Lively Integrated Health, LLC 920 E. Williams Field Rd., Suite 102, Gilbert, AZ 85295 | (480) 780-7214

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 Legal Responsibilities

We are 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 the notice currently in effect. We reserve the right to change our privacy practices and the terms of this notice at any time. If we make material changes, we will update this notice, post the revised version in our office and on our website, and make copies available upon request. Changes will apply to all PHI we maintain, including information created or received before the change.

You may request a paper copy of this notice at any time, even if you agreed to receive it electronically, by contacting our office at the address or phone number above.

How We May Use and Disclose Your Protected Health Information

The following categories describe the ways we may use and disclose your PHI. Not every use or disclosure within a category is listed, but all permitted uses and disclosures fall within one of these categories.

Treatment. We may use and disclose your PHI to provide, coordinate, and manage your care. This includes disclosing PHI to other medical providers, trainees, therapists, medical staff, and office staff involved in your care. For example, your provider may consult with another provider to coordinate your care, or our staff may share your PHI with a pharmacy when a prescription is sent.

Payment. We may use and disclose your PHI to obtain payment for services, including providing information to an insurance company or other third party — for example, for a pre-authorization of a medication we prescribed.

Health Care Operations. We may use and disclose your PHI to operate this medical practice, including training, case review with employees, quality improvement, and contacting you by telephone, email, or text to remind you of appointments. If we share PHI with third-party "business associates" (such as a billing service or transcription service), we will have a written contract requiring them to protect your PHI.

Appointment Reminders. We may contact you by text, phone, or email to remind you of an upcoming visit, follow-up, or lab work.

Marketing. We will not use or disclose your PHI for marketing purposes without your written authorization, except for face-to-face communications or promotional gifts of nominal value as permitted by law. We may send you information about our own services that may be of interest to you; you may ask us to stop these communications at any time.

Others Involved in Your Care. We may disclose your PHI to a family member or friend involved in your care if you verbally agree, or if you are given the opportunity to object and do not. If you are unable to agree or object, we may disclose information as necessary in your best interest based on professional judgment in urgent or emergent circumstances.

Research. We will not use or disclose your PHI for research purposes without your authorization.

Organ Donation. If you are an organ donor, we may release PHI to organizations that handle organ, eye, or tissue procurement or transplantation as necessary to facilitate donation.

Public Health. We may disclose PHI to prevent or control disease, report adverse events from medications or products, or prevent injury, disability, or death, including disclosures to public health authorities and to the Food and Drug Administration as required by regulation.

Health Oversight Activities. We may disclose PHI to health oversight agencies for audits, investigations, inspections, or licensing purposes.

Required by Law. We will disclose PHI when required to do so by federal, state, or local law.

Workers' Compensation. We may disclose PHI as authorized by workers' compensation or similar programs.

Lawsuits and Legal Proceedings. We may disclose PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process, subject to applicable legal requirements.

Law Enforcement. We may release PHI to a law enforcement official in response to a court order, subpoena, warrant, or similar process, subject to all applicable legal requirements.

Uses and Disclosures Requiring Your Authorization. Uses and disclosures not described in this notice will be made only with your written authorization. This includes most uses and disclosures of psychotherapy notes (if any), uses and disclosures for marketing purposes, and any sale of PHI. You may revoke an authorization at any time in writing; revocation will not affect uses or disclosures made while the authorization was in effect.

Your Rights Regarding Your Protected Health Information

Right to Access. You have the right to inspect and receive a copy of your PHI used to make decisions about your care. Submit a written request to the contact person listed below. We may charge a reasonable, cost-based fee for copies. If you request an electronic copy of records we maintain electronically, we will provide it in the form and format you request if readily producible.

Right to Amend. If you believe your PHI is incorrect or incomplete, you may request an amendment in writing, including the reason for the request. We may deny the request if it is not in writing, does not include a reason, or if we believe the information is accurate and complete; if we deny it, we will provide a written explanation and you may submit a statement of disagreement.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures of your PHI, other than disclosures for treatment, payment, health care operations, or those made pursuant to your authorization. Submit a written request to the contact person below; the accounting may cover up to six years prior to the date of your request. The first accounting in a 12-month period is free; we may charge a reasonable fee for additional requests.

Right to Request Restrictions. You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or health care operations. We are not required to agree to all requests, except: if you pay for a service in full out of pocket and request that we not disclose that information to your health plan, we must honor that restriction unless disclosure is required by law.

Right to Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location (for example, only by cell phone or only at a specific address). We will accommodate reasonable requests.

Right to Breach Notification. You have the right to be notified following a breach of your unsecured PHI.

Right to a Paper Copy. You have the right to a paper copy of this notice at any time, even if you agreed to receive it electronically.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office using the contact information below, or with the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue S.W., Washington, D.C. 20201, by calling 1-877-696-6775, or online at www.hhs.gov/ocr/privacy/hipaa/complaints. You will not be penalized or retaliated against for filing a complaint.

Contact Persons

Kristin Porter, FNP-C and Rebecca Powers, FNP-BC — Medical Directors and Co-Owners 

Lively Integrated Health, LLC 

920 E. Williams Field Rd., Suite 102, Gilbert, AZ 85295 

(480) 780-7214 

[email protected]