplete. Requests must be made in writing.

• Disclosure Accounting: You have the right to request a list of certain disclosures we have made of your PHI. Requests must be made in writing and may involve a fee if more than one request is made in a year.

• Restrictions: You may request that we place additional restrictions on our use or disclosure of your PHI. We are not required to agree to these requests but will abide by any agreement unless it is necessary to provide you emergency treatment.

• Confidential Communication: You may request that we communicate with you about your PHI in a more confidential manner, such as sending mail to an address other than your home. Requests must be in writing and specify the new method or location.

Complaints:

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with us, please contact our Clinical Director at: clinical_director@umiclinic.org

To file a complaint with the U.S. Department of Health and Human Services, please send your complaint to: Office for Civil Rights U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201; Toll-Free: 1-877-696-6775

Contact Information:

For more information about our privacy practices, or to make a request regarding your rights, please contact our office at the information provided above.

We support your right to the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.