Common use of Your Health Information Rights Clause in Contracts

Your Health Information Rights. The following are a list of your rights in respect to your PHI. Please contact the HIPAA Contact Person for more information about the below. Request restrictions on certain uses and disclosures of your PHI: You have the right to request additional restrictions of the Pharmacy’s uses and disclosures of your PHI; however, the Pharmacy is not required to accommodate a request. This includes the right to restrict disclosures to Insurances for those products and services you pay out-of- pocket for. The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the Pharmacy communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the Pharmacy to have an accurate address and phone number in case of emergencies. The Pharmacy will consider all reasonable requests. The right to inspect and/or obtain a copy of your PHI: You have the right to request access and/or obtain a copy of your PHI that is contained in the Pharmacy for the duration the Pharmacy maintains PHI about you. There may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring such charges, if any. The right to amend your PHI: You have the right to request an amendment of the PHI the Pharmacy maintains about you, if you feel that the PHI the Pharmacy has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we may deny your request for amendment. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who was not involved in the initial review. You may also ask the Secretary, United States Department of Health and Human Services (“HHS”), or their appropriate designee, to review such a denial. The right to receive an accounting of disclosures of your PHI: You have the right to receive an accounting of certain disclosures of your PHI made by the Pharmacy. The right to receive additional copies of the Pharmacy’s Notice of Privacy Practices: You have the right to receive additional paper copies of this Notice, upon request, even if you initially agreed to receive the Notice electronically Notification of Breaches: You will be notified of any breaches that have compromised the privacy of your PHI.

Your Health Information Rights. The following are a list of your rights in respect to your PHI. Please contact the HIPAA Contact Person for more information about the below. Request restrictions on certain uses and disclosures of your PHI: You have the right to request additional restrictions of the Pharmacy’s uses and disclosures of your PHI; however, the Pharmacy is not required to accommodate a request. This includes the right to restrict disclosures to Insurances for those products and services you pay out-of- of-pocket for. The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the Pharmacy communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the Pharmacy to have an accurate address and phone number in case of emergencies. The Pharmacy will consider all reasonable requests. The right to inspect and/or obtain a copy of your PHI: You have the right to request access and/or obtain a copy of your PHI that is contained in the Pharmacy for the duration the Pharmacy maintains PHI about you. There may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring such charges, if any. The right to amend your PHI: You have the right to request an amendment of the PHI the Pharmacy maintains about you, if you feel that the PHI the Pharmacy has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we may deny your request for amendment. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who was not involved in the initial review. You may also ask the Secretary, United States Department of Health and Human Services (“HHS”), or their appropriate designee, to review such a denial. The right to receive an accounting of disclosures of your PHI: You have the right to receive an accounting of certain disclosures of your PHI made by the Pharmacy. The right to receive additional copies of the Pharmacy’s Notice of Privacy Practices: You have the right to receive additional paper copies of this Notice, upon request, even if you initially agreed to receive the Notice electronically Notification of Breaches: You will be notified of any breaches that have compromised the privacy of your PHI.

Your Health Information Rights. The following are a list of Although your rights in respect to your PHI. Please contact the HIPAA Contact Person for more health information about the below. Request restrictions on certain uses and disclosures of your PHI: You is our property, you have the right to: Request access to your health information. You may request additional restrictions of the Pharmacy’s uses and disclosures of your PHI; however, the Pharmacy is not required to accommodate a request. This includes the right to restrict disclosures to Insurances for those products and services you pay out-of- pocket for. The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the Pharmacy communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the Pharmacy to have an accurate address and phone number in case of emergencies. The Pharmacy will consider all reasonable requests. The right to inspect and/or obtain a copy of your PHIhealth information. If we maintain your health information electronically, you may obtain an electronic copy of the information or ask us to send it to a person or organization that you identify. If you request a copy (paper or electronic), we may charge you a reasonable, cost-based fee. Any request to access your health information must be in writing and submitted to our Privacy Officer. Request a restriction on the use or disclosure of your health information. You may ask us not to use or disclose any part of your health information for a particular reason related to treatment, payment or health care operations. We will consider your request, but we are not legally obligated to agree to a requested restriction except for in the following situation: If you have paid for services out-of-pocket in full, you may request that we not disclose information related solely to those services to your health plan. We are required to abide by such a request, except where we are required by law to make the disclosure. Any request for a restriction must in writing and submitted to our Privacy Officer. We will notify you if we cannot accommodate your request. Request to receive confidential communications. You have the right to receive confidential communications from us by alternative means or at an alternative location. Such a request must be made in writing and submitted to our Privacy Officer. We will notify you if we cannot accommodate your request. Request an amendment to your medical information. If you believe that any information in your medical record is incorrect, or if you believe important information is missing, you may request that we correct the existing information or add the missing information. Such a request must be in writing and submitted to our Privacy Officer. We will notify you if we cannot accommodate your request. Request an accounting of certain disclosures. You have the right to request access and/or obtain a list of certain disclosures we have made of your health information. Any request for an accounting must be in writing and submitted to our Privacy Officer. The first list in any 12-month period will be provided to you for free, but you may be charged for any additional lists requested during the same 12- month period. Receive a paper copy of your PHI that is contained in the Pharmacy for the duration the Pharmacy maintains PHI about youthis Notice. There may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring such charges, if any. The right to amend your PHI: You have the right to request an amendment of the PHI the Pharmacy maintains about you, if you feel that the PHI the Pharmacy has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we may deny your request for amendment. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who was not involved in the initial review. You may also ask the Secretary, United States Department of Health and Human Services (“HHS”), or their appropriate designee, to review such a denial. The right to receive an accounting of disclosures of your PHI: You have the right to receive an accounting of certain disclosures of your PHI made by the Pharmacy. The right to receive additional copies of the Pharmacy’s Notice of Privacy Practices: You have the right to receive additional a paper copies copy of this Notice, Notice upon request, even if you initially agreed to receive the accept this Notice electronically Notification of Breaches: You will be notified of any breaches that have compromised the privacy of your PHIelectronically.

Your Health Information Rights. The following are a list of Your health record is owned by the clinic, however, the content is always available to you for your rights in respect to your PHIreview. Please contact the HIPAA Contact Person for more information about the below. Request restrictions on certain uses and disclosures of your PHI: You have the right to request additional restrictions of the Pharmacy’s uses and disclosures a review of your PHI; however, the Pharmacy is not required file and to accommodate a requestobtain copies of documents contained in your file. This includes the right to restrict disclosures to Insurances for those products and services you pay out-of- pocket for. The right to have your PHI communicated to you by alternate means or locations: You also have the right to request that amendments be made to your record. In addition, you may request that the Pharmacy communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the Pharmacy to have an accurate address and phone number in case of emergencies. The Pharmacy will consider all reasonable requests. The right to inspect and/or obtain a copy use of your PHI: You have the right information be restricted from certain uses and disclosures and to request access and/or obtain a copy list of individuals or entities to whom your PHI that is contained in the Pharmacy for the duration the Pharmacy maintains PHI about you. There may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring such charges, if any. The right to amend your PHI: You have the right to request an amendment of the PHI the Pharmacy maintains about you, if you feel that the PHI the Pharmacy information has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we may deny your request for amendment. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who was not involved in the initial reviewbeen disclosed. You may also ask the Secretary, United States Department of Health and Human Services (“HHS”), or their appropriate designee, to review such a denial. The right to receive an accounting of disclosures revoke any authorizations you have given regarding disclosure of your PHIhealth information at any time. This revocation must be provided to us, in writing. Our Responsibilities: You have the right We are required to receive an accounting of certain disclosures of your PHI made by the Pharmacy. The right to receive additional copies of the Pharmacy’s Notice of Privacy Practices: You have the right to receive additional paper copies of this Notice, upon request, even if you initially agreed to receive the Notice electronically Notification of Breaches: You will be notified of any breaches that have compromised maintain the privacy of your PHI.health information and to provide you with a copy of this notice upon request. We will follow the terms of this notice and advise you if we are unable to comply with a request you may make regarding the use of your health information. We reserve the right to amend our privacy policies and we use our best efforts to notify you of such amendments. Other than for reasons stated in this notice, we will not use or disclose your health information without your consent. I, have read and understand this Notice of Privacy Practices Regarding Disclosure of Health Information. I understand my health information will be treated in accordance with this notice. Patient/Guardian Name: (please print) Signature: Date: Patient Advisory To Consult A Physician To comply with Article 160, Section 8211 (b) of New York State Education Law, I request that you read and sign the following statement: WE, THE UNDERSIGNED, DO AFFIRM THAT (THE PATIENT) HAS BEEN ADVISED BY XXXXX XXXXXX X.XX. TO CONSULT A PHYSICIAN REGARDING THE CONDITIONS FOR WHICH SUCH A PATIENT SEEKS ACUPUNCTURE TREATMENT. Date: Patient’s signature Date: Xxxxx Xxxxxx X.Xx. Financial Agreement Assignment of Benefits and Release of Information for Insurance I authorize payment of benefits be directly to this healthcare provider and I understand I am responsible for charges not covered by this assignment. If insurance sends payments to me for services incurred in this office, I agree to send or bring those payments to this office upon receipt. However, if I pay for visits in full, the assignment will not be provided by this provider and any payment will be sent directly to me. I also authorize this office upon request from insurance carrier the release of any medical or other information necessary to process the claim. Payment Arrangements We require that you pay a co-pay on each visit. Your full portion of the balance is expected to be paid when payment is received from your insurance carrier. Returned Check Policy All returned checks will be subject to an additional charge of $25.00

Your Health Information Rights. The following health and billing records we maintain are the physical property of the office. The information in it, however, belongs to you. You have the right to: • Request a list of your rights in respect to your PHI. Please contact the HIPAA Contact Person for more information about the below. Request restrictions restriction on certain uses and disclosures of your PHI: You have health information by delivering the right request to request additional restrictions of the Pharmacy’s uses and disclosures of your PHI; however, the Pharmacy is our office – we are not required to accommodate grant the request, but we will comply with any request granted. • Obtain a requestpaper copy of the current Notice of Privacy Practices for Protected Health Information (“Notice”) by making a request at our office. This includes the right to restrict disclosures to Insurances for those products and services • Request that you pay out-of- pocket for. The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the Pharmacy communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the Pharmacy to have an accurate address and phone number in case of emergencies. The Pharmacy will consider all reasonable requests. The right be allowed to inspect and/or obtain and receive a copy your health record and billing record – you may exercise this right by delivering the request to our office. • Appeal a denial of access to your PHI: You have the right to request access and/or obtain a copy of your PHI that is contained protected health information, except in the Pharmacy for the duration the Pharmacy maintains PHI about you. There may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring such charges, if any. The right to amend your PHI: You have the right to request an amendment of the PHI the Pharmacy maintains about you, if you feel that the PHI the Pharmacy has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we • Request that your health care record be amended to correct incomplete or incorrect information by delivering request to our office. We may deny your request for if you ask us to amend information that: 1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment. 2) Is not part of the health information kept by or for the office 3) is not part of the information that you would be permitted to inspect and obtain a copy of. 4) Is accurate and complete. • If we do deny your request is denied, your will be informed of the request, you reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records. • Request that communication for your health information be made by alternative mans or at an alternative location by delivering the right request in writing to have the denial reviewed by someone we designate who was not involved in the initial review. You may also ask the Secretary, United States Department of Health and Human Services (“HHS”), or their appropriate designee, to review such a denial. The right to receive our office • Obtain an accounting of disclosures of your PHI: You have the right health information as required to receive be maintained by law by delivering a request to our office. An accounting will not include uses and disclosers of information for treatment, payment or operations; disclosures or uses made pursuant to an accounting of certain authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person’s involvement in your care or in payment for such care; or uses or disclosers to notify family or others responsible for your care of your PHI location, condition or your death. Revoke authorizations that you made previously to use or disclose information by the Pharmacydelivering a written revocation to actions that has already been taken. Our Responsibilities The right to receive additional copies of the Pharmacy’s Notice of Privacy Practicesoffice is required to: You have the right to receive additional paper copies of this Notice, upon request, even if you initially agreed to receive the Notice electronically Notification of Breaches: You will be notified of any breaches that have compromised • Maintain the privacy of your PHIhealth information as required by law • Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you • Abide by the terms of this notice • Notify you if we cannot accommodate a requested restriction of request We reserve the right to amend, change or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our Notice or by visiting our office and picking up a copy. Communication with Family: Using our best judgment, we may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency. We may use or disclose your protected health information to notify or assist in notifying a family member, personal representative or other person responsible for your care, about your location and about your general condition or your death.

Your Health Information Rights. The following health record and billing records I maintain are the physical property of this office. The information in it, however, belongs to you. You have a list of your rights in respect to your PHI. Please contact the HIPAA Contact Person for more information about the below. right to: ● Request restrictions a restriction on certain uses and disclosures of your PHI: protected health information by delivering the request in writing to my office. I am not required to grant the request, but I will comply with any request granted. ● Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information by making a request at my office. ● Request that you be allowed to inspect and receive a copy of your health record and billing record. You may exercise this right by delivering the request in writing to my office using the form provided to you upon request. ● Appeal a denial of access to your protected health information except in certain circumstances. ● Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to my office using the form provided to you upon request. ● File a statement of disagreement if your amendment is denied and require that the request for amendment and any denial be attached in all future disclosures of your protected health information ● Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to my office using the form provided to you upon request. The accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request. ● Request that communication of your health information is made by alternative means or at an alternative location by delivering the request in writing to my office using the form provided to you upon request. ● Revoke any authorizations that you made previously to use or disclose the information except to the extent information or action has already been taken by delivering a written revocation to my office. ● You have the right to request additional restrictions of review this Notice before signing the Pharmacy’s uses consent authorizing the use and disclosures disclosure of your PHI; howeverprotected health information for treatment, payment, and health care operations purposes. MY RESPONSIBILITIES The provider is required to: ● Maintain the Pharmacy is not required to accommodate a request. This includes the right to restrict disclosures to Insurances for those products and services you pay out-of- pocket for. The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the Pharmacy communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the Pharmacy to have an accurate address and phone number in case of emergencies. The Pharmacy will consider all reasonable requests. The right to inspect and/or obtain a copy privacy of your PHI: You have health information as required by law ● Provide you with a notice as to my duties and privacy practices as to the right to request access and/or obtain a copy of your PHI that is contained in the Pharmacy for the duration the Pharmacy maintains PHI information I collect and maintain about you. There may be ● Abide by the terms of this Notice. ● Notify you if I cannot accommodate a requested restriction or request. ● Accommodate your reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring such charges, if any. The right requests regarding methods to amend your PHI: You have the right communicate health information to request an amendment of the PHI the Pharmacy maintains about you, if you feel that the PHI the Pharmacy has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we may deny your request for amendment. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who was not involved in the initial review. You may also ask file a complaint by mailing or e-mailing it to the SecretarySecretary of Health and Human Services. I cannot, United States Department and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (“HHS”)) as a condition of receiving treatment. I cannot, or their appropriate designeeand will not, to review such retaliate against you for filing a denial. The right to receive an accounting of disclosures of your PHI: You have complaint with the right to receive an accounting of certain disclosures of your PHI made by the Pharmacy. The right to receive additional copies of the Pharmacy’s Notice of Privacy Practices: You have the right to receive additional paper copies of this Notice, upon request, even if you initially agreed to receive the Notice electronically Notification of Breaches: You will be notified of any breaches that have compromised the privacy of your PHISecretary.

Your Health Information Rights. The following are a list of your rights in respect to your PHI. Please contact the HIPAA HIPPA Contact Person for more information about the below. Request restrictions on certain uses and disclosures of your PHI: You have the right to request additional restrictions of the Pharmacy’s 's uses and disclosures of your PHI; however, the Pharmacy is not required to accommodate a request. This includes the right to restrict disclosures to Insurances for those products and services you pay out-of- of-pocket for. The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the Pharmacy communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the Pharmacy to have an accurate address and phone number in case of emergencies. The Pharmacy will consider all reasonable requests. The right to inspect and/or obtain a copy of your PHI: You have the right to request access and/or obtain a copy of your PHI that is contained in the Pharmacy for the duration the Pharmacy maintains PHI about you. There may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring such charges, if any. The right to amend your PHI: You have the right to request an amendment of the PHI the Pharmacy maintains about you, if you feel that the PHI the Pharmacy has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we may deny your request for amendment. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who was not involved in the initial review. You may also ask the Secretary, United States Department of Health and Human Services (“"HHS”"), or their appropriate designee, to review such a denial. The right to receive an accounting of disclosures of your PHI: You have the right to receive an accounting of certain disclosures of your PHI made by the Pharmacy. The right to receive additional copies of the Pharmacy’s 's Notice of Privacy Practices: You have the right to receive additional paper copies of this Notice, upon request, even if you initially agreed to receive the Notice electronically Notification of Breaches: You will be notified of any breaches that have compromised the privacy of your PHI.