THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION, HOW YOU CAN GET ACCESS TO YOUR HEALTH INFORMATION, AND HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR HEALTH INFORMATION OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION. YOU HAVE A RIGHT TO A COPY OF THIS NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH THE PRIVACY OFFICER AT PRIVACY@SOUNDPAINALLIANCE.COM IF YOU HAVE ANY QUESTIONS. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices (“Notice”) describes the privacy practices of SOUND PAIN ALLIANCE (“Organization”), a “covered entity” under the Health Insurance Portability and Accountability Act (“HIPAA”). We will share your medical and health information that is subject to HIPAA (“Protected Health Information” or “PHI”) as necessary to carry out treatment, payment and health care operations and as permitted by HIPAA and this Notice. This Notice does not apply to health information that is not subject to HIPAA or similar state health information privacy laws, or information used or shared in a manner that cannot identify you. This Notice does not apply to Organization as an employer.

This Notice only applies to those parts of Organization’s websites and mobile device applications, as applicable, where you can access your PHI or interact with a clinician regarding your specific care, such as Organization’s patient portal with respect to your PHI. However, these websites and applications may contain additional terms associated with your use. You should review those terms as well as the website terms contained on the Organization website that you visit.

You may have additional rights under other applicable state or federal law. Applicable state or federal laws that provide greater privacy protection or broader privacy rights will continue to apply and we will comply with such laws to the extent they are applicable. 

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

We may use and disclose your PHI in the following situations; however, applicable laws governing sensitive information (including behavioral health information, drug and alcohol treatment information, and information related to HIV/AIDS or other communicable diseases) may further limit these uses and disclosures.

• Treatment: We may use or disclose your PHI to provide medical treatment and/or services in order to manage and coordinate your medical care. For example, we may share your PHI with other providers to ensure that the medical provider has the necessary PHI to diagnose and provide treatment to you.

• Payment: Your PHI may be used or disclosed to obtain payment for your health care services. For example, we will provide your health care plan with the PHI it requires prior to paying us for the services we have provided to you. This use and disclosure may also include certain activities that your health plan requires prior to approving a service, such as determining benefits eligibility and prior authorization.

• Health Care Operations: We may use and disclose your PHI to manage, operate, and support the business activities of our organization. These activities include, but are not limited to, quality assessment, employee review, licensing, creation of de-identified data and conducting other business activities. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment or for important services such as annual checkups, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. For example, we may call, text, or e-mail you to remind you of a scheduled appointment. We may also share your PHI for case management and care coordination purposes. We may share PHI with our students, trainees, and staff for review and learning purposes. We may also use and share your PHI to confirm the time, place, and attendance of your appointment for treatment with third-party transportation services.

• Minors: PHI of minors will be disclosed to their parents or legal guardians acting as personal representatives, unless prohibited by law or in circumstances where the law permits us to withhold PHI, such as to prevent harm to the minor or another person or in cases of suspected child abuse or neglect.

• Required by Law; Judicial and Administrative Proceedings: We will use or disclose your PHI when required to do so by local, state, federal, and international law. We may use and disclose your PHI in conjunction with judicial or administrative proceedings or for purposes of litigation as permitted by law. We may also share your PHI in response to an administrative or court order, or in response to a subpoena, a discovery request, or other legal process if we are advised that you have been made aware of the request or that efforts were made to secure a qualified protective order.

• Abuse, Neglect, and Domestic Violence or Other Threats to Safety: Your PHI will be disclosed to the appropriate government agency if we believe that a patient has been or is currently the victim of abuse, neglect, or domestic violence and the patient agrees to the disclosure or we are otherwise permitted or required by law to do so. In addition, your PHI may also be disclosed when necessary to prevent a serious threat to your health or safety or the health and safety of others to someone who may be able to help prevent the threat. State laws may require such disclosure when an individual or group has been specifically identified as the target or potential victim.

• Law Enforcement: We will disclose your PHI for law enforcement purposes when all applicable legal requirements have been met. This includes, but is not limited to, law enforcement due to identifying or locating a suspect, fugitive, material witness or missing person; complying with a court order or warrant, and grand jury subpoena; reporting information about a victim of a crime, reporting a death we believe resulted from criminal conduct, reporting criminal conduct occurring on our premises, or reporting crime in an emergency, such as the location of the crime or victims or the identity, description or location of the person who committed the crime.

• Public Health: Your PHI may be disclosed and may be required by law to be disclosed for public health purposes. This includes to: prevent or control disease; help with product recalls; report adverse reactions to medications; or report births and deaths. We may share your PHI with public health authorities for public health purposes to prevent or control disease, injury, or disability and for conducting public health monitoring, investigations, or activities.

• Health Oversight Activities: We may disclose your PHI to a health oversight agency for audits, investigations, inspections, licensures, and other activities as authorized by law. The relevant agencies include governmental units that oversee or monitor the health care system, government benefit and regulatory programs, and compliance with civil rights laws.

• Military, National Security, and other Specialized Government Functions: We may disclose your PHI, if you are in the Armed Forces, for activities deemed necessary by appropriate military command authorities for determination of benefit eligibility by the Department of Veterans Affairs or to foreign military authorities if you are a member of that foreign military service. We may disclose your PHI to authorized federal officials for conducting national security and intelligence activities or special investigations (including for the provision of protective services to the President of the United States, other authorized persons, or foreign heads of state) or to the Department of State to make medical suitability determinations. 

• Worker’s Compensation: We will disclose only the PHI necessary for Worker’s Compensation in compliance with Worker’s Compensation laws. This PHI may be reported to your employer and/or your employer’s representative regarding an occupational injury or illness.

• Ownership Change: If all or a portion of our business is sold, acquired, or merged with another entity, your PHI may become the property of the new owner. However, you will still have the right to request copies of your records and have copies transferred to another provider.

• Breach Notification Purposes: If for any reason there is an unsecured breach of your PHI, we will utilize the contact information you have provided us with to notify you of the breach, as required by law. In addition, your Protected Health Information may be disclosed as a part of the breach notification and reporting process.

• Research: Your PHI may be used by or disclosed to researchers for the purpose of conducting research when an Institutional Review or Privacy Board has approved the research and in compliance with law governing research, or where you have provided your authorization. You may choose to participate in a research study that requires you to obtain related health care services. In this case, we may share your PHI (1) with the researchers involved in the study who ordered the hospital or other health care services; and (2) with your insurance company in order to receive payment for those services that your insurance agrees to pay for. We may use and share your PHI with a researcher if certain parts of your PHI that would identify you are removed before we share it with the researcher. This will only be done if the researcher agrees in writing not to share the information, will not try to contact you, and will obey other requirements that the law provides.

• Business Associates: We may disclose your PHI to our business associates who provide us with services necessary to operate and function as a health care provider. We will only provide the minimum information necessary for the associate(s) to perform their functions as it relates to our business operations. For example, we may use a separate company to process our billing or transcription services that require access to a limited amount of your PHI. Please note that all of our business associates are obligated to comply with the same HIPAA privacy and security rules in which we are obligated. Additionally, all of our business associates are under contract with us and committed to protect the privacy and security of your PHI. We may also share your PHI with a business associate who will remove information that identifies you so that the remaining information can be used or disclosed for purposes outside of this Notice.

• Decedents. We may disclose your PHI to a coroner, medical examiner, or funeral director as necessary for them to perform their duties. 

USES AND DISCLOSURES IN WHICH YOU HAVE THE RIGHT TO OBJECT AND OPT OUT

• Facility Directory: We may include limited information about you in a facility directory while you are a patient at Organization. You have the right to ask that all or part of your information not be given out. 

• Communication with family and/or individuals involved in your care or payment thereof: Unless you object, disclosure of your PHI may be made to a family member, friend, or other individual, whom you have identified that is involved in your care or payment thereof. We may share your PHI with these persons if you are available before we share your PHI with them and you do not object to our sharing your PHI with them, or we reasonably believe that you would not object to this. If you are not present and certain circumstances indicate to us that it would be in your best interests to do so, we will share information with a friend or family member or someone else identified by you, to the extent necessary. This could include sharing information with your family or friend so that they could pick up a prescription or a medical supply. 

• Disaster: In the event of a disaster, your PHI may be disclosed to disaster relief organizations to coordinate your care and/or to notify family members or friends of your location and condition. Whenever possible, we will provide you with an opportunity to agree or object.

• Fundraising: As necessary, we may disclose your PHI to contact you regarding fundraising events and efforts.

• Health Information Networks and Exchanges. We may participate in certain health information networks or exchanges (“HIEs”) that permit health care providers or other health care entities, such as your health plan or health insurer, to share your PHI for treatment, payment and other purposes permitted by law, including those described in this Notice. You are automatically opted in to such HIEs. If you wish to opt out, please submit a written request to us, which we will comply with unless disclosure is required by law. If you opt out of participating in these HIEs, your PHI will no longer be provided to other health care entities through the HIE. However, your decision does not affect the PHI that was exchanged prior to the time you opted out of participation. 

USES AND DISCLOSURES THAT REQUIRE YOUR WRITTEN AUTHORIZATION/CONSENT

We will not disclose or use your PHI in the situations listed below without first obtaining written authorization to do so. In addition to the uses and disclosures listed below, other uses and disclosures of your PHI not covered in this Notice will be made only with your written authorization/consent. If you provide us with an authorization/consent, you may revoke it at any time by submitting a request in writing. Revocation does not apply to PHI that have already been used or disclosed with your permission. You can obtain an authorization/consent form from us upon request. 

• Marketing: Disclosures for marketing purposes which result in our receiving financial payment from a third party whose products or services are being marketed requires your written authorization. This does not include compensation that merely covers our cost of reminding you to take and/or refill your medication or otherwise communicate about a drug or biologic that is currently prescribed to you. For example, we may use your PHI to assess your eligibility and propose newly available treatments. When we see you face-to-face, we may also use your PHI without your authorization to encourage you to get recommended tests, provide you with promotional gifts of nominal value, or tell you about government sponsored health programs. 

• Sale of PHI: Any activity constituting a sale of your PHI will require your prior written authorization.

PROTECTED HEALTH INFORMATION AND YOUR RIGHTS

The following are statements of your rights, subject to certain limitations, with respect to your PHI:

• You have the right to inspect and copy your PHI: Pursuant to your written request, you have the right to inspect and copy your PHI contained in a Designated Record Set (as defined by HIPAA) in paper or electronic format. Under federal law, you may not inspect or copy the following types of records: psychotherapy notes, information compiled as it relates to civil, criminal, or administrative action or proceeding; information restricted by law; information related to medical research in which you have agreed to participate; information obtained under a promise of confidentiality; and information whose disclosure may result in harm or injury to yourself or others. Where permitted by law, we may charge a reasonable cost-based fee. We will discuss any fees with you before processing your request. We may deny your request to inspect and copy in certain very limited circumstances. 

• You have the right to receive a notice of breach: In the event of a breach of your unsecured PHI, you have the right to be notified of such breach. We will notify you of a breach of your unsecured PHI experienced by us or one of our business associates in accordance with applicable law.

• You have the right to request amendments: Pursuant to your written request, you have the right to amend your PHI contained in a Designated Record Set if you reasonably believe that such information is inaccurate or incomplete. Your request for an amendment must detail what PHI is inaccurate and why. Please note that submitting a request for an amendment does not necessarily mean the PHI will be amended. If we approve your request, we will include the amendment in any future disclosures of the relevant PHI. If we deny your request for an amendment, you may file a written statement of disagreement, which we may rebut in writing. The denial, statement of disagreement, and rebuttal will be included in any future disclosures of the relevant PHI. In addition, we may deny your request if you ask us to amend PHI that: is not part of the PHI maintained by us, or was not created by us, unless the person or entity that created the information is no longer available to make the amendment. All denials will be made in writing.

• You have a right to receive an accounting of certain disclosures: Pursuant to your written request, you have the right to receive an accounting of certain disclosures of your PHI, either for paper and/or electronic disclosures. Certain disclosures are exempt from the accounting requirement, including but not limited to disclosures made for the purposes of treatment, payment, and health care operations and those required by law. Your request must include the time frame that you would like us to cover, which may be no longer than six years prior to the date of your request. We will provide the first requested accounting in any 12-month period without charge. However, we may charge you for the cost of providing the accounting for any subsequent accounting requested in a 12-month period. 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. 

• You have the right to request restrictions of your PHI: Pursuant to your written request, you have a right to request to restrict and/or limit the PHI we disclose to others. Your request must include (1) what PHI 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. Please note that we are not required to agree to requests to limit or restrict the PHI we use or disclose for treatment, payment, and/or health care operations except for disclosures for payment or health care operations to your health plan services in which you have paid us in full out-of-pocket. In any event, we still may provide PHI, as necessary, to give you emergency treatment.

• You have a right to request to receive confidential communications: You have a right to request confidential communications from us by alternative means or at an alternative locations. For example, you may request that we call you on your work phone. You do not have to disclose the reason for your request; however, you must submit a request with specific instructions in writing. We will make reasonable efforts to accommodate your request.

• You have the right to appoint a personal representative, such as a medical power of attorney or if you have legal guardian. Your personal representative may be authorized to exercise your rights and make choices about your PHI. We will confirm the person has this authority and can act for you before we take any action based on their request.

• You have a right to receive a paper copy of this Notice: Even if you have agreed to receive an electronic copy of this Notice, you have the right to request we provide it in paper form. You may make such a request at any time. You can also get a copy of this Notice at our website.

CHANGES TO THIS NOTICE

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided the change is permitted by law. We reserve the right to have such a change apply to all PHI we maintain, including PHI we received or created before the change. If we make changes to this Notice, we will post an updated form in our office and on our website. We will also make copies available of our new notice if you wish to obtain one. 

NOTICE OF REDISCLOSURE

PHI that is disclosed pursuant to this Notice may be subject to redisclosure by the recipient and no longer protected by HIPAA. Law applicable to the recipient may limit their ability to use and disclose the PHI received.

COMPLAINTS

If at any time you believe your privacy rights have been violated and you would like to register a complaint, you may do so with us or with the federal government. If you file a complaint, we will not retaliate against you or change our treatment of you in any way.

If you wish to file a complaint with us, please submit it in writing to our HIPAA Privacy Officer at the address or email provided in the Contact section below.

If you wish to file a HIPAA complaint with the Secretary of the United States Department of Health and Human Services, please go to the website of the Office for Civil Rights (www.hhs.gov/ocr/hipaa/), call 202-619-0257 (toll free 877-696-6775), or mail to:

Secretary of the US – Department of Health and Human Services

200 Independence Ave S.W.

Washington, D.C. 20201

To file a complaint with the Secretary, you must (1) name the Organization place or person that you believe violated your privacy rights and describe how that place or person violated your privacy rights; and (2) file the complaint within 180 days of when you knew or should have known that the violation occurred. 

CONTACT

ATTN: HIPAA PRIVACY OFFICER

Josh Leder

5650 South Green Street, Suite B

Murray, UT 84123

EMAIL: privacy@soundpainalliance.com

We are required by law to provide individuals with this Notice of our legal responsibilities and privacy practices with respect to PHI. We are also required to implement safeguards to maintain the privacy of PHI and abide by the terms of the Notice currently in effect. If you have any questions in reference to this Notice, please our Privacy Officer by email or by phone at the number listed above. 

Please sign this form to acknowledge that we have offered you a copy of our Notice of Privacy Practices

The Notice of Privacy Practices (“Notice”) describes your rights in regard to your protected health information, the possible uses of your protected health information, and how we must protect the confidentiality of your protected health information.

Please note, this is not a consent/authorization. By signing this document, you are only stating that we have offered a copy of the full Notice. 

We encourage you to carefully read the full Notice. You may also access the Notice on our website, www.soundpainalliance.com/notice-of-privacy-practices. This website is also listed on the Notice. If you wish to receive a copy of this form or the full Notice, then please ask the staff member who is helping you. 

I agree that a copy of the Notice of Privacy Practices has been made available to me.

Patient/ Legal Representative Signature Date/ Time

For internal use only:

Please document witness to for any of the following:

□ Minor (Under 18 years)    □ Mental or Physical Condition   □ Verbal Consent    □ Telephone Consent

Witness Date/ Time

If not signed, reason:

☐ Patient refused to sign ☐ Other:

☐ Patient not able to sign (give additional information below regarding disability, emergency situation, etc.)

Comments:

Name of Reviewer Date

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